Abstract
This study provides support that accurate understanding of the experiences of people of color enables the development of effective strategies to foster their successful transition into the occupational therapy workforce.
Matching the demographics of health professionals with those of the diverse populations served fosters better relationships and increases access to and quality of care for underserved populations (Saha & Shipman, 2007). In occupational therapy, people of color make up less than 15% of the workforce in the United States; of that percentage, 3.0% identified as African American/Black, and 3.9% identified as Latino or Hispanic (American Occupational Therapy Association [AOTA], 2019). The revised Vision 2025 (AOTA, 2018) calls for occupational therapy to be an inclusive profession. In addition, increasing the diversity of health care professionals can affect recruitment and retention of diverse students transitioning into the profession (Saha & Shipman, 2007).
Barriers to and Facilitators of Entering and Remaining in Health Care Professions
The literature has identified challenges for health professionals and students of color entering and remaining in the field as well as factors that can inform strategies to increase diversity. One study found that racial–ethnic minority medical students identified lack of support, discrimination, and lack of financial resources as barriers to success (Odom et al., 2007). Students further expressed that feelings of self-doubt were exacerbated in situations in which they were tokenized. Of particular concern was when students “internalized negative views held by others and began to question their legitimacy” (Odom et al., 2007, p. 151), which negatively affected recruitment and retention in the health professions. Another study found that students of color experienced situations described as high in “degree of offensiveness” and “degree of discrimination” in college classrooms (Suarez-Balcazar et al., 2003).
Finally, studies have found that for students of color, academic, financial, family, and geographic factors are compounded, because most health professions now require a graduate degree (Carnevale & Strohl, 2013; Essary & Wade, 2016). As a result, less than 2% of people of color in higher education are enrolled in health profession programs (Valentine et al., 2016). Conversely, facilitators of recruitment and retention were focused on the development and use of mentorship programs that incorporated mentors of color who advised on how to address these barriers (Banister et al., 2014; Lucas, 2017; Peifer et al., 2016.)
Although these themes were consistent in most studies, only a few occupational therapy studies have addressed diversity (Black, 2002; Lucas, 2017; Murden et al., 2008; Whiteford & St. Clair, 2002), and none have addressed facilitators of and barriers to recruitment and retention of occupational therapy practitioners (OTPs) of color. As a profession that focuses on the person (which includes race and ethnicity) and the environment (which includes cultural values), developing these strategies is crucial to provide a template for other health professions that can be used to target current and future OTPs. Therefore, the purpose of this research is to answer the following question: What are the perceived challenges to and facilitators of the recruitment and retention of OTPs and students of color?
Method
Research Design
A qualitative approach with an interpretive, constructionist design (Merriam & Tisdell, 2016) was used to examine perceptions of facilitators and barriers experienced by OTPs and students of color regarding recruitment and retention in educational programs and work settings. This design produces rich descriptions of lived experience of OTPs and students of color, portrays how they construct their world in a predominantly White profession, and communicates the meaning they give to their experiences.
Sample and Recruitment
Purposive recruitment was used at the 2017 AOTA Annual Conference & Expo through the distribution of flyers at the Coalition of Occupational Therapy Advocates for Diversity meeting and via an online recruitment flyer on the National Black Occupational Therapy Caucus (NBOTC) Facebook group by the first author. A convenience sample was obtained initially followed by snowball sampling to recruit additional participants.
Inclusion criteria included being an OTP or a student of any age, setting, or geographic location who identified as a woman and a person of color. OTPs and students who identified as non-English speaking, White, or male were excluded.
Instrumentation
The interview guide was developed on the basis of two theoretical lenses. Relational–Cultural Theory identifies how sociocultural and contextual factors impede or foster relationships in life, with an emphasis on experiences of women, people of color, and other marginalized groups (Comstock et al., 2008). Feminist Intersectionality Theory (Walby et al., 2012) considers how all aspects of a person’s identity intersect when examining that person’s experiences.
