Understanding Accreditation Requirement Trends of Teaching Occupation in Occupational Therapy Curricula

Occupation in Occupational Therapy Education

ACOTE was officially established in 1994, after 71 yr of educational standards developed by the AOTA Accreditation Committee and the American Medical Association (ACOTE, 2020a). At present, ACOTE accredits, or is in the process of accrediting, nearly 600 occupational therapy programs, including occupational therapy assistant and occupational therapy programs in the United States (ACOTE, 2023). As components of the requirement of initial accreditation or maintaining active accreditation, academic programs teach courses that address student competence across the required B standards assigned to a given program type (Doctorate of Occupational Therapy [OTD], Master of Occupational Therapy [MOT], occupational therapy assistant [OTA] baccalaureate degree, or occupational therapy assistant associate’s degree. According to ACOTE (2022), the B standards are written as expected student outcomes. Faculty are responsible for developing learning activities and evaluation methods to document that students meet these outcomes. Programs must demonstrate compliance with all components of a content standard.

Since 1994, ACOTE accreditation standards have undergone periodic revision; in the meantime, the focus on the teaching and learning of the knowledge of occupation has also changed. Attention to how the teaching and learning of occupation has evolved in ACOTE educational standards published from 1991 (and revised in 1995) to the most recent version in 2018 is warranted. Understanding action verbs, such as in Bloom’s (1956) taxonomy, can be a useful way to understand the complexity of teaching and learning of concepts, such as the teaching and assessment of learning occupation. According to Burwash et al. (2016), Bloom’s taxonomy remains an influential framework for curriculum design. These taxonomy levels are evident, if not explicitly acknowledged, in the current ACOTE standards for American occupational therapy educational programs.

Bloom’s Taxonomy

Bloom’s taxonomy was originally developed in 1956 by Benjamin S. Bloom and a large team of contributors for the purpose of “classifying the goals of the educational process, since educational objectives provide the basis for building curricula and tests and represent the starting point for much of our educational research” (Bloom, 1956, p. 4). The original taxonomy is organized to classify the intended behaviors of students after participating in an assignment, task, exam, or activity related to an objective. These intended behaviors include how an individual acts, thinks, or feels after the instructional unit (Bloom, 1956, p. 12). The order of the taxonomy is also important to creating objectives or standards for the educational process; therefore, the categories are exceedingly complex. Originally, there were six categories: (1) Knowledge, (2) Comprehension, (3) Application, (4) Analysis, (5) Synthesis, and (6) Evaluation (Bloom, 1956, p. 18).

In 2001, the taxonomy was revised to include action verbs that could be more readily adoptable in academia. The revised Bloom’s taxonomy classifies thinking skills into six hierarchically organized categories that range from lower level cognitive skills (know and understand) through higher order cognitive skills (Apply, Analyze, Evaluate, Create) and are based on the verbs teachers select when they describe expectations for students’ thinking skills and behaviors in a learning outcome (Anderson & Krathwohl, 2001). Verbs at lower levels of the revised Bloom’s taxonomy describe the acquisition of knowledge and facts, whereas verbs at the higher levels describe complex thinking skills, including application of knowledge to practical problems, analysis of competing interpretations, and creation of new knowledge or alternative interpretations of existing findings (Stanny, 2016).

The degree to which occupational therapy assistant and occupational therapy students are required to learn about occupation can be understood by referencing how frequently ACOTE includes hierarchical revised Bloom’s taxonomy action verbs with occupation in the B standards. Because the revised taxonomy is hierarchical in nature, learning at higher levels of complexity is dependent on having attained prerequisite knowledge and skills at lower foundational levels of learning. For occupational therapy practitioners to use occupation therapeutically with people, populations, and communities, it is important to reference their degree of past academic preparations, including both the lower level cognitive skills and higher order cognitive skills of learning occupation. We believe that for occupational therapy practitioners to maximize their skills in occupation-based practice, they first must gain an understanding of the knowledge and understanding of occupation at the lower foundational levels of learning about occupation.

Connecting Accreditation Standards to the Revised Bloom’s Taxonomy

To take a historical view of accreditation standards that center on occupation as a foundational concept, we reviewed each published version of the accreditation standards, from 1923 to its most current, 2018 version (AOTA, 1924; AMA, 1935, 1943, 1949, 1965; AOTA & AMA, 1973, 1983, 1991; AOTA, 1999, 2007, 2012, 2018). The keyword terms occupation and occupations were identified. Other derivatives of occupation, such as occupation-based practice, were not included because this term, for example, implies the application of occupation in practice and not the understanding of occupation.

