Abstract
Now more than ever, the lack of racial and ethnic diversity must be addressed within the health care system, specifically in occupational therapy. This change starts with the successful completion of educational programs by underrepresented minority (URM) occupational therapy students. To increase diversity in the profession, accrediting bodies should mandate support for students of all backgrounds to be successful in higher education. As addressed in the American Occupational Therapy Association 2020 Code of Ethics, the Vision 2025 statement and its pillars, current knowledge on health disparities and occupational therapy demographic data, and other health professional programs’ accreditation standards, there is a need for an addition to, or revision of, the Accreditation Council for Occupational Therapy Education (ACOTE®) standards to support the recruitment and retention of URM occupational therapy students.
The authors provide a rationale for an ACOTE® standard requiring support for the recruitment and retention of underrepresented minority occupational therapy students.
By 2040, it is projected that more than 50% of the U.S. population will consist of people identifying as a minority race or ethnicity (Ewert, 2015). As the United States continues to grow as a diverse nation, its health care system is failing to provide adequate care to minority populations, resulting in health disparities (Centers for Disease Control and Prevention [CDC], 2021; Jackson & Gracia, 2014; Wilbur et al., 2020), defined as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage” (U.S. Department of Health and Human Services, 2020, p. 28). Health disparities among underrepresented minority (URM) populations can be attributed in part to a lack of racially or ethnically diverse health care clinicians, because many individuals who identify within an URM group prefer to see a health care professional from the same background and have better health care experiences when they do so (Institute of Medicine, 2004; Jackson & Gracia, 2014; Noonan et al., 2016; Taff & Blash, 2017; Wilbur et al., 2020).
Diversity can be defined as “the range of differences among population groups” (Gill et al., 2018, p. 196). In this column, we discuss the lack of racial and ethnic diversity in occupational therapy education. “Race refers to physical differences that groups and cultures consider socially significant, while ethnicity refers to shared culture, such as language, ancestry, practices, and beliefs” (italics added; American Sociological Association, 2020, “Race and Ethnicity” section). In this column, URM refers to identifications that differ from non-Hispanic White.
As the nation continues to diversify, the health care field must follow this trend by increasing diversity among its members to reflect the population and support equitable health outcomes (Breslin et al., 2018). To address the lack of racial–ethnic heterogeneity among health care professionals, the scarcity of diverse students entering health professional academic programs must be considered (Noonan et al., 2016). According to the American Occupational Therapy Association (AOTA; 2020c), approximately 84% of occupational therapists identify as non-Hispanic White. In addition, approximately 77% of doctoral students identify as White, and 91% identify as non-Hispanic; 78% of master’s students identify as White, and 90% identify as non-Hispanic (Harvison, 2019). Similarly, about 71% of occupational therapy assistant students identify as White, and 85% identify as non-Hispanic (Harvison, 2019). These statistics emphasize the lack of diversity among current occupational therapy clinicians and students. These numbers should ideally reflect the true racial–ethnic makeup of the U.S. population.
Barriers for URM students to enter and complete higher education programs include inadequate academic preparation before starting a program, a lack of diversity among other students and faculty, and financial concerns (Alicea-Planas, 2017; Bednarz et al., 2010; Gates, 2018; Valentine et al., 2016). Additionally, student stress levels often increase while they are completing their occupational therapy education (Govender et al., 2015). Therefore, when endeavoring to recruit and retain URM students, an understanding of the specific barriers they may face and the general stress levels noted in occupational therapy students is crucial. Recruitment and retention efforts can include enrichment programs for preprofessional students, bridge programs, social support groups, mentorship programs, tutoring, academic workshops, financial support, and remediation programs to promote an inclusive academic environment (Alicea-Planas, 2017; Bleich et al., 2015; Gates, 2018; McCarthy et al., 2014; Valentine et al., 2016; Wilbur et al., 2020). A lack of these supports may exacerbate challenges and stressors, thus hindering students’ academic performance.
