Asserting Our Competence and Affirming the Value of Occupation With Confidence

Why Does Uncertainty About Occupational Therapy Persist?

The obvious challenge is the concept of occupation. One reason occupational therapy is not understood is because occupation is simultaneously incredibly complex and elegantly simple. Most people think of occupation as a job or having to do with work. I am not proposing that we change our name. Rather, I propose that our strength is situated in our commitment to engagement in meaningful occupation and how what we do helps clients achieve that engagement. Our focus on occupation is essential to the lives of our clients and essential to our competence.

Occupations—all the things we do throughout our day—are simple and full of complexity, ordinary and extraordinary, and saturated with meaning. In a chapter titled “Valuing the Ordinary,” Linda Florey (1996) quoted the French philosopher Pierre Teilhard de Chardin, suggesting that he was describing occupational therapy when he wrote, “What matters is not to do remarkable things, but to do ordinary things with conviction that their value is so enormous” (p. 425). In other words, we must value the ordinary. Although Florey suggested that de Chardin’s quote was relevant to the profession, it is also relevant to the construct of occupation. What may appear as ordinary occupations to some, such as eating or grooming, take on new, extraordinary meaning if there are disruptions in one’s daily life. Often the meanings of the occupations are unspoken or taken for granted, and we come to appreciate them only when they no longer feel possible. So, to make this concept clear, we must understand that when we enable others do the ordinary that they cannot do without occupational therapy intervention, we are doing the extraordinary.

As conceptualized by Betty Hasselkus in her 2006 Slagle address, “Everyday occupation is the primary means by which we organize the world in which we live; the intermeshed patterns of ordinary occupations are what give shape to our daily lives” (p. 627). Environmental gerontologist Graham Rowles (2003) explained that we “tend to develop a regular time–space rhythm and routine in the use of the physical environment that becomes taken for granted and subconscious as our body adapts to the setting” (p. 113). For example, we develop regular routines for walking down the street to catch the bus. Yet, occupations can have deep meaning when they happen less frequently—such as a new achievement such as learning to ride a bike, or a cultural rite of passage such as a baptism or a quinceañera. They can also be simultaneously routine and special, as in the use of a favorite tea set passed down through the generations of the family to drink tea every afternoon.

We all know that the meaning of occupations can change over time and across contexts, as meaning unfolds throughout life. For example, cooking a meal for family for a special occasion is very different from the daily routine of cooking dinner for one’s family after a busy day at work. Cooking may be considered work for the chef in a restaurant. For others, cooking may be a leisure occupation, as it is for my sister, who enjoys decorating cakes. A dear friend enjoys cooking for the church supper in her community and considers cooking a form of volunteering and community service. These examples illustrate that the meaning of our occupations is personally constructed and constantly changing. We can observe people cooking, but the meaning associated with the occupation of cooking is hidden and often unarticulated.

How we experience occupations is interconnected with the environments (sometimes called contexts) in which we live. Our occupational therapy theoretical frameworks are informed by a transactional view of relationships among people, occupations, and environments (Cutchin et al., 2017). Different environments shape our lives in different ways. In this view, environments are not just containers for occupations; rather, our engagement in occupations is always situated, supported, and restricted by the physical, sociocultural, economic, temporal, technological, institutional, and political environments. Using our occupational therapy perspectives, we consider all these features of the environment in supporting engagement in occupation. Sometimes we advocate for changes to the physical environment, and sometimes we advocate for social change—for example, when we partner with adults with mental illness to design an antistigma campaign in their community.

Our concerns are related to daily occupation and real-world function or performance, objective phenomena that are performance based and measurable—for example, how well we complete a particular task. As Wendy Coster pointed out in her 2008 Slagle Lecture, our concerns are also subjective, personally constructed, unique to every person, and harder to measure. These concerns include phenomena such as meaning, quality of life, and belonging or inclusion. When we attend to these concerns, we address what truly matters to our clients.

Here are four stories that represent the diversity of meaningful occupations and the diversity of valued outcomes of occupational therapy:

Parenting an infant, fishing, feeling welcomed at a museum, and volunteering are uniquely valued outcomes of occupational therapy. Because these occupations are so diverse, and ordinary, it is challenging to explain precisely what we do that is extraordinary. And, I argue, this challenge has led to a lack of confidence. We must learn to explain how we achieve the extraordinary. In doing this, we refuse to “hang back,” we demonstrate confidence, and we improve the ability of others to understand our profession.

