Abstract
The concept of occupation has experienced a renewal in the past 3 decades and is widely accepted as the core subject in occupational therapy. Professional education has a critical stewardship role in continually enhancing how occupation is taught and understood to enrich new occupational therapy practitioners' ability to grasp the purpose of the profession and reason clinically in complex practice environments. The authors discuss three questions that frame approaches educators can use to effectively centralize occupation in teaching and learning environments: (1) To what degree is a curriculum and its courses and class sessions subject centered? (2) To what degree do instructional processes create links to occupation? and (3) To what degree do instructional processes expose and promote complex ways of knowing needed for learning occupation? Keeping occupation in the foreground is important to facilitate new research, teaching methods, and curricular relevance to practice.
At the end of the 20th century, occupational therapy experienced a “renaissance of occupation,” referring to a time of recapturing rich and fruitful scholarship, education, and discourse centered on the field’s core concept of occupation (Whiteford, Townsend, & Hocking, 2000, p. 61). In response to that renaissance, education scholars called for stronger “occupation-centered education,” meaning stronger curricular designs and teaching approaches that explicitly place occupation at the center of all learning (Wood, 1998, p. 322). In essence, these scholars called on education to play a central role in sustaining and expanding occupation’s prominence in occupational therapy. To that end, among many strategies, educational standards were established worldwide requiring that occupation be taught as an “essential area of knowledge” in all occupational therapy programs (Hocking & Ness, 2002, p. 10).
Although nearly 2 decades of attention have now been given to centralizing the concept of occupation, clearly establishing it as the field’s core, education still plays an important stewardship role in keeping it so and continually enhancing how occupation is taught, understood, and applied in practice. Moreover, in the same 2 decades, the evolution of ideas in the field of higher education broadly, and in occupational therapy education specifically, has offered new tools to support this stewardship role. Specific approaches are now available that can guide occupational therapy’s assessment of whether and to what extent its curricular and teaching processes make occupation as central and explicit as possible.
In this article, we argue that occupation-centered education is not a fait accompli and cannot be taken for granted; rather, diligence in building educational programs and learning experiences that have occupation as the core requires continual renewal as new insights become available. Therefore, we advocate for a renewed commitment to continual assessment that ensures occupation is the explicit focus of education. By assessment, we refer to the process of collecting data that inform faculty about what is actually being taught and learned and where improvements are needed (Fink, 2013). Three questions, informed by contemporary understandings of subject-centered education, can help sustain and energize assessment that is focused on how effectively occupation is centralized: (1) To what degree is a curriculum and its courses and class sessions subject centered? (2) To what degree do instructional processes create links to occupation? and (3) To what degree do instructional processes expose and promote complex ways of knowing needed for learning occupation?
Subject-Centered Curricula, Courses, and Class Sessions
A profession’s distinct body of knowledge is created not from learning a constellation of discrete topics but through the explicit integration of those topics with the profession’s core subject (Hooper, Krishnagiri, et al., 2014). Topics are the explicit focus of a course or class; they are usually listed in syllabi and form the basis for readings, discussions, and lectures (Hooper, Greene, & Sample, 2014). A core subject focuses on the central concern or concept around which a professional community is formed and that defines the community’s knowledge and service (Hooper, Krishnagiri, et al., 2014). In other words, although many health professions require understanding of interprofessional topics such as anatomy, physiology, neuroscience, kinesiology, or evidence-based practice, these topical areas of knowledge are not what make each profession distinctive. Rather, it is how such topics are reformulated in relation to a profession’s core subject that makes the health profession unique (Sullivan, 2005). For instance, occupational therapy practitioners learn neuroscience because of its relation to the way humans select and participate in daily occupations. Physical therapists learn neuroscience because of its relation to how humans move with ease or limitation (Hooper, Krishnagiri, et al., 2014). In each instance, neuroscience’s relevance is revealed in its intersection with the profession’s unique core.