The first author prepared open-ended questions and probes about facilitators and challenges faced by OTPs and students with regard to recruitment and retention within their respective settings (Figure 1). All authors met to revise questions to reflect the purpose of the research.
Interview and focus group items.
Data Collection
Data were collected online from three focus groups and four interviews via FaceTime (Apple Inc., Cupertino, CA) and Google Chat (Google LLC, Menlo Park, CA) led by the first author, scheduled at mutual convenience for participants (Figure 2). Interviews were used if participants felt uncomfortable speaking in a group. Focus groups consisted of 2 or 3 participants and lasted 60 to 75 min; interviews lasted 30 to 45 min. Participants were asked open-ended questions that informed additional probes based on group priorities. Before interviews or focus groups, demographic information and consent were (1) collected via an online form approved by the institutional review board, (2) de-nominalized, (3) coded, and (4) kept in an encrypted file separate from a participant name list matched to the codes. Responses were recorded with a smartphone app, downloaded to an encrypted file, and stored separately from participant information.
Research process.
Data Analysis
Using both theoretical lenses (i.e., Relational–Cultural Theory and Feminist Intersectionality Theory), we used inductive analysis to interpret the open-ended questions (Merriam & Tisdell, 2016). During analysis, the first author, an occupational therapy doctoral student of color, bracketed her feelings and reactions in a reflexive approach. Potential biases regarding her experiences with these challenges were identified and discussed with all authors; concerns were then addressed. Demographics data were descriptively analyzed as a percentage of the total sample (N = 12).
After transcription, we reviewed each interview or focus group transcript using Colaizzi’s (1978) seven-step method of data analysis. This method included (1) reading transcripts to acquire an understanding, (2) extracting significant statements, (3) formulating meanings of significant statements, (4) organizing meanings into themes and patterns, (5) integrating results into an exhaustive description, (6) describing and identifying fundamental structure of the experience, and (7) validating findings with participants.
Results
The results of the descriptive analysis showed a final sample that included 5 occupational therapists with a mean age of 41.8 yr (SD = 14.6) and 7 students with a mean age of 25 yr (SD = 2.1; Table 1). The majority of participants (91.7%) identified as African-American or Black. The following five themes emerged that summarized the experiences of women of color in educational and work settings: (1) lack of representation in and knowledge about occupational therapy, (2) feeling like an outsider, (3) need for financial support, (4) individualized mentor–mentee relationships, and (5) connections with national organizations specifically for people of color.
Participant Demographics (N = 12)
Note. MSOT = Master of Science in Occupational Therapy; NBCOT = National Board for Certification in Occupational Therapy; OTD = Doctor of Occupational Therapy; PhD = Doctor of Philosophy.
Range = 23–64 years.
n = 3.
Barrier: Lack of Representation in and Knowledge About Occupational Therapy
All participants attributed the lack of women of color in occupational therapy to the lack of knowledge of, access to, and exposure to this discipline in communities of color. According to Participant 6,
A lack of education is one because I had no idea that OT even existed. I feel like in the general population people only know about nurses and doctors, especially those who are minorities because these communities don’t have the same access to health care resources that a lot of other people have. Specifically, White people.
The majority of participants (67%) also identified that people will not pursue a career in which they do not see people like themselves. Participant 3 stated,
OT has become kind of an elitist profession for lack of a better term. The profile of the professional does not fit the profile of people from certain demographics.
Barrier: Feeling Like an Outsider
Participants identified social, cultural, environmental, and interpersonal challenges that affected their experiences. The feeling of being an outsider was a theme echoed across 100% of participant responses. According to Participant 5,
There were no minorities; teachers were not minorities—even classmates. I felt I didn’t belong. You know how you set up the right environment for your patients . . . the environment in school was not very welcoming because I didn’t fit in and was also alienated because of my Latina accent.