Four sets of educational standards have been published since ACOTE was established in 1994 (1998 [AOTA, 1999], 2006 [AOTA, 2007], 2011 [AOTA, 2012], and 2018 [AOTA, 2018]). Action verbs were not used in the 1991 (AOTA, 1991) and 1998 (AOTA, 1999) editions of the standards. Explicit inclusion of action verbs in ACOTE standards began in 2006. We conducted an academic standards review for ACOTE standards for the 2006, 2011, and 2018 versions. In each ACOTE standards review, the keyword occupation(s) and its associated revised Bloom’s taxonomy action verbs were recorded for each occupational therapy program type. Action verbs were then categorized under their respective hierarchical learning of occupation, for example, whether occupation was required to be taught at a lower order cognitive skill level (Remember and Understand) or whether it was required at a higher order cognitive skill level (Apply, Analyze, Evaluate, Create).

Many versions of Bloom’s taxonomy action verb lists exist, and it was important for our analyses that we use a version that was relevant to occupational therapy education. Stanny (2016) completed a review of 30 different compilations of measurable action verb lists created by educational programs, institutions, and teaching and learning centers. This analysis recorded the verbs used in each taxonomy and the frequency with which each verb was used in each column. For example, among the 30 lists Stanny reviewed, the verb explain was recorded in the “Understand” column 28 times and in the “Apply” column 5 times. For our purposes, action verbs that had the highest frequency in each column were placed in that column. We used Stanny’s list in our review of ACOTE standards from 1991 to 2018. Table 1 contains the reconstructed list of ACOTE B standard verbs in their taxonomy columns.

We used the data in Table 1 to conduct an analysis of action verbs across ACOTE standards from 2006 to the most recent version in 2018 across occupational therapy assistant, MOT, and OTD programs. Before conducting our analysis, we proposed two hypotheses: There would be (1) a reduction of B standards requiring the teaching and learning of occupation from 2006 to 2018, and (2) fewer standards that included the lower order action verbs compared with higher order action verbs for learning occupation across B standards for all academic programs.

The number of B standards addressing lower level and higher level cognitive skills for occupational therapy assistant, MOT, and OTD programs are presented in Appendix Tables A.1, A.2, and A.3. The total number of B standards for lower level versus higher level cognitive skills of occupation are compared in a bottom-row frequency count under each version of the standards. The total number of B standards that include occupation for each version year is included in the far-right column of each table.

Accreditation Standards on Occupation for Occupational Therapy Assistant and Occupational Therapist Programs

Table A.1 illustrates the categorization of action verbs within the occupational therapy assistant B standards. In the 2006 standards, there were 11 occupational therapy assistant B standards with the keyword occupation out of 86 B standards. Six of the 11 B standards were foundational (“Remember” or “Understand” columns). In the 2011 standards, 9 of the 88 total B standards included the term occupation(s). Of these 9, 5 were foundational in nature. In the 2018 standards, 6 B standards of the 55 B standards included occupation(s). Only 1 B standard was foundational.

Table A.2 shows the categorization of action verbs within the MOT B standards. In the 2006 standards, 12 of 103 B standards had the keyword occupation. Of these 12 B standards, 7 were categorized in the two foundational levels of the taxonomy. In the 2011 standards, 10 of 103 B standards included occupation. Six of these 10 B standards were foundational. In the 2018 standards, only 6 of the 61 B standards included the word occupation. Only 1 of these 6 standards was categorized in the lower order cognitive skill levels.

Table A.3 illustrates the categorization of action verbs within the OTD B standards. In the 2006 standards, 12 of 111 B standards included occupation. Seven of these 12 were foundational in nature. In the 2011 standards, 10 of 110 B standards included occupation. Six of these 10 were in the foundational categories. In the 2018 standards, 7 of 61 B standards had the keyword occupation, with only 1 of these 7 in a lower order cognitive skill level.

Our findings have important implications for B standards. Our first hypothesis—that there was a reduction in B standards on occupation from 2006 to 2018—was true across all academic programs. It was interesting to observe that the lower order cognitive action verbs were reduced from 6 or 7 B standards in 2006 to just 1 B standard in 2018 across all degree areas. Our second hypothesis—that there would be fewer standards that included the lower order action verbs compared with higher order action verbs for learning occupation across B standards for all academic programs—was not true in 2006 and 2011 but was true in 2018. Overall, the requirements have a reduced emphasis on student learning of occupation across degree levels for occupational therapy assistant and occupational therapy students.