Therefore, to convey occupational therapy’s distinct knowledge base to students, it makes sense to organize a curriculum, course, and class session not only in relation to topics but also in relation to how those topics intersect with the concept of occupation. Such an approach to curriculum, course, and class design is called subject-centered education (Hooper, 2010; Palmer, 1998). Curricula, courses, and classes are designed, in part, to require students to integrate the topics of the day—whether they be neuroscience, research evidence, ethics, interdisciplinary collaboration, interpersonal interaction, or client-centered care—with the subject of occupation. It follows that if such connection making is the focus of educational designs, then continual assessment of the curriculum, course, and class involves evaluation of how effectively such connection making is accomplished and by what processes. Educational assessment may include questions such as,
Do the curriculum, course, and class session objectives target students’ abilities to make connections to occupation?
What curricular, course, and class processes worked well to ensure students explicitly made those connections?
What curriculum, course, and class assessment strategies held students accountable for linking topics to occupation, not only learning discrete topics?
How might such connections and assessments of learning become even more explicit and focused on students’ ability to relate topics to occupation?
Instructional Processes’ Support of Subject-Centered Education
Subject-centered education allows faculty to use the core subject as a well-sharpened scalpel to carefully excise unnecessary content and learning assessments and clarify only what is essential. Once carefully delineated, faculty may then select instructional processes and assessment strategies that foster connectivity. It follows that continual evaluation of instructional processes will involve assessment of how directly and explicitly those processes have fostered links to occupation. Within any course or class session, the presence of links to occupation may be absent, implicit, or explicit because the relation of topics to occupation may be unconnected, connected, or integrated (Mitcham, 2014). One can envision six descriptors as the horizontal and vertical axes of a 3 × 3 grid depicting each interaction as a particular condition for instruction (Figure 1):
Condition A: Absent–unconnected
Condition B: Implicit–connected
Condition C: Explicit–integrated.
Pedagogical choices for relating the core subject to course topics.
These three conditions may be used to guide assessment in a curriculum, course, or class session. The sections that follow illustrate analysis of courses using each of the three conditions.
Condition A: Absent–Unconnected
An anatomy course for occupational therapy students focuses on learning outcomes related to students’ understanding of the body structures of nerves, bones, muscles, and insertions. Lecture is the major delivery method with support from real and virtual models; perhaps a dissection lab is available. Student assignments include reading the textbook and lab manual and performing self-directed activities in lab, usually in a group of peers; student learning outcomes are assessed with multiple-choice and lab examinations. However, students are not expected to apply anatomical knowledge to engagement in occupation in environmental contexts.
In this case, anatomy is a topic taught as foundational knowledge, and it is assumed that students need the facts before applying them to the core subject of the profession. Because the course is designed in this manner, it cannot address the core subject or connect the topic to the core subject. Therefore, it misses an opportunity for students to connect anatomical concepts to everyday occupation and thereby understand how this content relates to their chosen profession.
Condition B: Implicit–Connected
An introduction to occupational therapy course targets learning outcomes related to students’ understanding of occupational therapy philosophy and theory. Experiential activities, discussion, and reflection are the key delivery methods. The core subject is implicitly subsumed within philosophy and theory and within community experiences and explorations of what occupational therapy practitioners do in different practice settings. For example, students may be asked to prepare the infamous 15-second elevator speech on “What is occupational therapy?” or to analyze a given occupation and write a synopsis. In these instances, students must apply occupation-related concepts in the face of incomplete understanding. The concept of occupation itself is “jumped over” or assumed to be evident in conducting an occupational analysis; to educators who have habitually made the connection for years, it may simply seem obvious.
Because of the educators’ assumptions, the instructional design does not explicitly link the skill of analyzing an occupation to the subject of occupation itself, and the onus falls on students to make the connections with no additional or explicit instruction or assessment. The result is a risky assumption that students will make the necessary connections and integrate the construct of occupation into occupational therapy content. In such a scenario, occupational therapy is connected to occupation or vice versa but by a tenuous thread.
Condition C: Explicit–Integrated
A health care policy course targets learning outcomes related to students’ ability to demonstrate an occupational perspective of policy by explicitly linking the legislative and policy process to occupation. Students work in teams to develop arguments that go beyond general social justice to clearly understand and articulate how people’s occupations are affected by the presence or lack of policies such as the Americans With Disabilities Act of 1990 (Pub. L. 101–336), the Voting Accessibility for the Elderly and Handicapped Act of 1984 (Pub. L. 98–435), or the Air Carrier Access Act of 1986 (Pub. L. 99–435). This kind of instructional design promotes connectivity between the topic and the subject, that is, between legislative processes and their subsequent effects on what people can do each day, thereby opening possibilities for learning the unique viewpoint of occupational therapy.
