Abstract
Low vision is a condition that cannot be corrected by medical or surgical intervention and that is severe enough to interfere with completing activities of daily living (ADLs; Warren, 2011). Low vision rehabilitation provided by occupational therapy practitioners enables people with low vision to complete ADLs that they need and want to do. Because low vision conditions are generally irreversible, practitioners focus on helping the client use remaining vision as efficiently as possible through modification of environments and tasks, training in use of optical devices prescribed by a low vision physician, and use of assistive technology and devices to compensate for low vision (Warren, 2011).
Since Medicare formally established coverage criteria for low vision services provided by occupational therapy practitioners in May 2002 (Stelmack, 2005), acknowledgment that occupational therapy practitioners are a primary provider of low vision services has grown. In fact, the American Occupational Therapy Association (AOTA) identified low vision as a growing practice area for practitioners in the Centennial Vision (Yamkovenko, 2013). A survey of low vision services in the United States reported that occupational therapy practitioners provided 15% of low vision services overall (Owsley, McGwin, Lee, Wasserman, & Searcey, 2009). With the current prevalence of and anticipated rise in clients with vision impairment over the coming decades (Centers for Disease Control and Prevention, 2009; Eichenbaum, 2012), occupational therapy practitioners will be likely to encounter clients with low vision in their practice settings (McGrath, 2011). Given this information, it has become essential for practitioners to be prepared to provide low vision services.
In response to the demand for low vision services, academic programs (both occupational therapy and occupational therapy assistant) across the country have begun to add specialized education to prepare entry-level graduates to provide services for clients with low vision (Mogk & Goodrich, 2004). A recent survey revealed that nearly all the respondent professional entry-level occupational therapy and occupational therapy assistant programs in the United States indicated that they include low vision content in their curricula (Deacy, Yuen, Barstow, Warren, & Vogtle, 2012).
Cate, Baker, and Gilbert (1995) advocated that all occupational therapy practitioners be able to provide basic services to persons with low vision, including visual screening, interventions (suitable environmental modifications and provision of adaptive devices) to facilitate safe and independent engagement, and referrals to appropriate services. However, it is unknown how comfortable occupational therapy practitioners are in performing visual screening and providing interventions for persons with low vision. To begin addressing this gap in the literature, we designed this study to describe the adequacy of educational preparation and comfort level of occupational therapy practitioners without specialty credentials in low vision when providing services to persons with low vision and to identify factors associated with their comfort level. Exploring factors associated with practitioners’ comfort level in providing services for persons with low vision may assist in devising strategies to improve low vision content in entry-level occupational therapy education curricula and designing appropriate continuing education courses.
Method
Research Design
This descriptive study involved a cross-sectional survey research design. The study was approved by the institutional review board of the University of Alabama at Birmingham. Implied consent was provided by participants upon submission of the completed survey.
Participants
Occupational therapists and occupational therapy assistants who were not specialists in low vision (i.e., did not have a postprofessional specialty certification in low vision rehabilitation, Specialty Certification in Low Vision from AOTA, or Certified Low Vision Specialist from the Academy for Certification of Vision Rehabilitation and Education Professionals) were invited to participate in a survey.
To recruit participants, we posted a hyperlink along with a complete explanation of the survey on multiple e-mail lists, including those of the AOTA Special Interest Sections; the New York State Occupational Therapy Association; the North Carolina Occupational Therapy Association; and the State University of New York Downstate, James Madison University, and Rush University alumni. In addition, hard copies of the survey were made available to eligible participants at the 2010 American Occupational Therapy Association 90th Annual Conference & Expo, Orlando, Florida.
