Curriculum-Level Strategies That U.S. Occupational Therapy Programs Use to Address Occupation: A Qualitative Study

Research Design

The larger study incorporated both qualitative and survey methods in a descriptive design. This article reports a portion of the qualitative methods using a basic or generic approach. Generic qualitative research refers to studies that are not clearly matched to established methodologies; therefore, the approach is often defined in the negative: research that is not focused on culture (ethnography), building theory (grounded theory), understanding the inner experiences of a phenomenon (phenomenology), or a bounded case study (Kahlke, 2014). The generic qualitative approach subdivides into the qualitative descriptive approach, used to produce “low-inference description,” and the interpretive description approach, used to produce evidence for practice (Kahlke, 2014, pp. 40–41). In generic qualitative work, researchers are interested more “in the actual outer-world content” or “real-world events and processes” than they are in inner subjectivities and cultural meanings (Percy, Kostere, & Kostere, 2015, pp. 78–79). Our primary interest was in reports of the outer-world processes used to address occupation. This study was approved by the lead author’s (B. Hooper) institutional review board.

Sampling and Participants

To obtain broad representation, all occupational therapy and occupational therapy assistant programs in the United States were stratified by geographical region and the Carnegie Classification of Institutions of Higher Education (n.d.). Computer-generated random sampling was used to identify programs that were subsequently invited via email to participate in the study. Some programs did not respond, and others declined because of time constraints, being in the midst of curricular revisions, or not teaching a course that addressed occupation at the time of the study. Random sampling continued until 25 programs consented (15 occupational therapy and 10 occupational therapy assistant). The study initially targeted 30 programs, but saturation, or the repetition of findings, occurred after analyzing approximately 20 programs. Five more programs were analyzed to examine the team’s decision around saturation and ensure adequate representation from both groups.

After giving consent, each program identified one person to be interviewed who had direct knowledge of the curriculum design, usually the program director. Because of shared responsibility for curriculum design, one program chose two people to be interviewed, and one program chose three people, bringing the total number of interviewees to 28. Then, 16 programs identified one additional person who recorded a classroom session that represented teaching occupation, bringing the total number of participants to 44. Demographic data were not collected, but owing to the criteria that participants be able to speak to the curriculum design, all participants were seasoned educators.

Data Collection

Three types of data were collected: interviews, artifacts, and video recordings. The first, second, and third authors (B. Hooper, S. Krishnagiri, P. Price) individually conducted 25 semistructured interviews through 60- to 90-min recorded telephone conversations. The interview protocol was first piloted on three programs outside those included in the study. The protocol asked participants to describe the curriculum overall, specific examples of how the curriculum addressed occupation, how students’ knowledge of occupation was assessed, and any challenges to addressing occupation.

Some interviewees were known professionally to the interviewers. When possible, interviewers were assigned programs with which they were unfamiliar. Two interviewees were known by and interviewed by the first author; in these cases, the professional relationship seemed to support rich dialogue about curricula. Participants also submitted 245 artifacts (e.g., syllabi, assignments, written curriculum, and teaching philosophies) and 16 video recordings of teaching, selected because the class session reflected how occupation was addressed in the program.

Data Analysis

Interviews were transcribed verbatim; interview, artifact, and video data were entered into the qualitative software program ATLAS.ti (Version 6.2; Scientific Software Development, Berlin, Germany) for analysis. Interview data were analyzed inductively. Artifact and video data were analyzed deductively while still allowing for new or revised codes.

Six researchers individually read the same interviews, attaching conceptual labels, or codes, to text that was relevant to the research questions. Interviews from both occupational therapy and occupational therapy assistant programs were selected for this initial coding process. The team refined and defined inductively developed codes, leading to creation of a code book. After establishing shared understandings of codes and their uses, interviews were distributed among pairs of researchers who independently coded each interview and then discussed code assignment until the pair reached consensus. Code decisions were brought to the team for discussion. The inductively developed 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. No systematic comparison of occupational therapy and occupational therapy assistant programs was conducted because there was no apparent variation during the coding process.