Two publications, both written about 25 years ago, have greatly influenced my thinking about our profession. Mary Radomski’s 1995 paper titled “There’s More to Life Than Putting on Your Pants” has one of my all-time favorite titles of an article published in the American Journal of Occupational Therapy. Where would you be without your pants? Of course, putting on your pants is important, but for the occupational therapy practitioner, addressing the relationship between putting on your pants and your quality of life is what is most important. Occupational therapy is more than skill development. We focus on the subjective and objective—that is, clients’ satisfaction with engagement in valued occupations. If we focus only on the skill of putting on your pants, we miss an opportunity to trumpet the value of how being able to put on your pants connects to enabling you to engage in meaningful occupations.

In the late 1980s, I had the honor of working with an anthropologist, Cheryl Mattingly, on a study of clinical reasoning among occupational therapists sponsored by AOTA and the American Occupational Therapy Foundation. This study is described in Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice (Mattingly & Fleming, 1994), the second publication that has influenced my thinking about the profession. We discovered a phenomenon that has stayed with me. We observed that the therapists confronted a professional dilemma many of us face related to the commitment to promote clients’ engagement in meaningful occupations. Because our interventions may appear to be difficult to measure in objective and reimbursable terms, especially in a medical context, we tend to overemphasize the objective and document outcomes that comply with reimbursement regulations. For example, we document outcomes related to sequencing of tasks or level of assistance required for dressing. In the study, we called the response to this dilemma underground practice: The outcomes our clients value, such as fishing or volunteering, are not documented in the charts and thus remain underground. This ongoing dilemma between occupational therapy that truly matters to clients and what is reimbursable has interfered with our confidence in proclaiming the full scope of our practice. This dilemma is the antithesis of our competence narrative.

The good news is that ideas about health and reimbursement have changed since then, and I argue today that we are now well prepared and positioned to embrace the power of meaningful occupation as a strength, as an asset to our profession. Once again, our focus on occupation is essential to the lives of our clients and essential to our competence. We must communicate that we support people to engage in the everyday occupations that give their lives meaning. We must communicate this focus to others with competence and confidence. We must clearly describe how we create the extraordinary out of the ordinary.

Now, let’s consider the constructs of competence and confidence and why we need both to affirm the value of occupation.

What Is Competence?

Exploring the etymology or origins of words is another form of understanding meaning—that is, the meaning of words. The word competence comes from the Late Latin word competere, which means to “strive after something in company with or together” (Online Etymology Dictionary, n.d.-a).

I find this etymology fascinating because it highlights what it means to be a competent occupational therapy practitioner. Our competence is rooted in our commitment to collaborate—that is, to meet and strive after something together with our clients and to understand the significance of events and relationships in their lives. Effective therapy requires an understanding of the meaning of occupations to our clients and may involve helping clients recognize what is meaningful to them. As Lawlor and Mattingly (2019) eloquently stated, “Collaboration involves complex interpretative acts in which the practitioner must understand the meanings of the interventions, the meanings of the illness or disability in a person and family’s life, and the feelings that accompany these experiences” (p. 201). Our competence is rooted in this relational work of listening to and communicating with clients.

In current times, we view competence as the ability to perform a specific task in a manner that yields desirable outcomes. In our professional roles, we acquire competence over time as our ability to apply knowledge, skills, and abilities successfully to new and familiar situations evolves. Competence is viewed as a determinant of practitioners’ ability to provide quality intervention and to do their job (Lane & Ross, 1998).

As I stated in the beginning of this lecture, the thesis of our grand narrative is that we are competent, regardless of the definition we adopt.

Society’s views about health are becoming more congruent with the long-standing ideals of occupational therapy. The current reforms to the U.S. health care system that emphasize value-based care provide an opportunity for the profession to highlight its competence. Health care and rehabilitation now value well-being, function, and participation in desired contexts, aspects of human behavior that have always been the constant focus of occupational therapy.