Instrument
A survey was developed to explore factors associated with occupational therapy practitioners’ comfort level in providing services for persons with low vision. The first section of the survey sought descriptive information regarding professional background (including occupational therapy or occupational therapy assistant, degree levels, and years of practice experience) and information on current practice (practice settings, age groups of clients being served). Specific practice questions related to low vision were percentage of clients screened for vision problems, percentage of clients who received interventions for low vision (responses to these two items were in 20% incremental brackets), types of low vision interventions (e.g., environmental modifications and skills training) provided, presence of a low vision protocol in the practice setting (yes or no), and attendance at continuing education courses in low vision (yes or no). Questions about practitioners’ beliefs related to the provision of low vision were included. Using 5-point Likert-type scales, these questions addressed perceptions of adequacy of occupational therapy education for preparing practitioners to provide low vision services and practitioners’ comfort level with providing visual screening and interventions for clients with low vision. The last section of the survey explored the practitioners’ awareness or presence of and use of consultation services (including eye-care and vision rehabilitation professionals) and referral resources (including eye-care professionals, low vision centers, and support groups). Responses to these items were yes or no. A final open-ended question offered an opportunity for respondents to provide feedback about issues related to their preparation for and comfort level in providing low vision services.
Survey content was developed by an occupational therapist with 10 years of work experience and two experienced occupational therapy academicians, one of whom developed and has taught a postprofessional certificate program in low vision rehabilitation since 2002. The initial survey draft was pilot tested for clarity and content validation from target population members and experts in the field of low vision.
Procedures
The survey was posted on Survey Monkey (Surveymonkey.com, Portland, OR), an online survey Web site engine. We posted the link to the survey instrument and a cover letter explaining the purpose of the survey on the earlier mentioned e-mail lists. The sites were chosen because they allowed nonmembers to post the Web link or because the first author (Winner) had a personal or professional affiliation with them. Participation was voluntary with no incentive other than contributing to general knowledge. A follow-up reminder was sent in mid-April 2010 to the appropriate e-mail lists to help increase the response rate. Data were collected between the end of February and mid-May 2010. The participants who completed the hard copies of the survey at the AOTA Conference & Expo returned the completed survey to the University of Alabama at Birmingham booth at the conference.
Data Analysis
Variables were summarized by percentages of responses for each category. The two outcome variables were the occupational therapy practitioners’ comfort level in (1) performing visual screening and (2) providing interventions for clients with low vision. The outcomes were assessed from responses to the following two questions: “How comfortable are you with providing basic visual screening to clients?” and “How comfortable are you with providing basic modifications or interventions for clients with low vision?” The response categories on these two questions were not at all comfortable, not very comfortable, neutral, somewhat comfortable, and very comfortable. To model occupational therapy practitioners’ comfort level in performing visual screening and providing interventions for clients with low vision, a dichotomous variable for comfort was created with 1 (comfortable) being very comfortable or somewhat comfortable and 0 (not comfortable) being neutral, not very comfortable, or not at all comfortable.
Responses to the item on adequate preparation for the provision of low vision services, as an explanatory variable, were also dichotomized into two categories, with 1 (agree) being strongly agree or somewhat agree and 0 (disagree) being neutral, somewhat disagree, or strongly disagree. Responses from each of the survey items were considered to be potential explanatory variables for the two outcomes (i.e., occupational therapy practitioners’ comfort level in performing visual screening and providing interventions for clients with low vision). The pairwise association between each explanatory variable (i.e., professional background, current practice, perceptions of adequacy of occupational therapy education for provision of low vision services, awareness or presence of and frequency of the use of consultation services and referral resources) and each outcome was assessed through univariable logistic regression. Explanatory variables with associated p < .25 in the pairwise tests were included in the subsequent multivariable models (Mickey & Greenland, 1989).
Separate multivariable analyses were carried out for the comfort measures in performing visual screening and providing interventions for clients with low vision. Because occupational therapy assistants are not licensed to perform assessments (i.e., visual screening), they were excluded when conducting analyses related to the outcome variable of comfort level in performing visual screening. Explanatory variables whose regression coefficients had p < .05 were retained in the multivariable models. All hypothesis tests were based on a two-sided α of .05. Data analyses were conducted using SPSS Version 20 (IBM, Armonk, NY).
Results
We received 108 responses; the majority of them (92, or 85%) were from the online survey. Of the 108 respondents, 1 did not practice in the United States; 6 answered only the first few questions in the professional background section, with more than 80% missing information; and another identified the work setting as academia. Because the target population of this study was occupational therapy practitioners in the United States, these 8 respondents were excluded. Thus, the analytic sample consisted of 100 respondents with usable data. Descriptive data of the sample are summarized in Table 1.
