Abstract
Professions are built on particular texts that define their core contributions to society (Sullivan, 2005). Through educational practices, core texts are preserved and disseminated or obscured and eroded. Educational practices that illumine and therefore preserve a profession’s core help students acquire that field’s characteristic perspectives and practices. When educational practices obscure a field’s core, practitioners lose that field’s distinctive perspective and are at risk of becoming uncritical responders to the demands of various stakeholders (Bruner, 1996; Fink, 2003; Paul, 1995). It is therefore vital that each profession understand the educational practices by which its core subject is preserved and disseminated and by which its practitioners gain the perspective, understanding, character, and skill necessary for that profession.
In occupational therapy, the term core text has been referred to as the field’s core subject (Hooper et al., 2014), which is now well established as occupation as a source of health, well-being, and life satisfaction (American Occupational Therapy Association, 1995). Wilcock (2005) asserted, however, that the profession has not fully realized occupation in practice because the concept has not been fully realized in education; instead, occupation is often obscured by other important, but not core, topics such as activities of daily living, standardized assessments, or evidence-based practice. These and other topics, though important, can be mistaken for the core focus of the profession, which is to help people “transcend difficulties and reach towards potential” through occupation (Wilcock, 2005, p. 10). It is therefore important to examine educational processes that intentionally portray occupation as the core subject.
Since the beginning of what has been referred to as the occupation paradigm, when leaders and scholars began to refocus the field on occupation (Kielhofner & Burke, 1977; Reilly, 1962; Yerxa, 1998a), and since the establishment of occupational science worldwide, knowledge of occupation has evolved in relation to, but also beyond, application to practice (Christiansen, Baum, & Bass-Haugen, 2005; Pierce, 2014). Going beyond application to practice, scholars have examined the complexity of occupation in relation to concepts including culture, meaning (Eakman & Eklund, 2012), identity (Christiansen, 1999; Christiansen et al., 2005), quality of life (Law, 2002), and transactionalism (Cutchin & Dickie, 2012). In relation to occupational therapy practice, scholars have elaborated models centered on occupation (Iwama, Thomson, & Macdonald, 2009; Law et al., 1996), established the efficacy and outcomes of occupation-based practice (Clark et al., 2012; Law, Baum, & Dunn, 2005), and differentiated occupations from purposeful and preparatory activities (Pierce, 2001; Price, 2014).
Although knowledge of occupation has grown substantially, potentially contributing to broad and deep depictions of occupation in education, the nature of those depictions has not been widely studied. Indeed, across a decade of scholarship, occupation was rarely explicitly integrated into educational approaches (Hooper, King, Wood, Bilics, & Gupta, 2013). Scholarship on occupation in education is limited to conceptual work and small-scale studies of instructional methods and course designs. Conceptual work in education has identified the relation of occupation to health as a core subject (Hooper et al., 2014) and a threshold concept (Fortune & Kennedy-Jones, 2014), thus promoting occupation as an organizing concept for curricula.
Studies of instructional methods used to teach occupation have highlighted formal methods such as service learning (Gitlow & Flecky, 2005; Vroman, Simmons, & Knight, 2010) and informal or improvisational methods such as orienting remarks, clinical stories, contradictory readings, particular content sequences, and inductively structured discussions (Hooper, 2006a). In studies of course design, Ikiugu and Rosso (2003) found that a course organized around occupational therapy philosophy and occupational science promoted learning about philosophy, the relation of theory to practice, the occupation paradigm, and occupation applied to practice. Similarly, Smallfield and Anderson (2008) found that a course on behavioral health in a rural agricultural population promoted learning about how the occupations of farmers and ranchers transacted with sociocultural, temporal, and physical contexts.
Three hypotheses elucidate the sparseness of scholarship on occupation in education. First, professions’ core subjects are largely taken for granted, and thus language has not evolved to guide research (Hooper et al., 2014). Second, perhaps until recently, an epistemological mismatch existed between traditional occupational therapy education and the view of knowledge inherent in learning about occupation (Hooper, 2006b). That is, traditional education, perhaps inadvertently, reflected knowledge as certain, whereas learning about occupation has depended on a view of knowledge as fluid and situational and, thus, on particular research paradigms. Third, because educators in the field are traditionally not immersed in educational theory and practice (Nolinske, 1999), the field’s capacity to translate the concept of occupation explicitly and clearly into learning activities is evolving, resulting in less opportunity for research. Nevertheless, Hooper et al. (2015) and Mitcham (2014) advocated for research that examines how occupation is portrayed, taught, and assessed. Examining how occupation is addressed can identify educational practices that illumine rather than obscure the field’s core concept.