Patient- or client-centered practice and patient-reported outcomes have also gained considerable attention in assessing the value of health care (Mroz et al., 2015). Patient centeredness, or attending to what matters to patients, is now valued and viewed as both an outcome and a means to improve health. Health care payment reform initiatives to improve quality are tied to measures and indicators of patient centeredness as critical outcomes of quality. Providing care that is respectful of and responsive to patient preferences has been a long-standing hallmark of occupational therapy. We are competent in patient-centered care.

These shifting views provide us with an opportunity to demonstrate our competence, and we now have a mechanism to do so. Thanks to the advocacy efforts of the AOTA Federal Affairs Department, in physical medicine and rehabilitation settings, occupational therapy evaluation and reevaluation CPT ^® codes for reimbursement now require the inclusion of an occupational profile (American Medical Association, 2017). Consistent use of the occupational profile enables us to demonstrate our commitment to patients as collaborators in the therapy process and facilitates patient-centered care.

The Improving Medicare Post-Acute Care Transformation Act (2014; Pub. L. 113–185) is another example of a health care evolution that aligns with occupational therapy values. In the past, we have measured intervention by volume in the form of hours, minutes, or days in therapy. We have moved to value-based models in which payment is driven by quality. Function has become the foundation for defining value and quality. Function relates not only to physical function, but to cognitive and psychosocial function as well. Function has always been at the center of occupational therapy, although I would argue that occupational therapy outcomes go beyond function. Remember, it is not just about putting on your pants.

We now have compelling and rigorous scientific evidence and cost-effectiveness data to provide support for our competence to address our health care system’s greatest needs for people throughout their life course. Health policy researchers Rogers and colleagues (2017) recently analyzed associations between Medicare claims and cost data with spending and readmission rates. The researchers noted, “Investing in occupational therapy has the potential to improve care quality without significantly increasing overall hospital spending” (p. 683). Occupational therapy was the only spending category in which additional spending had a statistically significant association with lower readmission rates for patients with heart failure, pneumonia, and acute myocardial infarction. Rogers and colleagues reported that occupational therapy “places a unique and immediate focus on patients’ functional and social needs, which can be important drivers of readmission if left unaddressed” (p. 668). How great is this study? Just this fall, Stevens and Lee (2018), researchers at the Centers for Disease Control and Prevention, published a study demonstrating that addressing home hazards with the assistance of an occupational therapy practitioner could save our health care system more than $400 million by reducing medically treated falls.

Twenty-seven different studies have documented the benefits of the Cognitive Orientation to daily Occupational Performance (CO–OP) approach. This task-oriented problem-solving approach enables people to be actively involved in solving their performance problems and achieving self-identified goals. Studies have documented the effectiveness of the CO–OP intervention for children and adults with a range of conditions (Scammell et al., 2016).

These examples are only a glimpse of the plethora of studies that support the range and depth of our competence as a profession. I reiterate my earlier point: Our competence and ability to excel have never been stronger. However, to realize the full potential of occupational therapy to benefit society, we also need confidence, because success correlates with both competence and confidence.

What Is Confidence?

Whereas competence is task oriented and measured according to standards of a specific domain, confidence is a mind-set, an abstraction of our own internal state. Once again, I start with the etymology of the word. Confidence comes from the Latin word confidere, meaning “to have full trust or reliance” (Online Etymology Dictionary, n.d.-b).

This is what Eleanor Clarke Slagle asked us to do when she said, “Stand up and face them. Don’t hang back.” Today, to be confident means “to have faith in our convictions” or, stated another way, “a trusting belief in our abilities.” Confidence is “the way we meet our circumstances” (Kay & Shipman, 2014, p. 25). If we believe in our abilities, then we will be free to approach circumstances without self-doubt. However, confidence is not bravado, arrogance, or bluster. Although confidence is related to self-efficacy or self-esteem, it is more than feeling good about ourselves—it is “a wholeheartedness” (Kay & Shipman, 2014, p. 25) or, to use Slagle’s words again, it’s not hanging back.