Once all interviews were coded, the researchers compiled texts associated with each code and analyzed the range of responses per code. Similar codes were collapsed into categories and assigned to the research question they most directly addressed. Finally, themes were identified that cut across the data.

Researchers used the codes and themes from the interviews to deductively analyze the artifacts, though codes were refined and new codes were developed that were unique to the artifacts. Researchers also deductively coded video data. Researcher pairs analyzed sequential 10-min segments of each video and assigned themes prevalent in each segment. Themes developed from the interview data were largely substantiated in the video data. To support credibility, this study used triangulation of three data sources, triangulation of researchers, and negative case analysis (Marshall & Rossman, 2014). The negative cases involved instances in which occupation was not explicit, thus informing the findings on curricular challenges discussed later.

Addressing Occupation Through the Curriculum Infrastructure

Curriculum Threads: “Really, We Embrace Occupation Through Our Core Threads.”

Programs reported using “threads” to convey occupation to students and stakeholders. Faculty believed that certain themes and concepts have particular value to occupational therapy, hence they selected them as threads to emphasize across courses. These threads were either occupation focused or indistinctly related to occupation (Figure 1).

OPEN IN VIEWER

Figure 1.

Sample of curriculum threads related to occupation.

For some programs, curricular threads steered course and instructional design and were believed to help students say that occupation is “what we bring to the table; that’s our uniqueness.” For example, one program designed a seminar in which students studied one thread weekly. When studying the thread of occupation, students compared occupation and activity and “why it’s so important to us as OTs [occupational therapists].” Another program designed workshops organized around one thread annually to educate the community about the curriculum.

Challenges at the Level of Curriculum Infrastructure

“So much content to cover in such a short time” was a widespread challenge. Participants also noted that sorting and delineating content areas was difficult because occupation was intermingled with other concepts and domains of knowledge such as education and practice. In other words, descriptions of how occupation was addressed in the curriculum flowed back and forth from occupation to other concepts, including function, professional skills such as creating an occupational profile, and learning approaches such as service learning.

Consequently, at best, occupation held parity with other concepts and at worst was supplanted by them. For example, curricular threads, although reported as a strategy to convey occupation, included a mix of occupation-related, skills-related, and learning-related threads. Indeed, more threads fell into the latter two categories (see Column 1 in Figure 1). Educators may have themselves connected such threads as diversity, wellness, ethics, leadership, professional reasoning, adult learning, and service learning to occupation, but specific connections were seldom explicated. Sometimes the name given to a thread was associated with occupation, yet the meaning assigned to the thread and communicated to students was aligned with other concepts, such as function, that were presented as if they were synonymous with occupation. For example, a participant reported that occupation was a thread, but the thread was represented in terms of function and purposeful activity:

Similar to threads, some philosophies intermingled numerous concepts with occupation without stipulating exact connections, for example, statements such as, “Occupational therapy views the individual from a holistic perspective: an essential unity of mind and body acting as part of a social system.” Occupation as the mind–body–social system unifier was not made explicit, even though educators may have made that connection themselves. Additionally, program and learning philosophies were occasionally intermingled, such as when programs stated that “our philosophy and structure [are] transformative learning” or “our program philosophy is constructivism.” Philosophies sometimes intermingled professional skills such as helping students “be more self-directed and lifelong learners,” “be advocates for the profession,” “be ready for entry-level practice,” and “be a community of learners and consumers of research.” Overall, intermingling multiple knowledge domains, without articulating relationships to occupation, hampered how explicitly the concept of occupation could be realized through various identified strategies.

Another challenge involved the degree to which strategies drove learning. Most programs reported using curricular threads to convey occupation, yet several participants viewed curricular threads as existing largely “on paper only” for the self-study process, limiting the potential for threads to guide learning. Similarly, some stated that the curriculum graphic “probably hasn’t guided our curriculum that much.” And of philosophies, programs expressed disappointment with the degree to which written philosophies guided teaching and learning. One educator noted that it was challenging to discuss with colleagues “how we need to change, improve, [and] update to match the current philosophy.” Another explained that although the philosophy had “occupation as the premise,” it was difficult to enact because the local practice community “is very biomechanical in nature.”