Those who attended minority schools (33%) found that their experience was better when they were not the “token” minority. Participant 1 stated,
I went to an HBCU [historically Black college/university], and my class was majority Black. Now fieldwork was a completely different story. . . . I was the only Black person in the whole rehab department and one of two Black people in the entire hospital. It was very blatant they did not want me to succeed and they tried to pull everything. They could not fault me for academics because I had the book knowledge, but absolutely it was a race issue 100%.
Along with feeling like an outsider, lack of social support by peers, clinical supervisors, coworkers, and professors as well as racism were identified by 83% of participants. According to Participant 2,
I definitely had one of my professors pull me into her office and tell me I need to be fluffier. She said I had worked really hard to get here and knew that I had to go through a lot of things. . . . “I’m sure you’re from the hood.” My mom has two master’s degrees.
In addition, Participant 8 stated,
My CI [clinical instructor] was just straight racist, everyone was racist. . . . They would be at lunch like you know Black people love their chicken and you know how Asians love peas and rice. . . . I felt I had to go above and beyond to prove her wrong. She made it very clear that her goal was to fail me because I was too different than her.
Most participants (91.7%) identified having to prove they were qualified to be in their positions and occupational therapy programs. According to Participant 7,
Barriers in OT school are the same as with the profession, and that was a lack of welcome. Having to prove that you deserved to be there, a burden of proof that was not on other students. How did you get here? What are you doing here? Prove that you deserve to be here . . . especially for African-Americans. Be better and work harder.
Barrier: Need for Financial Support
All participants emphasized the need for financial support to pursue higher degrees required to practice. Participant 7 identified occupational therapy becoming an exclusive profession with the move to the higher degree:
I do not agree with all of the degrees required to practice nowadays . . . the higher the degrees, the more money required to pay for the education. This makes it so difficult for minorities to achieve . . . and that is systematic racism. It’s like purposively keeping the field for privileged Whites.
Facilitator: Connections With National Organizations Specifically for People of Color
Most participants (75%) emphasized the importance of having connections with a community of people who had similar experiences, allowing them to receive and share resources specific to minorities, such as tips on how to deal with racist patients, not otherwise provided at their health care institution. According to Participant 2,
I didn’t know that there was a national Black OT caucus until my mentor told me about it. Coming from a predominantly White school and being somebody that is very much about us promoting each other in the program, that’s the whole reason I started that Black student group. Since forming a group we have been able to share resources and experiences, and it’s been great.
Eight participants identified the following groups within occupational therapy as good support systems and places to link mentors and mentees from around the country: Asian/Pacific Heritage Occupational Therapy Association; Terapia Ocupacional para Diversidad, Oportunidad y Solidaridad (TODOS) Network of Hispanic Practitioners; and NBOTC. Participant 3 stated,
Having Black caucus meetings occur at the annual conference, I’ve had an opportunity to take students from all over [the United States]. I think to have someone that can encourage them and strategize around program issues is very important. The more that is available to students I think the better it will be, and I do think that there needs to be a formalized network to help minority students in these programs that are at majority institutions.
Facilitator: Individualized Mentor–Mentee Relationships
Having a positive mentor–mentee relationship was mentioned as crucial for retention. According to the participants, it is imperative that mentors and mentees create a set of expectations early in the relationship to establish a mutual understanding of what each wants to get out of the mentorship. According to Participant 10,
I found mentoring relationships that worked best are when my mentee and I had similar interests. It allowed us to connect better. I have also found that when you pick the relationship based on these shared things rather than just going in blindly, it’s more beneficial for both people. Both people contribute and learn.
To many participants (83%), having a mentor who was a person of color and who could share in similar experiences was the most desirable relationship. This partnership helped participants feel comfortable having an open dialogue around societal, school, and workplace issues.
Discussion
The results of this study identify the experiences of OTPs and students of color and how identified barriers can be addressed through strategies to foster effective recruitment and retention into occupational therapy careers. Specifically, participants suggested availability of a mentoring program that provides access to financial support, connections to national multicultural organizations, and individualized mentor–mentee relationships as facilitators of recruitment. Lack of knowledge about occupational therapy as a profession and not seeing people of color in the profession were mentioned as barriers to recruitment. This finding suggests a need to highlight diverse OTPs and caucuses in marketing materials and to develop recruitment strategies targeting institutions (e.g., HBCUs) with higher percentages of potential applicants of color.