Yes, confidence is a mind-set, but it is also linked to doing and action. To quote Richard Petty, a psychologist who studies confidence, “Confidence is the stuff that turns thought into action” (as quoted in Kay & Shipman, 2014, p. 50). The view that confidence is about action follows the circular logic that we are all familiar with: “If confidence is a belief in our success, which then stimulates action, we will be more confident when we take that action” (Kay & Shipman, 2014, p. 50). Although action seems to follow feeling, they really go together; by taking action to communicate the value of our profession, we can indirectly regulate our feeling. For example, our confidence in explaining the value of occupational therapy to one person gives us confidence to try something new, perhaps to take action to explain the value of occupational therapy to policymakers. Confidence also comes from striving to master a challenge. Learning to embrace struggles shows us that it is possible to make progress, without being perfect on our first try. Just like a yoga master who practices poses, we need repeated practice to develop confidence. That’s why yoga is called a “practice.” Similarly, developing confidence as part of that practice is the result of that process.

Conversely, a consequence of limited confidence is inaction. Often we wait to act until the stars align, everything feels right, and we think we are fully ready. When we are unsure, we hang back. We hang back because we think others will not understand the focus of occupational therapy, or we fear that our work appears too simple and others may not value it. Lack of confidence leads to inaction. This logic helps us see that seeking perfection actually inhibits confidence and keeps us from action. If we are constantly seeking the perfect description of occupation, we will never be fully confident because the bar will always be too high.

When we embrace self-limiting attitudes such as “occupational therapy is too complex to explain,” we close off possibilities. These doubts exist for all of us at certain points and in certain circumstances. Students, if you do not answer a question because you are not completely sure of the answer, you never take the risk to build your confidence. However, if you take the risk, you will receive feedback. The feedback you receive, even if your performance is not perfect, helps you improve for the next time. If you make corrections and try again, you can build confidence.

What Do Competence and Confidence Have in Common?

Confidence is an essential life ingredient that has a complicated relationship with competence. Competence matters, but projecting confidence is equally as important when interacting with clients or promoting the profession. Professional confidence includes trust in our role as occupational therapy practitioners and faith in our scope of practice. Thus, our professional confidence can bolster our professional competence, our professional identity, and our ability to communicate what we do.

But, overall, it is not a lack competence that holds us back; rather, it is our self-limiting perception. As Slagle said, we need to act instead of hanging back. The synthesis component of our shared grand narrative will enable us to envision a new narrative.

What Does It Look Like When We Merge Our Competence and Confidence?

To understand more clearly what happens when we do assert our competence and affirm the value of occupation with confidence, I interviewed the competent and confident occupational therapist I mentioned at the beginning of this lecture. Caitlin Synovec is a triple Terrier. That means she has three degrees from Boston University—a baccalaureate degree in therapeutic studies and a master’s and a postprofessional doctoral degree in occupational therapy. Like BU’s Boston Terrier sports mascot, Caitlin has courage and determination. Caitlin developed an evidence-based and theory-driven occupational therapy program in a primary care setting for people experiencing homelessness. She took a risk and she did not hang back, and I was curious to hear her story.

Like many students, Caitlin began her education with a desire to work with children. But Caitlin loved what her fieldwork supervisor was doing at a day program for people with mental illness. The experience shifted Caitlin’s career trajectory. Caitlin told me, “My supervisor was engaged with the clients and problem solving day-to-day things that are so important. She was helping the clients develop practical strategies to try something they thought they couldn’t do.” It’s time for a special shout out to all the fieldwork educators who mentor students!

When I asked Caitlin what drove her to develop a new program, she described her deep frustration while working in the inpatient setting. Many of the patients admitted to the hospital were experiencing homelessness. Once the patients were medically stable, discharge planning was difficult. Caitlin was disturbed that the best place for discharge was often a shelter without resources to support people to make a change. Caitlin believed that occupational therapy had something to offer these patients, if only she could provide services in the community.

A social worker who had worked with Caitlin in the inpatient setting started a new job at a community primary care health center. The center included wraparound support services to address the health and housing needs of people experiencing homelessness. Because the social worker had observed the occupational therapy services Caitlin provided in the inpatient setting, he understood the value of what we do. Caitlin and her social worker buddy got together and brainstormed possibilities for integrating occupational therapy into the health center.