Addressing Occupation Through Curriculum Implementation

Occupational therapy programs implemented instructional processes to address occupation, including informal and formal practice experiences, teaching science courses with an emphasis on occupation, and adopting service learning or other engaged learning approaches. These strategies went beyond instructional processes seen at the course and instructor level. Instructional-level strategies are reported elsewhere (Krishnagiri et al., 2017). Instructional strategies reported here were generally discussed and monitored by the program as a whole and often involved additional program resources and were, therefore, considered to be curriculum-level strategies implemented with students.

Challenges at the Level of Curriculum Implementation

A disconnect sometimes existed between what was intended and what was present in curriculum-level implementation strategies. For example, practice experiences and science teaching were intended to make occupation visible, yet its actual presence through those strategies was sometimes weak or missing. As reported by educators, monitored practice experiences were intended to elicit reflection on occupation or its possibilities in practice; however, the questions students answered about such experiences were unrelated to occupation (e.g., “What are you seeing on fieldwork?” “Describe how client-centered practice is implemented in the setting.” “What types of interventions are you seeing?”).

Educators seemed to take for granted that students would link actively engaging in experiential learning activities and occupation. It was as though educators expected students who were engaged with community agencies and populations to automatically learn about occupation. For example, students often developed group activities for improving social and coping skills, managing stress, and managing money. Yet, relating such activities to occupation was not a requirement of accompanying assignments. In addition, learning objectives and grading rubrics for community-based learning did not consistently or explicitly require students to link these experiences to knowledge of occupation. This challenge was also apparent in the teaching of medical sciences and intervention courses. For example, educators had an expectation that when they taught function, occupation was inherently understood, such as when certain levels of spinal cord injury were equated with tasks clients could be expected to do.

What Prevents Occupation From Being Fully Realized in Curricula?

When occupation was not fully manifest in a strategy, two factors seemed salient. First, there was a presumption that the intention for each strategy to convey occupation was materialized in its products. In the example of discussion boards during fieldwork, there was at times a presumption that learning materials (i.e., posted questions) manifested the aim of focusing students on occupation. The actual questions, however, did not always reflect that aim. Second, occupation was intermingled with, and not carefully differentiated from, a host of other important and relevant knowledge domains, rendering unclear how occupation relates to numerous other curricular topics. Threads, for example, reflected multiple knowledge domains. Without differentiating and specifying linkages among them, the threads may have inadvertently conveyed that occupation-related concepts were no more central than concepts such as active learning, communication, or advocacy.

Because of these two factors, knowledge of occupation has not, on a widespread scale, made its way fully to the explicit curriculum. First coined by Eisner (1985), the term explicit curriculum is that which is visible in curriculum documents, programs of study, course syllabi, and specific assignments and learning activities. In this study, occupation ranged from visible and integrated into curriculum materials to partially visible in some items and to not yet visible in others. Thus, knowledge of occupation remained somewhat in the implicit curriculum, residing in the intentions, values, assumptions, rituals, and discourses of a program. On the positive side, the implicit curriculum plays a significant role in student learning; on the downside, students can dismiss what is not made tangible in, or is at odds with, the concreteness of their everyday learning (Foster, Dahill, Golemon, & Tolentino, 2006). By at odds with, we mean that the patterns of discourse can emphasize occupation as the core of the field, yet the explicit curriculum emphasizes other knowledge domains without specifying how they link to occupation.

Alternatively, the stand-alone thread of advocacy and the stand-alone thread of occupational justice could be joined to convey that access to occupation is the focus of occupational therapy practitioners’ advocacy initiatives. Similarly, the thread of professional reasoning joined to the thread of occupation conveys that occupation is the hub of reasoning for occupational therapy practitioners. The thread of experiential learning joined to the thread of humanity’s occupational nature could convey that doing is central to students and clients alike. Without explicit connections, threads lose their capacity to manifest educators’ intentions for them—to address occupation and hold it foremost in the minds of students. Overall, curricular strategies reflected this dynamic: The many important topics practitioners must know vied for prominence with knowledge of occupation because their connections to occupation were not consistently explicated.