The literature suggests that general policy initiatives, such as a review of a program’s strategic plans, curriculum, and admissions process, would support an increase of URM students, and that these suggestions can be addressed in accreditation standards (Bleich et al., 2015; Jaegers et al., 2020; Jarus & Douglas, 2018; McCarthy et al., 2014; Taff & Blash, 2017; Wilbur et al., 2020). Accreditation boards such as the Accreditation Council for Occupational Therapy Education (ACOTE®) have the power to address these issues by revising current standards to require that all accredited programs support the increase of URM students by providing documentation of strategic plans to recruit and retain URM occupational therapy students (Jaegers et al., 2020).
Gaps in Current Standards
The issue is that there is no mandate from ACOTE requiring programs to document efforts to recruit and retain students from diverse racial–ethnic backgrounds (ACOTE, 2018). Instead, the current standards focus on the expected student outcome of becoming a generalist clinician while being mindful of diversity and cultural differences; yet, there is no definition of diversity within the document. Diversity must first be defined before being applied to ACOTE standards. The establishment of an ACOTE standard would create the general requirement stating that each program must document the efforts taken to recruit and retain a diverse student population (ACOTE, 2018).
Advancements in the recognition of diversity, equity, and inclusion have been made within the profession, and official documents have been revised to incorporate these terms. Equity ensures that each student has the resources necessary for success and that “outcome equity judges equality based on educational outcomes rather than human, material, and financial inputs” (Dowd & Bensimon, 2015, p. 11). Inclusion ensures that each student feels welcome and comfortable in an academic and clinical environment regardless of any personal factor; this “takes time and requires work beyond merely ‘not-excluding’” (Gill et al., 2018, p. 196).
In 2016, AOTA announced its Vision 2025 platform, stating, “Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living.” In 2018, AOTA’s board of directors added two items related to diversity to Vision 2025: “As an inclusive profession” was added as an introduction, and equity, inclusion, and diversity were added as a pillar. This pillar claims, “We are intentionally inclusive and equitable and embrace diversity in all its forms” (AOTA, 2019). Moreover, AOTA (2020a) established a Diversity, Equity, and Inclusion Task Force, whose purpose is to support the progression of these components in various areas of occupational therapy.
According to the AOTA 2020 Occupational Therapy Code of Ethics (AOTA, 2020b), occupational therapy practitioners have a duty to provide equitable treatment, enhance well-being, respect autonomy, and prevent harm. ACOTE standards state that programs must “uphold the ethical standards, values, and attitudes of the occupational therapy profession” (ACOTE, 2018, p. 2). This standard implies that occupational therapy ethical standards must be implemented into the content of the curriculum in order for programs to receive accreditation; however, it does not hold programs accountable for demonstrating ethical behavior when it comes to supporting students upon admission and throughout completion of their education. Despite an understanding of the barriers and challenges faced by URM students in higher education (Alicea-Planas, 2017; Bednarz et al., 2010; Gates, 2018), the absence of an ACOTE standard to support these students throughout their academic programs is a disservice. If clinicians are to adhere to these ethical standards while providing services to clients, and academic programs must adhere to the standards to receive accreditation, then academic programs should also be required to specifically incorporate them to ensure that current students are supported throughout their education.
Despite AOTA’s Vision 2025, the AOTA 2020 Occupational Therapy Code of Ethics, and statistics that reveal the lack of racial–ethnic diversity in the occupational therapy profession, there has been no revision to the ACOTE standards to ensure support for URM students. The time for change is now given that many new occupational therapy programs are in the development phase (Harvison, 2019). Moreover, the coronavirus disease 2019 (COVID-19) pandemic and the Black Lives Matter movement present a monumental time in history that has highlighted health disparities and injustice within various professional and educational systems in this country, including health care and higher education (CDC, 2021; Noonan et al., 2016). These injustices have led to responses recommending steps for action to support justice in health care, academia, the criminal justice system, and the field of occupational therapy (Jaegers et al., 2020). An action step identified in academia expects academic programs to report recruitment and retention strategies for Black and Indigenous people and people of color as well as students from other URM groups (Jaegers et al., 2020). This action step can be implemented by revising the current ACOTE standards.
What Are Other Disciplines Doing?