Just like Eleanor Clarke Slagle years earlier at Johns Hopkins, Caitlin was persuasive. She took a risk. She convinced her boss to allow her to offer occupational therapy services on an outpatient basis. Planning her schedule to see these patients was risky because if the patients did not show up, she might not meet her productivity requirements for billable hours. Caitlin thought the risk was worth it because she had a trusting belief that access to occupational therapy was important to the health and well-being of all patients. She viewed the risk in terms of equity and social justice. Working toward goals that come from your values builds confidence. Stepping out of your comfort zone also builds confidence. Caitlin was willing to step out of the comfort zone of reliable billable hours because she had faith in her conviction that occupational therapy was valuable and that she had the skills necessary for the task. She did not have the whole program perfectly figured out, but she took a risk.

That was 5 years ago. The program is now firmly established, and Caitlin is evaluating it to demonstrate the effectiveness of occupational therapy within a community-based primary health care setting. Caitlin’s confidence—her firm belief in the value of occupational therapy—enabled her to use her competence to build a successful new program.

Caitlin took another risk. She advocated for the very first patient referred to her, a 50-yr-old man she called Doug (not his real name). Doug was referred to occupational therapy to assess his potential to succeed in supportive housing. Doug had chronic medical needs; he had experienced a stroke and had left-sided hemiplegia. He was drinking alcohol and living in a shelter. The staff at the shelter thought he needed more support than they could provide but were worried that an assisted living facility or nursing home would not accept him because he was not ready to stop drinking. Furthermore, they did not think Doug could be successful in supported housing. They did not see his possibilities, only his limitations.

Caitlin told me that it was important to consider “alternative ways of thinking about his potential.” Caitlin collaborated with Doug, explored what was important to him, and learned that he aspired to safely take care of his daily hygiene and mealtime needs. He repeatedly said to her, “Caitlin, I just want to take a shower.” Doug was unable to take a shower in the shelter because residents were allocated only 10 minutes for a shower, there were no grab bars, and the dials were too far away to reach while seated in a shower chair. Doug had to wash up at a sink. Caitlin believed that, working together, she and Doug could brainstorm strategies to help him be safe in the shower and cook with a microwave at the supported housing complex. She helped him imagine new possibilities and then supported him as he practiced the strategies in the housing complex. After Doug mastered the shower, they moved on to managing his fixed Supplemental Security Income so that he could save money for a TV. A few months later, Doug invited new friends to join him in his apartment to watch the football game.

At first glance, Doug’s occupations seem ordinary. Yet, with the guidance of occupational therapy, Doug moved into supportive housing, took care of his daily living needs, developed social networks, and lived his life with dignity—that’s extraordinary. Just as Slagle did for clients in her day, Caitlin helped Doug regain dignity by establishing basic habits of self-care and social behavior.

Caitlin considered Doug’s identity. She understood that supporting Doug to move to a new housing situation would bolster his image of himself as a self-sufficient person capable of self-management in his home. The value of occupational therapy was more than simply teaching Doug how to shower with one hand. The sum of achieving what we may consider ordinary occupations led to the extraordinarily complex outcome of reconnecting him to a sense of humanity in a social world.

What Can We Learn From Caitlin’s Story to Help Us Communicate the Value of Occupational Therapy?

Numerous scholars have urged us to describe the distinct features and values of our profession. In his 1996 Slagle Lecture, David Nelson (1997) pressed us to “take personal responsibility for explaining to the world why we are called occupational therapists” (p. 24). In 1977, the philosopher and physician Tristram Engelhardt recommended that we highlight our distinct focus on human occupation and quality of life. He eloquently noted, “The virtue of occupational therapy is engagement in the world” (Engelhardt, 1977, p. 672).

To communicate our competence, we must be able to demonstrate and explain the features of all occupational therapy interventions that we value and believe are essential to promote the desired change, because these concepts shape what we do. Caitlin’s story highlights the essential features of all occupational therapy and the value of occupation as a therapeutic agent and a meaningful outcome.

Collaboration with clients focused on occupations that matter is at the center of our interactions with all clients and essential to all occupational therapy. We value a respectful, collaborative partnership of mutual participation because effective therapy demands a high level of commitment from clients and practitioners. Caitlin explored what was important to Doug; they considered his goals and values and then brainstormed strategies together, rather than Caitlin dictating goals and strategies to him.