These results are similar to those of studies in which participants identified individualized mentor–mentee relationships as critical in retaining minority students (Banister et al., 2014; Lucas, 2017; Peifer et al., 2016). Participants’ feeling of being an “outsider” was consistent with research showing that being tokenized, a lack of support, and discrimination limit professional success and satisfaction (Fassiotto et al., 2016; Odom et al., 2007). Examples of overt racism were identified and need to be addressed within the profession. To better support OTPs and students of color, the results of this and other studies have demonstrated a need to create more inclusive environments. For example, one study found that universities that incorporated a holistic admissions approach, diversity-driven mission statements, and diversity training for staff had increased numbers of diverse students in their health profession programs (Artinian et al., 2017).
Limitations and Strengths
This study has several limitations and strengths that affected trustworthiness of the research process. Credibility was addressed through use of relevant data analysis, the lead author’s familiarity with the cultures of participating organizations, reflexivity, iterative questioning, and debriefing between coauthors. Transferability was managed through consideration of the contexts of school and work effects. Dependability was addressed through use of overlapping methods such as focus groups and individual interviews. Finally, confirmability was obtained through a description of the process to inform an audit trail. Despite this method, because recruitment was through social media and various caucuses at the AOTA conference and because participation was voluntary, viewpoints may not be shared by all practitioners and students of color. For example, there was a low response rate from Hispanic and Latino OTPs and students, although it is unclear why; as a result, our findings may not transfer to those populations and should be considered in future research recruitment. In addition, perceptions and experiences of those who dropped out of school or practice were not obtained. However, results of this study do provide important information that can be used to design strategies to address the barriers identified regarding recruitment and retention of OTPs and students of color.
Future Research
Future research should focus on creation and evaluation of evidence-based strategies for the recruitment and retention of students of color in occupational therapy. Further research is also needed to understand how occupational therapy standards and curricula can be changed to provide training in biases and cultural awareness, providing a more welcoming environment for both minority practitioners and clients.
Implications for Occupational Therapy Education and Practice
The World Federation of Occupational Therapists (2010) asserted the importance of considering diversity and culture within the profession with a position statement recommending strategies and actions to promote adherence to the Guiding Principles on Diversity and Culture (Kinébanian & Stomph, 2009). However, to make this a reality, people of color seeking and entering the field need to have the following organizational systems in place to provide support for success in education:
Creation of an academic environment in which students of color feel included
Incorporation of cultural awareness and unconscious bias training into professional development for professors and clinical instructors
Inclusion of curricula for peers that intentionally address and decreases racism
Formalization of a mentoring program through the national occupational therapy diversity caucuses to support students of color through school and transition into practice
Provision of financial support to students for increased access to higher education in health professions, specifically occupational therapy programs.
In addition, the following organizational systems need to be in place to provide support for success in practice:
Support of the creation of a diverse occupational therapy workforce and the use of multicultural theories and conceptual models to guide the provision of culturally sensitive care
Advocacy for increased access and exposure of occupational therapy services in underserved communities of color.
Conclusion
This study highlights the voices of occupational therapy practitioners and students of color regarding challenges and facilitators experienced in the profession. With accurate understanding of experiences of people of color, effective strategies can be developed to foster their successful transition into the occupational therapy workforce. Such strategies include diversity and inclusion training within occupational therapy programs and work settings, creation of mentoring programs that address the needs of students of color, and improved social identity through inclusive environments. Examining and understanding the impact and effectiveness of these strategies in future research will create the evidence needed to help diversify the profession and decrease health disparities for underserved populations.
Footnotes
Acknowledgments
This research was conducted at the MGH Institute of Health Professions.