Summary
These three examples illustrate that time spent on instructional design and decision making is vital for effective integration of the core subject throughout a curriculum, course, and class session. The focus of assessment is, ideally, to design more experiences of Condition C throughout the curriculum.
Student Engagement in Complex Ways of Knowing
Myriad connections may be made between topics and occupation, especially when making those connections in response to the situations of individuals and communities in practice contexts. Therefore, subject-centered education is equivalent to Schön’s (1987) premise that the problems encountered in practice present themselves as “messy, indeterminate situations” for which there is not one clear solution (p. 4). To prepare students for these messy experiences in which discernment, rather than simply getting the right answer, is essential, educators design learning experiences in which students face indeterminate and complex issues and engage in an in-the-moment, in-the-situation form of knowing. To succeed in such experiences requires that students possess a certain level of awareness that for most practice situations, no prescribed “right” approach exists. When students develop this awareness and fully embrace the role of integrating multiple viewpoints and approaches to discern what to do, they have acquired a specific way of knowing (Baxter Magolda, 2014b).
It takes students some time and maturation to accept knowledge as conditional and learn to draw upon multiple incomplete viewpoints to decide for themselves what course of action to take (Baxter Magolda, 2014a). This maturation process often begins with students seeing knowledge as absolute. Absolute knowing is focused on acquiring information as certain and unquestioned from experts in the field. For example, using absolute knowing, students may focus on learning the discrete categories in the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association, 2014) rather than the transactions among them that vary constantly over the course of a day in clients’ lives. Education can inadvertently reinforce views of knowledge as absolute through instructional design that is heavy on memorization, practice of procedures, passive receipt of information, teacher-centered instruction, and examination-focused assessments.
As students mature, they come to understand and accept that knowledge is neither absolute nor static (Baxter Magolda, 2014a). This awareness indicates a shift from absolute knowing toward contextual knowing, the belief that knowledge is multifaceted and is dependent on and crafted within situations. Education should intentionally promote students’ maturity toward contextual knowing because this approach is consistent with practice demands. Opportunities for maturing views of knowledge may be created through instructional design that emphasizes multiple and conflicting viewpoints and sources, critique, integration, justification of selected positions and decisions, and continual revisions of ideas as new evidence and experiences emerge, among other learning processes.
In the case of learning the Framework, for example, students may examine how and why the document evolved over time. They may be assigned readings that present other views of the environment, categorize occupation differently, or challenge categorization altogether. They may be assigned a case study of a person for whom few of the areas of occupation in the Framework actually constitute occupation. An assignment may require that students document specific transactions among categories and how the transactions vary. In other words, learning experiences that illuminate how content is evolving, contested, and situational have been shown to promote shifts toward contextual knowing (Baxter Magolda, Meszaros, & Creamer, 2012).
Supplementary to students’ development of contextual views of knowledge, Biesta (2007) distinguished, in a Deweyian fashion, knowing from knowledge. Knowing is the means, whereas knowledge is an end product. Knowing is inquiry into things “as lived” in the moment at which the process of learning and solving problems is the focus (Boyles, 2006). An education focused on the process of knowing helps students acquire abilities to respond “in those situations in which we are not sure how to act” (Biesta, 2007, p. 13), a crucial component of professional reasoning as described by Schell (2014).
In sum, subject-centered education involves special attention to knowing and to the process of building linkages between topics and occupation, yet holding those linkages tentative and molding them to specific situations in practice. Subject-centered education thus depends on views of knowledge as contextual. This approach therefore can have a built-in capacity to develop students’ ways of knowing, preparing them for ways of knowing in practice.
Ways of knowing thus become a third tool for assessment of educational design and implementation. Assessment may include such questions as,
On a continuum from absolute to contextual, what views of knowledge are most commonly portrayed to students through assignments and assessment strategies?