In this article we present findings that were part of a larger study that examined how the core text of occupation was addressed in curricula across the United States (Krishnagiri, Hooper, Price, Taff, & Bilics, 2017). The larger study explored the following five research questions:
How is occupation addressed at the curriculum level?
How is occupation addressed at the instructional level?
What topics are taught in relation to occupation?
How is knowledge about occupation assessed?
What are the challenges to addressing occupation in education?
One finding from the larger study suggested that the degree to which occupation was explicit in teaching ranged from explicit to absent. In the present study, we explored the question “When occupation was taught explicitly, how was it depicted?”
Method
Design
For the larger study, we used a descriptive design that involved generic qualitative methods (Lichtman, 2013; Portney & Watkins, 2009). Generic or basic qualitative designs explore descriptions of external phenomena (rather than internal or cultural), such as, in this study, descriptions of addressing occupation. The study was approved by Colorado State University’s institutional review board.
Sampling and Participants
For the larger study, the researchers targeted a stratified random sample of 30 occupational therapy and occupational therapy assistant programs in the United States. Programs were stratified by geographic region, level of education, and Carnegie Classification of Institutions of Higher Education (2016). Programs were randomly selected from each stratification using an Internet-based random number generator. Invitations were sent to each program through email. Twenty-five programs (15 occupational therapy and 10 occupational therapy assistant) ultimately participated because findings were redundant or saturated prior to enrolling all 30 programs. Once enrolled, programs selected one to three faculty to be interviewed and to video record a teaching session. For this study, a subset of 8 programs was studied: Each described the importance of teaching occupation explicitly as its own concept, beyond applications to practice. Five were occupational therapy assistant programs, and 3 were occupational therapy programs. Each author had prior professional relationships with some of the participant programs; authors were assigned data from programs with which they were least familiar.
Data Collection
The first, second, and third authors individually conducted semistructured telephone interviews, lasting 60–90 min, with program directors or informants who had knowledge of the curriculum. The interview guide was piloted with three programs that were not participants in the actual study. At the conclusion of the interviews, interviewees submitted artifacts (e.g., program philosophies, curriculum designs, syllabi, assignments, examples of student work) and video recordings of instruction that exemplified teaching occupation. In all, the data set included 25 interviews, 16 videos, and 243 artifacts.
Data Analysis
Interviews were transcribed verbatim. For the larger study, we used a basic qualitative research analytic process involving both inductive and deductive approaches. Working in pairs, all authors conducted open coding on the interview and artifact data using Atlas.ti software (Version 6.2; Scientific Software Development, Berlin, Germany). The initial branches of the code tree emerged as occupation addressed, occupation not addressed, content, curriculum design, facets of occupation, contextual influences, instructional processes, outcomes expectations and measures, and resources. We kept research memos of impressions, questions, and reflexivity. The team discussed and refined codes until an extensive codebook was created for analysis (MacQueen, McLellan, Kay, & Milstein, 1998). Coded data were analyzed for recurring themes. Both codes and themes were used to deductively analyze artifact and video data.
The detailed methodology for the larger study has been published elsewhere (Hooper et al., 2014; Krishnagiri et al., 2017). For this study, a secondary inductive analysis was conducted on the interview data from the selected 8 schools. Occupational therapy and occupational therapy assistant programs were not analyzed separately because both met the same criterion for inclusion in this subset of articles: teaching occupation explicitly and beyond its application to practice. The results of this secondary analysis were then compared with the themes of the larger study and found to be highly congruent. To further address credibility, a colleague outside the team coded the 8 interviews independently; results were consistent across the two analyses.
Results
The overarching theme from this subset of 8 interviews was “occupation as a way of seeing,” meaning occupation was addressed as a perspective to be acquired. This perspective was further delineated into occupation as a lens for seeing self, others, and the profession. When occupation was addressed as a way of seeing self, educators created learning activities through which students explored how occupation had been an instrument in their own lives, helping them develop skills, relationships, meaning, identity, habits, and other characteristics. Addressing occupation as a way of seeing others involved learning experiences through which students observed and discussed how occupation was and had been a similar instrument in others’ lives. When educators addressed occupation as a way of seeing the profession, they created learning activities that emphasized occupation as the central purpose of occupational therapy. Often, ways of seeing self, others, and the profession overlapped in descriptions of a single learning activity. The overarching and subthemes were similar among the 5 occupational therapy assistant and the 3 occupational therapy programs.