Professional Background and Practice Characteristics of the Respondents (N = 100)
Note. OTA = occupational therapy assistant.
Percentage calculation is based on 85 respondent occupational therapists.
There were 85 respondents identifying themselves as occupational therapists and 15 who identified as occupational therapy assistants. Forty had <6 yr practice experience. The three most commonly reported work settings were hospitals (acute and inpatient rehab), school systems, and skilled nursing facilities; 22% of respondents worked in each of these settings. More than 60% of the occupational therapists had master’s degrees, and about 33% had baccalaureate degrees. All the occupational therapy assistants had associate degrees only.
Fifty-two percent of the respondents (49% of occupational therapists and 67% of occupational therapy assistants) agreed that the education they received in occupational therapy school was adequate to provide services for persons with low vision. A significant association between perceived adequate preparation to provide low vision services and years of clinical experience was observed (p = .006). A higher proportion of respondents who had graduated within the previous 5 yr agreed that their education was adequate to provide services for clients with low vision. For example, 68% of the respondents with <6 yr clinical experience versus 30% with >15 yr clinical experience agreed that their education was adequate.
Fifty-four percent of the respondent occupational therapists said they felt comfortable in performing visual screening. Sixty-three percent of respondents (64% of occupational therapists and 60% of occupational therapy assistants) reported that they were comfortable in providing interventions for persons with low vision. The top four reported interventions were environmental modifications (83%), print modifications (78%), lighting modifications (57%), and visual skills training (52%).
Factors Associated With Practitioners’ Comfort Level in Performing Visual Screening
Univariate analyses indicated that respondents (occupational therapists only) who felt occupational therapy school had adequately prepared them to provide low vision services attended continuing education in low vision, performed visual screening for a larger percentage of clients, had a low vision protocol at their workplace, or had previously consulted an eye-care professional (i.e., optometrist or ophthalmologist) about the care of clients were more likely to be comfortable in performing visual screening (all ps < .05; Table 2).
Univariate and Multivariate Analyses Examining Factors Associated With Occupational Therapists’ Comfort Level in Performing Visual Screening
Note. Analyses were performed on respondents who identified themselves as occupational therapists. Blank cells indicate that the variable was not included in the multivariate model. Adj OR = adjusted OR; CI = confidence interval; OR = odds ratio.
Multivariate analyses, controlling for background characteristics, indicated that factors significantly associated with perceived comfort in performing visual screening were adequate preparation in occupational therapy school, having performed visual screening for a larger percentage of clients, and having consulted an eye-care professional about the care of clients. The odds of the respondents perceived to be comfortable in performing visual screening were 3.4 times greater for those who agreed that their entry-level occupational therapy program adequately prepared them to provide low vision services than for those who disagreed with the statement. The odds that the respondents were comfortable providing low vision screening increased by 60% with every 20% increase in the number of clients for whom they performed visual screening. The odds that the practitioners were comfortable performing visual screening were 2.8 times greater for those who had previously consulted an eye-care professional about the care of clients than for those who had never consulted an eye-care professional (see Table 2).
Factors Associated With Practitioners’ Comfort Level in Providing Interventions for Clients With Low Vision
Univariate analyses indicated that respondents who felt occupational therapy school had adequately prepared them to provide low vision services and who had provided interventions to a larger percentage of clients with low vision were more likely to be comfortable providing interventions for clients with low vision (all ps < .05; Table 3).
Univariate and Multivariate Analyses Examining Factors Associated With Occupational Therapy Practitioners’ Comfort Level in Providing Low Vision Intervention
Note. Blank cells indicate that the variable was not included in the multivariate model. Adj OR = adjusted OR; CI = confidence interval; OR = odds ratio.