Implications for the Occupational Therapy Profession

From 2006 to 2018, the number of ACOTE B standards requiring the teaching and evaluation of occupation declined in both lower order and higher order cognitive skill levels across all degree programs. Lower order cognitive skills–level standards set the foundation for the use of higher order cognitive skills–level standards. Having a reduced number of lower order cognitive skills B standards over the years may have resulted in a reduced ability for students to apply, analyze, evaluate, and creatively use occupation in education and practice. In addition, having a reduced number of B standards centered on occupation can make it challenging for educators to hold occupation as a central organizing idea in their academic curriculum when they are simultaneously trying to remain in compliance about 100 other academic B standards.

The issue is, why has there been a reduction in the number of ACOTE B standards that cover occupation? Is there an assumption that occupational therapy assistant and occupational therapy students already understand occupation so that they can apply, analyze, evaluate, and creatively use occupation during their education? The preamble to the B.1.0 Foundational Content Requirements of the 2018 ACOTE standards states that “Program content must be based on a broad foundation in the liberal arts and sciences. A strong foundation in the biological, physical, social, and behavioral sciences supports an understanding of occupation across the lifespan.” (AOTA, 2018, p. 25). An understanding of occupation across the lifespan could better be supported with a foundational education focused on occupation itself as opposed to expecting students from a variety of other disciplines to have an understanding of occupation. Student learning of occupation as a foundation is necessary for the application of occupation to fieldwork education (C standards) and capstone/baccalaureate projects (D standards). However, C and D standards do not use revised Bloom’s taxonomy action verbs and do not have a focus on lower or higher level cognitive skills. Because there was a considerable reduction of standards related to student learning of occupation in the 2018 ACOTE standards compared with earlier versions, one could argue that students and practitioners who learned under the 2018 ACOTE standards may have had greater challenges in fieldwork, capstone/baccalaureate projects, and using occupation-focused and -based methods in practice.

According to the World Federation of Occupational Therapists (WFOT; 2016), “rapid technological advances in science and education, as well as new research findings in occupational therapy, demand greater attention to foundational knowledge in order to scaffold professional content and learning processes” (pp. 5–6). Moreover, WFOT (2016) stated that “in the same way that using occupation to promote people’s health and well-being is the distinctive element to occupational therapy, occupation is central to all programmes for the education of occupational therapists” (p. 23). WFOT also discussed applying the foundational use of occupation: “An understanding of the local beliefs, values, and meaning of occupation will inform how occupational therapists use occupation in the local context (p. 28).

Knowledge of occupation that comes from personal experience and observation must be augmented by the understanding of occupation drawn from research in occupational therapy and occupational science as well as other disciplines (Johnson & Dickie, 2019). Occupational science is important to occupational therapy because the knowledge of, and skills in, understanding and enabling human occupation are essential foundations of occupational curricula (WFOT, 2012). WFOT (2012) outlined several thematic examples of how academic programs can infuse a deeper level of occupation into academic programs. In the 2011 ACOTE standards, occupational science was a required B standard (Standard B.1.3). In the latest 2018 ACOTE standards, occupational science was removed and is no longer required to by taught in academic programs. If Yerxa (1998) was correct in stating that the strength of the occupational therapy profession is connected to the power of those it serves through the knowledge of occupation, has the profession been weakened with the reduction of ACOTE B standards on occupation, coupled with the relatively recent removal of occupational science?

Some specific strategies can be implemented in educational programs to elevate the focus on occupation outside of relying on ACOTE B standards. We offer three recommendations for programs that are seeking to include more occupation in their curricula:

Examine your curricular design and build in foundational course content on occupation aside from the application of occupation to practice. This would occur at the beginning of the program and be reinforced sequentially throughout the program as courses build in complexity.

ACOTE is currently revising the academic standards that, beginning in 2025, will guide the landscape of occupational therapy assistant and occupational therapy education. It will be interesting to see whether there is a change of course in adding more occupation to the B standards as well as returning occupational science (not the science of occupation) back to them. The stronger the foundation our students have on occupation, the more equipped they will be in terms of having a greater ability to apply, analyze, evaluate, and creatively use occupation in practice.