Unlike ACOTE, the Commission on Accreditation in Physical Therapy Education (CAPTE, 2020) mandates that physical therapy programs “describe the efforts of the program to recruit a diverse student population” (p. 17) and “describe how retention practices support a diverse student body” (p. 19). In addition, CAPTE (2020) defines diversity in its document, whereas ACOTE does not. Approximately 89% of physical therapists identify as non-Hispanic White (American Physical Therapy Association, 2020), while 73% of physical therapy students identify as non-Hispanic White (CAPTE, 2019). These numbers signify that the student population being enrolled in physical therapy programs is more diverse than current physical therapists, a shift that is occurring alongside the presence of accreditation standards addressing the needs of a diverse student population.
The Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA, 2020) mandates that “the program makes reasonable adaptations in curriculum, policies, and procedures to accommodate differences among individual students” (p. 26). CAA (2020) specifically stated that “the program must provide evidence that its curriculum and program policies and procedures for admission, internal and external clinical placements, and retention of students reflect a respect for and understanding of cultural, linguistic, and individual diversity” (p. 26). The demographic data gathered by the American Speech-Language-Hearing Association (2021) indicate that approximately 91% of practitioners identify as non-Hispanic, and 92% identify as White. Of master’s students, approximately 75% identify as non-Hispanic White, 24% identify as URM, and 1% identify as international students (Council of Academic Programs in Communication Sciences and Disorders & American Speech-Language Hearing Association, 2021). Among post–entry-level clinical doctorate students, approximately 62% identify as non-Hispanic White, 37% identify as URM, and 1% identify as international. These data reveal an increase in the number of current URM speech-language pathology students enrolled in academic programs, which again could potentially be attributed to the accreditation standard that emphasizes the importance of a diverse student body.
The number of physical therapy and speech-language pathology students is increasing to represent a more racially and ethnically diverse population in each field. The standards identified by our therapy colleagues, as well as Jaegers and colleagues’ (2020) call to action, indicate an opportunity for change in occupational therapy. A revised set of ACOTE standards can make recruitment and retention of students from diverse racial and ethnic backgrounds a priority.
Where Do We Go Now?
Given the knowledge on health disparities, the demographics of health care professionals in our diversifying nation, and the various accreditation standards that govern the different health care fields, action must be taken at a systemic level to diversify students enrolled in occupational therapy programs, as they will become the future workforce. In this column, we have emphasized the need for an addition to, or revision of, the current ACOTE standards to outline general requirements each program must have to support URM occupational therapy students. Therefore, similar to other accrediting bodies that govern health care disciplines, and in response to occupational therapy’s call to action for justice (Jaegers et al., 2020), ACOTE should add a standard that supports the recruitment and retention of URM students, because the data reflect a disproportion between non-Hispanic White and URM occupational therapy students (Harvison, 2019). This proposed mandate would require programs to document strategic efforts taken to recruit and retain URM students throughout their occupational therapy education. This standard would ensure accountability among programs to make efforts but would not punish those who do not see an increase in URM occupational therapy applicants or students. Documented efforts to recruit and retain URM occupational therapy students may include steps such as
A holistic admissions process that looks beyond standardized test scores and grade point average (Goode & Landefeld, 2018; Jaegers et al., 2020; Zerwic et al., 2018),
Mentorship programs to recruit and retain students and help graduates transition into the workforce (Bleich et al., 2015; Gates, 2018; Taff & Blash, 2017; Valentine et al., 2016), and
Remediation and tutoring programs (Alicea-Planas, 2017; Gates, 2018).
These suggested changes to ACOTE standards are ultimately intended to increase the number of URM students who complete occupational therapy programs, which could inevitably help reduce injustices for URM populations as these students enter the workforce (Institute of Medicine, 2004; Jaegers et al., 2020; Noonan et al., 2016; Wilbur et al., 2020; Woolf & Braveman, 2011). With an addition to or revision of the current ACOTE standards, an occupational cascade will begin to effectively support the academic performance of URM occupational therapy students. It also will begin to shift our profession, and those affected by it, toward equity, inclusion, and justice.