Multivariate analyses, controlling for background characteristics, indicated that factors significantly associated with perceived comfort in providing interventions for clients with low vision were adequate preparation in occupational therapy school, having provided interventions to a larger percentage of clients with low vision, and having an eye-care professional to whom they could refer clients with low vision. The odds that respondents were comfortable providing interventions for clients with low vision (1) were 8.5 times greater for those who agreed that their entry-level occupational therapy program adequately prepared them to provide low vision services than for those who disagreed with the statement; (2) increased by a factor of about 3 with every 20% increase in the number of clients for whom they provided intervention; and (3) were 3.4 times greater for those who had an eye-care professional to whom they could refer clients with low vision than for those who did not have such an eye-care professional available (see Table 3).
Discussion
Findings from this study revealed a significant relationship between respondents’ perceived preparation in occupational therapy school and their comfort level in providing services to clients with low vision, thereby affirming the importance of entry-level education in this practice area. Although low vision is being addressed in occupational therapy curricula, this study revealed that more needs to be done in entry-level education because only about half of the respondents perceived that their occupational therapy education adequately prepared them to provide low vision services. It appears that respondents who felt their occupational therapy education adequately prepared them were recent graduates (within 5 yr), a pattern consistent with the appropriate action taken by academic programs since the establishment of Medicare coverage for low vision services in 2002. Conversely, it was not years of clinical experience that were positively associated with respondents’ comfort level but the proportion of clients to whom the respondents had provided low vision services.
One practical way to improve the comfort level of occupational therapy practitioners in the provision of low vision services is to enhance the low vision content in the entry-level occupational therapy curriculum. Identification of an eye-care professional (i.e., optometrist or ophthalmologist) in the community to whom practitioners can refer clients with low vision and consultation with an eye-care professional about the care of clients were significantly associated with the respondents’ comfort level in providing low vision services. However, fewer than 45% of the respondents had ever consulted an eye-care professional or referred clients to that person on a regular basis. The occupational therapy academic curriculum should include content on strategies to identify eye-care professionals in the community and form partnerships with them. One respondent described an experience of how this partnership worked: By inviting an eye-care doctor to the facility to provide in-service education to the staff, a two-way referral process was established.
Further study should include surveying occupational therapy practitioners to suggest topics they consider to be most important when providing services for clients with low vision and incorporating this information into the entry-level curriculum. This practice may improve the uniformity of the essential core skills of graduates in the area of low vision services.
Even though “attended continuing education” was not included in the final model, continuing education in low vision was univariately associated with comfort level in performing visual screening. This avenue of training is especially important for practitioners who graduated prior to their entry-level program adding low vision content in the curriculum.
Although comfort level is not an indicator of competence or knowledge, it is an essential component in characterizing competent practitioners (Woodard, Havercamp, Zwygart, & Perkins, 2012). Given that our study did not investigate competence, we could not conclude that comfort level is equivalent to competence. Future study is needed to determine the relationship between occupational therapy practitioners’ comfort and competence levels (i.e., knowledge and performance skills) in providing low vision services.
Limitations
Without a direct contact approach for data collection, results of this study should be interpreted with caution. Because of potential selection and nonresponse biases, our study may have drawn more respondents who were interested in low vision. Findings may overestimate occupational therapy practitioners’ comfort level because respondents may have more experience or knowledge than other practitioners in working with persons with low vision.
We acknowledge that the sample in this study is a convenience sample, which may or may not represent the occupational therapy practitioner population; however, it should be noted that the professional background and practice characteristics (including distribution of occupational therapists vs. occupational therapy assistants, education, years of practice experience, practice settings, and age groups of clients served) of the respondents in this study are similar to those reported in the AOTA 2010 Occupational Therapy Compensation and Workforce Report (American Occupational Therapy Association, 2010), which suggests that the sample was a fair representation of occupational therapy practitioners in the United States. Confirmation of results reported in this study should come with a population study using state licensure databases.
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice:
Given that the respondents’ comfort level in providing low vision services was associated with perceived preparation in occupational therapy school and partnership with an eye-care professional, we suggest that low vision content in the entry-level occupational therapy curriculum include strategies on how to identify and partner with eye-care professionals who may assist practitioners in providing better quality services for clients with low vision.
Along with expanded low vision content in entry-level occupational therapy curriculum, it is also important for practitioners to seek out continuing education opportunities in low vision.
Footnotes
Acknowledgment
We thank all the occupational therapy practitioners who participated in our survey.