Occupation as a Lens for Seeing Self
Educators consistently taught students about occupation as its own concept before applying it to therapy. Participant faculty felt it was imperative that students first see and understand occupation in their own lives and experiences; thus, students were given opportunities, often early in the curriculum, to explore occupation as a shaping force in their lives. Most participants had teaching stories similar to this educator’s:
They start out in their journaling . . . they’re summarizing what has been the power of occupations in their own lives. I would have to say the majority of them have a really clear understanding of the importance of occupation in their own lives. . . . They begin to look at, What brings change, development, growth in your own life? . . . What are the impacts of their activities in their lives? How is time consumed? How does context play a part in that?
Some assignments required students to learn a new and challenging occupation, such as a craft or sport. Students subsequently reflected on the learning process and how, through the occupational experience, they overcame challenges, made or did something that produced satisfaction, and even transformed their roles and identities:
The first thing I have them do is, they’re going to get to learn something that is meaningful to them that they’ve always wanted to do. Why? I want them to learn something unfamiliar, which is similar to what our clients have to do. . . . I want them to experience how occupation can serve to transform their personal roles. . . . They have to learn it within the confines of the course. And I make sure that it’s something that is going to take some time. They do a journal about “the hills and valleys,” I call it, about what it was like and how it transformed the roles.
This instructor provided experiences of what the instructor called “adaptation and transformation” through learning an occupation, believing that, as students understand themselves as occupational beings, they can understand others, namely their future clients, similarly.
Further, educators reported numerous assignments in which students reflected on their own cultures to understand how the historical, social, and physical contexts in which they were raised have shaped their values, occupational possibilities, and choices, asking, “Where do we derive our meaning, our values about an activity from a social, historical perspective, cultural perspective?”
Educators also assigned readings on the differences between cultural notions of activity and meaningful, context-situated occupation. On the basis of what they read, students wrote about the differences between occupation and activity:
They’re looking at both their personal experience of that activity and what is that sociocultural constructed perspective of that activity . . . between what are activities and what are occupations, and how are they similar and how are they different?
In sum, through various instructional strategies, such as performing an occupational self-analysis, journaling, learning an occupation, and reading, students reflected on how their occupations developed, changed, influenced their development, and shaped their roles and identities, with the aim of learning to see and see with occupation.
Occupation as a Lens for Seeing Others
Educators taught students—again, usually early in a curriculum—to understand others through the lens of occupation. Through interviews and observations, students explored the iterative relationship of occupation and meaning, development, and roles, among other aspects. In effect, students were taught to see others as occupational beings. Commonly, educators depicted learning experiences like this one:
They interview a family member or a friend about their occupations and how those have changed over time and then the impact that some of their occupations have had on them as a person and their development. . . .
Assignments often required students to interact with persons from backgrounds different from their own and explore how those backgrounds influenced occupations, opportunities, and choice. This multicultural perspective included persons with impairments, disease, or other social factors that might limit occupation:
They have to go out and experience different things in different [cultural] communities. It could also be attending a festival where they might talk to some of the people that are attending . . . and learn a little bit about the occupations that they do within their culture.
In sum, educators helped students cultivate a way of seeing others and their worlds through the lens of occupation; to do so involved apprehending occupation as its own concept beyond practice, experiencing themselves and others as occupational beings, and developing skills to explore occupation in others’ lives. This perspective formation, instructors felt, laid the foundation for embracing the ethos of occupational therapy and occupation-based practice.
Occupation as a Way of Seeing the Profession
Educators described three subcategories related to teaching occupation as a way of seeing the profession: (1) seeing the profession as a whole, (2) understanding occupational therapy practice, and (3) understanding academic content.
Seeing the Profession as a Whole.
During foundational courses, in which students were exposed to occupation in their own and others’ lives, coursework also focused on socializing students into occupational therapy’s culture, values, and philosophy:
They’re immersing themselves in their own personal occupations and then beginning to see occupations in the community and then beginning to think about occupations for people in the community. . . . [They’re seeing] this is what [occupational therapists] do.
Educators wanted students to see occupation as what makes the field distinct from other professions and as the outcome with which the profession is concerned. Instructors frequently used statements such as “It’s why we exist,” “Occupation is who we are,” and “[Occupational therapy] is about occupation” to convey their intentions to teach a perspective of the field through which students relate the various topics and skills taught:
We really do want them to use the concept of occupation to define who they are as clinicians . . . to understand everything else they learn. . . . How’s this related to something that makes human life worth doing or give real satisfaction to the people I’m working with?