Do All Elements of a Curriculum Need to Link to Occupation?

Contributing to the implicit and explicit curricula being at odds seemed to be different understandings of how occupation relates to all the elements of a curriculum and required content. Although participants described occupation as the field’s central focus, they also described it as a separate content area that stood apart from, or alongside, other topics taught in science and intervention courses. Consequently, occupation was sometimes taught as its own course early in a program or integrated into theory courses but diminished as students progressed in the curriculum. Thus, this study raised a critical question: Do all elements of a curriculum and all topics need to be explicitly related to occupation? In other words, is occupation the all-encompassing concept under which curricular elements and topics are subsumed and to which they all directly relate? Or is it a foundation concept, a building block, upon which curricular elements and courses are placed but need not be directly linked?

This study suggested that there are different views about how extensively occupation ought to permeate a curriculum. One view was that some curricular elements and content can and should stand alone and apart from occupation—some interventions, for example. Another view held that occupation, as the primary concept, should connect with and be portrayed through all curricular elements, courses, and topics. Each viewpoint makes sense when examined in light of two approaches to a curriculum.

One curriculum and course design approach is that of “the logic of the content” (Wiggins & McTighe, 2005, p. 292). The premise here is that knowledge is acquired through accumulation of information about multiple content areas or topics. Curriculum and course design start with selecting content, which is largely determined by instructors’ preferences and by topics available in textbooks (Hansen, 2011). After content is selected, planning moves to what students need to do in a course. Assessment becomes focused on students’ acquisition of content. Thus, using the logic of the content, one can easily argue that courses and topics can stand alone and that connecting everything to occupation is superfluous. It also makes sense that occupation, being a content area, would be taught primarily through stand-alone courses.

Alternatively, curriculum and course design can be approached using “the logic of learning the content” (Wiggins & McTighe, 2005, p. 292). The premise here is that knowledge is acquired by continuously linking topics to a larger whole. Curriculum and course design start with articulating the conceptual big picture of the field and from there move to how courses and topics will link to that whole. Students are required to make connections between topics and the field’s core ideas and are assessed on their capacity to demonstrate these linkages. This process is referred to as whole-to-parts-to-whole learning, a key principle in how people learn and transfer knowledge. Connecting parts to the whole requires higher-level thinking as students synthesize, or construct, the content into a larger frame “that makes the pieces meaningful” (Wiggins & McTighe, 2005, p. 20). Thus, using the logic of learning the content, one can easily argue the importance of connecting curricular elements, courses, and topics to occupation.

Explored further, the logic of the content has at least two limitations (Hansen, 2011). First, stand-alone courses and topics engage lower levels of thinking because requirements for integration are limited. Second, having no core to which the stand-alone topics and courses connect, students can confuse which content requires simply familiarity and which is “crucial for conceptual understanding” (Hansen, 2011, p. 38). According to Hansen (2011), “unless big, overarching ideas that hold the content together are provided, the course [and curriculum] could appear as one long string of disconnected content bits. What is missing is a larger conceptual framework that makes the pieces meaningful” (p. 38). Thus, course content and instructional methods can be superb yet fail to produce profession-specific understandings if content does not link to the larger whole (Wiggins & McTighe, 2005). For occupational therapy, students may do well at learning topics such as orthotics, technology, or advocacy but still not be able to, in the words of several study participants, “think like an OT [occupational therapist]” by connecting all facets of their education to occupation. Wiggins and McTighe (2005), drawing on Dewey (1933), claimed that relying on the logic of content has contributed to disappointing outcomes in education, that is, to students’ inability to use the big idea or ideas of a field.

In sum, explicitly linking curricular elements and content to occupation as the overarching idea of occupational therapy is consistent with the logic of learning the content, which in turn is grounded in contemporary scholarship on learning. Although some programs in this study reflected a logic of learning the content, the challenge going forward will be to practice that logic consistently within each curriculum, course, and class session across the profession.