Caitlin’s story also emphasizes an essential feature of all occupational therapy that is so familiar to us—that is, our transactional view that the person, the occupations, and the environments where they occur are inseparable (Cutchin et al., 2017). How these elements influence each other is a recurring question for all occupational therapy interventions. We “systematically analyze what and how a person or groups of people actually engage in their occupations” (Schell et al., 2019, p. 320). You all know this: We conduct an occupational analysis, and this view of human behavior is an essential feature of all occupational therapy. This is why we call ourselves occupational therapists. We use this occupational analysis to help us define the barriers to clients’ engagement in occupation and where to intervene. Of course, we then use treatment theories to guide the intervention. Ultimately, these processes focus on supporting people to engage in the everyday occupations that give their lives meaning.

What Can We Do to Support Each Other to Affirm the Value of Occupation With Confidence?

We are competent, and our long-standing values are congruent with society’s contemporary views about health. We have a strong and growing body of research evidence to demonstrate our value. We need to assert our competence to support our confidence. Like Caitlin, each of us needs to routinely demonstrate and share the complexity and value of our work. We can do so by communicating our propositions about how change typically works in occupational therapy. We each have examples of how some ordinary aspect of our work led to extraordinary outcomes: engagement, connection to others, reestablishment of pride, improved quality of life, inclusion, or more cost-effective health care. Our task is to share these stories with confidence.

It will take a village to confidently rewrite our grand narrative from “nobody knows what we do” to “the virtue of occupational therapy is meaningful engagement in the world.” And like Caitlin, we all have to feel confident in our ability to stand tall and take a risk. We need to ensure that our clients and their families, our professional colleagues in other disciplines, our funders, and policymakers all understand the virtue of occupational therapy. To communicate confidently the grand narrative of our competence, we need to be role models and mentors for each other. Role models show us what is possible, just as Caitlin did, and as her fieldwork supervisor did for her. We must reinforce our belief in the value of occupation and occupational therapy, take chances, and try something new. We need to show that it is possible to make progress without being perfect the first time.

We know that taking on challenges and achieving successes that are slightly out of our comfort zone build confidence. Socialization and professional identity formation begin to develop in our occupational therapy education programs, so we can begin by designing learning opportunities that encourage and nurture students to venture into unknown territory. Learning experiences that spur students to communicate the complexity of occupational therapy to people unfamiliar with the profession may provide a foundation for confidence. Assignments might include practicing with interprofessional students, advocating with legislators, and, of course, reflecting on the learning experience.

How many times has someone asked you, “What’s occupational therapy?” Some of you may have a go-to answer. If you do not have one, let me invite you to develop a response that you might share with confidence. If you are an educator or fieldwork educator, please help your students develop and refine their description of occupational therapy in a way that embraces and describes the value of and mechanisms of occupation. I challenge you to reflect on how you describe occupational therapy to others and to ask yourself whether you include a focus on engagement in meaningful occupations (Engelhardt, 1977). Similarly, if you are an experienced practitioner, consider how you might adapt your description for a specific audience. How would it sound if you described occupational therapy to a federal, state, or local policymaker? Might you revise your description if you were explaining occupational therapy to a new member of an intervention team? That new story, that new narrative, must create an understanding that occupational therapy practitioners do the extraordinary to ensure that every client succeeds at the ordinary.

Confidence and competence come from understanding our distinct strengths and values. Our distinct strength is enabling people to engage in occupations that promote health and well-being (AOTA, 2014, p. S4). I have focused on two words throughout this talk—competence and confidence. Before I conclude, there is one more word to consider—commitment. When we enter our profession and become occupational therapy practitioners, we make a commitment to our clients, to ourselves, and to all we meet that our actions and our words will both maintain and extend our competence, particularly as we mentor and support each other. We all need to make a commitment to communicate our competence confidently as we explain the ordinary and extraordinary power of occupation. In doing so, we provide the best possible occupational therapy for clients and their families and advocate for our profession.

I am so grateful for this extraordinary honor and privilege to honor Eleanor Clarke Slagle and engage in an ongoing reflection on our profession. I express my deep appreciation to my colleagues and dear friends who nominated me. Throughout my career, I have been pushed beyond my comfort zone and supported by clients, students past and present, colleagues, mentors, teachers, and my family. Thank you all for stretching my thinking. To my family, your love and support sustain me and remind me to be safe, make good decisions, and have fun. And, of course, my last words come from Eleanor Clarke Slagle herself: “Don’t hang back.”