Understanding Practice.
In the midst of teaching occupation as a way of seeing self and others, some educators also sprinkled in questions about practice, such as, How does engaging in occupation produce therapy outcomes? Some assignments required analysis of environmental factors that limit participation in occupation, a process that consequently helped students see practice as enabling occupation through altering contexts and environments. Educators prompted perceptions of occupation in practice with statements such as, “You’ve got to ask your client what’s important to them. [It] doesn’t matter what you want them to do; we need to know what they need to do to make themselves happy.” They also asked questions:
Who is your client? What are the occupations they participate in? What is it important to know? . . . What do they do? And do they have family members [and] social commitments, and do they go to church? And what is their network . . . ?
In addition, instructors frequently asked students to participate in occupational experiences with simulated impairments to help students see the impact impairments have on occupation, again shaping a perspective of practice as centrally focused on occupation:
If you’ve only got the use of one arm, how will you be able to do the things you need to do? Which areas of occupation are going to be the most heavily impacted if you can no longer drive, or you can’t see . . . ?
Sometimes the experiences required students to adapt themselves or the occupation to allow participation and to reflect on the healing and transformation that engaging in occupation promoted:
There’s a case with health and wellness deficits . . . we begin looking at the constructs of the activity with an individual with . . . deficits in a context. . . . Within that triad, how does occupation actually bring about change? . . . They develop more of an idea of what is the power of occupation. . . . What is the potential that that occupation has for that individual?
In sum, although educators taught occupation as a concept unto itself apart from therapy, they used occupational experiences and created additional ones to help shape students’ ways of seeing practice as rooted in occupation.
Seeing Academic Content.
Educators wanted students to see content, especially client-factor content such as neuromotor and cognitive factors, through the lens of occupation. Assignments often tried to build in an occupational perspective on analyzing body structures and functions and performance skills: “They actually begin doing a kind of an activity analysis from a neuromotor perspective, so they begin to understand that all activities and occupations have that kind of motoric component.”
In sum, the educators in this study who explicitly taught occupation created learning experiences they hoped would indoctrinate students in an occupational perspective. They wanted students to (1) perceive their own and others’ lives as requiring and resulting from occupation situated in particular places and times and (2) perceive occupation as the central focus of the profession in both education and practice.
Discussion
For this study, we examined a subset of 8 programs from the 25 in the larger study that offered illuminating examples of addressing occupation as its own concept beyond therapy. It was clear that the key informants from these 8 programs were committed to occupation as the core of occupational therapy education. In their dedication to teaching occupation as the core, these educators were knowledgeable about occupation as a complex, multidimensional concept. The overarching finding that occupation was addressed as a way of seeing demonstrated that faculty, in their hope that students adopt it as a worldview, valued occupation as the field’s central tenet or core subject. This aim aligns with Yerxa’s (1998b) premise that curricula and instruction “provide learners with a perspective of humans as agents, embedded in culture and history. This will create the . . . pair of glasses necessary for the study of occupation, assuring that professional education will not limit students’ vision” (p. 369). Teaching occupation as a way of seeing is congruent with helping students gain “a pair of glasses”—an occupational perspective that has been promoted in the literature for decades (e.g., see Kielhofner & Burke, 1977).
Given the emphasis on shaping students’ perspectives, an important question becomes, If occupation is taught in part as a way of seeing, with the aim of forming students’ perspectives on humans and the profession, then upon what theoretical basis might we build such teaching? Three concepts from the education literature helped frame the present findings on teaching occupation as a way of seeing: subject-centered learning, threshold concepts, and perspective formation through transformative learning.
Subject-centered learning is based on the premise that professions have a core text (Sullivan, 2005) or a core subject (Hooper et al., 2014). The core subject serves as a “pair of glasses” on learning and research in a profession, shaping the shared perspective of the professional community. Educators in this study were committed to teaching occupation as the central idea and shared perspective of the profession and as the field’s raison d’être.
In addition to a core subject, scholars have also conceptualized occupation as a threshold concept for occupational therapy (e.g., Fortune & Kennedy-Jones, 2014). In educational research, threshold concepts are defined as “concepts that bind a subject together, being fundamental to ways of thinking and practicing in that discipline” (Land, Cousin, Meyer, & Davies, 2005, p. 54). Threshold concepts change students’ ways of seeing. When taught effectively, students internalize threshold concepts, a process that transforms their perspectives and enables them to systematically integrate varied topics and skills. Conversely, students who have not internalized threshold concepts or established the field’s perspective use new knowledge and skills in a fragmented fashion (Land et al., 2005).