To what degree do curriculum, course, and class session objectives require advanced ways of knowing?
To what degree are instructional processes consistent with challenging students toward views of knowledge as uncertain and tentative?
How are ways of knowing made explicit to students?
What strategies have been effective for moving students from absolute to contextual knowing?
Why the Conversation About Occupation-Centered Education Is Still Important
The importance of teaching occupation seems obvious and perhaps feels like a dated conversation. However, a profession’s core body of knowledge and its educational practices are not automatically connected or, if connected, do not remain so over time without due diligence (Smith & McCarthy, 2010). As early as 1960, Bruner observed that students regularly learn facets of a subject, often during introductory courses, but rarely engage with the “underlying structure or logic of the discipline itself” (p. 6). In other words, learning facets of a field’s core subject is not the same as learning and thinking with the core itself. Smith and McCarthy (2010) argued similarly that a curriculum can become so focused on the topics surrounding a field’s core subject that those topics can be mistaken for the core itself. In occupational therapy, Wilcock (2005) asserted that the core subject of occupation has been obscured by numerous important, but not core, topics such as evidence-based practice, technology, activities of daily living, and standardized assessments. Thus, occupational therapy curricula can, over time, reflect the dynamic explored by the German philosopher Wittgenstein (2001): “The aspects of things that are most important for us are hidden because of their simplicity and familiarity” (p. 129).
For many reasons, it is still imperative to engage in the conversation about how to make and keep occupation explicit in curricula. Primarily, when students fail to learn and think with the core subject, they are limited in their ability to grasp the profession as a whole, reason independently within it, collaborate with and not duplicate the work of other professions, and articulate and deliver the core subject across a variety of practice contexts (Paul, 1995). Without occupation as the core organizing principle of a curriculum, educators and students alike can struggle to delimit and cohere what can be an overwhelming number of topics (Yerxa, 1998). Students are often unclear about why or how so many topics contribute to an occupational therapy view of humans and health and tend to “turn [the topics] into ends themselves” rather than a means for understanding dimensions of the central organizing subject, occupation (Whiteford & Wilcock, 2001). A deep understanding of the core subject of one’s field contributes to a strong professional identity and distinctive contribution to health care.
Beyond the benefits and cautions related to student outcomes, new conceptual territory remains to be gained by engaging in the conversation. Working out linkages among any number of curricular topics and the concept of occupation would bring clarity to the meaning of occupation- or subject-centered education and open new areas of educational research. Grappling with the specific interactions among topics and occupation would simultaneously expand understandings of the concept itself, thereby also benefiting occupational therapy and occupational science. Imagine a line of scholarship, for example, on what it means to teach the topics of anatomy or neuroscience as they directly relate to the subject of occupation. In what ways does this teaching focus extend beyond naming the anatomical features that support or limit occupational performance? Could it include, for example, the ways in which physical aspects of performance emerge and organize in direct response to the occupation being performed in a given context? Gaining clarity could change what is taught, how it is taught, and how learning is assessed. Such clarity may help graduates carry occupation into practices where a priority is placed on these topics.
Closer to home, and maybe even more challenging, further clarity is needed to understand what it means to teach occupational therapy topics, such as the Framework or activities of daily living, as they directly relate to the subject of occupation. It is easy to assume that learning these topics is equivalent to learning the subject of occupation. Imagine a line of scholarship that explored that assumption. In sum, engaging in the occupation-centered conversation is not old or over; however, a need exists to move it into new questions, scholarship, and research.
Conclusion
It has long been argued and accepted that deeply understanding the concept of occupation is essential knowledge for occupational therapy practitioners and thus for the programs that educate them. What that means, though—that occupation is the essential core of education and practice—is still evolving. Assessing how and how explicitly occupation is being addressed is also still evolving. Therefore, there is a need for continued diligence in the form of assessment, scholarship, and research to keep developing what is meant and achieved by occupation-centered education. The approach of subject-centered education can be a start for recommitting to and deepening reflection, assessment, and research on the meaning and processes of centering learning on occupation.
Footnotes
Acknowledgments
The authors thank Wendy Wood for her review of earlier drafts of the manuscript.