Learning a field’s core subject and threshold concepts, therefore, is related to assuming the perspectives of a profession and thus involves perspective formation (Matheson, 2013). In the field of education, perspective formation has been linked with transformative learning, which occurs when teaching strategies promote transformation of existing “habits of mind” (Matheson, 2013, p. 40) or the assumptions through which people see and interpret their experiences. Educators integrate the core subject with pedagogies that facilitate transformative learning (Zepke, 2013). For example, Smallfield and Anderson (2008) created a transformative learning experience through a course in which students interacted with farmers and ranchers to understand their sociocultural, temporal, and physical contexts and promoted their occupational participation. These learning opportunities addressed occupation as a way of seeing others and transformed the students’ perspectives. Similarly, participants in our study aimed to help students adopt a way of seeing occupation in their own and others’ lives. Therefore, although few in the study named their approach as such, they approximated transformative learning when teaching the concept of occupation as perspective formation.
This study’s findings reflect concepts from education that can guide teaching occupation as a way of seeing: subject-centered learning, threshold concepts, and perspective formation through transformative learning. Although not yet developed as such, these concepts are pertinent as theoretical underpinnings for teaching occupation as the shared perspective of the profession. Further theory-building research is needed to elaborate these concepts and advance how teaching shapes ways of seeing within occupational therapy.
Limitations
Interviews were conducted with persons designated as being knowledgeable of each curriculum, which included mostly program directors. Additional interviews with other faculty members may have provided additional information regarding how occupation was taught. Student perspectives and learning outcomes were not examined. Future studies should include data from diverse faculty perspectives and students’ experiences and learning outcomes related to acquiring occupation as a perspective, or way of seeing themselves, others, and the profession.
Implications for Occupational Therapy Education Practice
Implications from this study of 8 programs that taught occupation as a concept unto itself separate from practice suggest that occupation is not only a concept and an instrument used for health; it is also a perspective educators help students acquire. Therefore, the following commitments may support teaching the field’s core subject:
Developing deep understandings of the complex, multidimensional concept of occupation through immersion in the body of work from occupational science and other fields;
Decoupling occupation from therapy for a portion of coursework;
Building courses on theoretical foundations that involve subject-centered learning, threshold concepts, and perspective formation through transformative learning as these each relate to acquiring ways of seeing;
Conducting theory-building research to operationalize what is meant by an occupational perspective and how it forms; and
Reflecting on teaching to illumine how explicitly occupation is taught and on how to assess students’ acquisition of an occupational perspective.
Conclusion
Many scholars have promoted occupation as the central organizing idea for occupational therapy curricula, believed to be a means to produce autonomous professionals and a self-directed profession (Yerxa, 1998b). Many educators have consequently embraced the importance of occupation at the center of learning and have developed innovative instructional strategies to teach an occupational perspective. Moreover, the science of occupation has developed substantially, elaborating an occupational perspective. This study identified three approaches faculty participants used in teaching occupation: (1) developing opportunities for students to experience novel occupations and their transformative processes, (2) developing learning experiences for students to understand others as occupational beings in need of and shaped by occupation, and (3) developing instructional strategies for students to understand the process and outcomes of occupational therapy practice through an occupational perspective. The examples from these 8 programs demonstrated a diligence to teach deep understandings of occupation; these examples may be used by other faculty to more explicitly address occupation.
In this critical period in occupational therapy history and the era of health care reform, it is important to articulate the distinct value of the profession’s services. Promoting health through engagement in occupation as the process and the outcome of occupational therapy requires a deep understanding of the complex and multidimensional concept of occupation and effective instructional processes to convey occupation as “the thing we do.” This commitment will produce occupational therapy graduates with strong professional identities who can articulate to clients, families, professionals, and the public the health-promoting aspects of occupation and who can see clients as occupational beings and create the therapeutic conditions to promote adaptation and enable occupation.
Footnotes
Acknowledgments
We thank William Roberts from Colorado State University for his insights as a peer debriefer for data analysis. We also acknowledge the humor, intellect, and valuable insights of the late Maralynne Mitcham, who graced our team for too short a time. This study was supported by a collaborative initiative of the Society for the Study of Occupation—USA and the American Occupational Therapy Foundation. We thank Beth Cardell from the University of Utah for her review of previous versions of this article.