Saturday, August 29, 2015

Investigating the status of "The Pledge and Creed for Occupational Therapists"

A little over a year ago I presented an argument that the Emmanuel Movement provided important core values for the occupational therapy profession.  This argument was constructed in context of a debate on whether or not Social Justice was a historical value of the profession.

I was curious as to why we neglected to include the Emmanuel Movement when we discussed our values and beliefs.  In the beginnings of the 20th century the Emmanuel Movement was based on the notion that a new method was required to address the social problems of disability and illness.  That new method was a philosophy regarding responsibility and self reliance - and surrounded by Christian values of charity.

Furthermore, that method was most certainly not based on a governmental model of redistribution or in a new age construct of oppression and liberation.  That fact is what made some of the recent social justice debates so curious.


Shannon (1977) warned that "a discipline that forgets its founders may be lost."



I have been studying these Values and Beliefs articles for a couple years and I recently noticed something that seemed to be missing.  In the initial article for the series covering the dates from 1904-1929 there is no mention of the  Occupational Therapy Pledge and Creed.  Certainly a Pledge and Creed would be an important document that would reflect both values and beliefs. 

The Occupational Therapy Pledge and Creed was submitted by the Boston School of Occupational Therapy and adopted by AOTA in 1926.  What is noteworthy is that the Pledge and Creed is mentioned in the book of one of the authors of the Values and Belief series (Reed and Sanderson, 1999, p. 408).  The Pledge and Creed states:


REVERENTLY AND EARNESTLY do I pledge my whole-hearted service in aiding those crippled in mind and body.

TO THIS END that my work for the sick may be successful, I will ever strive for greater knowledge, skill and understanding in the discharge of my duties in whatsoever position I may find myself.

I SOLEMNLY DECLARE that I will hold and keep inviolate whatever I may learn of the lives of the sick.

I ACKNOWLEDGE the dignity of the cure of disease and the safeguarding of health in which no act is menial or inglorious.

I WILL WALK in upright faithfulness and obedience to those under whose guidance I am to work, and I pray for patience, kindliness, and strength in the holy ministry to broken minds and bodies.


Most interestingly, Reed and Sanderson document that this Pledge and Creed "remains official today" when their book was published in 1999.  Since Reed wrote about the Pledge and Creed in 1999 certainly she was aware of it when she wrote the Values and Beliefs series.  I am not sure why it would not be mentioned in the series.

I have not been able to locate any documentation or announcement that this Pledge and Creed has ever been rescinded but this is an area that I am continuing to investigate.

Aside from the curious omission from the values and beliefs series it is important to note that such a Pledge and Creed incorporates a view of occupational therapy that is at severe odds with the changes that have been espoused by some therapists in the last twenty years.  Values of social justice, political redistribution of resources, client-based ethics, and redefinition of who we provide services to (whole communities, agencies, non-human entities, etc) are all severely out of step with the Pledge and Creed.  

The words 'pray' and 'holy ministry' are certainly interesting and I wonder if that is why the Pledge and Creed are not mentioned by those who espouse a secular interpretation of occupational therapy history.

I am not advocating the position that OT has to be explained in Christian terms but perhaps the inability to advance and explain the spiritual dimension of practice is why we have become so lost with our definitions. The existence of the Pledge and Creed presents itself as a philosophic conundrum for the profession.  

The Pledge and Creed is not on the AOTA website.  Has it been rescinded?

Does it 'remain official today?'

Is it the will of the association to rescind the document if it has not already been done?

If not expressed in specific terms of Christian ethics, how does the occupational therapy profession express its interest in spirituality?  We have lost our way on this topic. Howard and Howard (1997) asked "What does spirituality have to do with occupational therapy?"  They mentioned the early influence of the Immanuel (sic) movement, but it is clear that even in attempting to cover the topic that they apparently missed the mark.  Christiansen (1997) stated that "by failing to acknowledge a spiritual dimension, occupational therapy practitioners lose important opportunities for understanding the full potential of occupation to enhance the health and well-being of clients."

Egan and Swedersky (2003) state that "given the diverse definitions and the multiple meaning of spirituality in practice it is perhaps not surprising that studies of American, British, and Canadian occupational therapists are unsure of the role of spirituality in practice."

But even with these acknowledgements of spirituality in practice we have approached the subject as if we are doing so for the first time.  What an unusual position for a profession to be in when its very roots were based in a notion of mind-body-spirit healing!

References:

embedded links, and...


Christiansen, C. (1997).  Acknowledging a spiritual dimension in occupational therapy.  American Journal of Occupational Therapy, 51, 169-172.

Egan, M. and Swedersky, J. (2003). Spirituality as experienced by occupational therapists in practice.  American Journal of Occupational Therapy, 57, 525-533.
Howard, B.S. and Howard, J.R. (1997). Occupation as spiritual activity.  American Journal of Occupational Therapy, 51, 181-185.

Sanderson, S.N. and Reed, K.L. (1999).  Concepts of occupational therapy, 4th ed. Philadelphia: Lippincott, Williams, and Wilkins.

Shannon, P.D. (1977). The derailment of occupational therapy. The American Journal of Occupational Therapy, 31, 229-34.


Friday, August 28, 2015

Ethical occupational therapy practice in nursing home care

I teach ethical decision making to occupational therapy students.  One of the most common concerns that I hear from students each year is the pressure that they experience regarding productivity and 'meeting minutes requirements' in skilled nursing facilities.  Nursing homes receive higher rates of reimbursement based on intensity of rehab services that are provided, so there is an incentive for facilities to provide as much 'high intensity' therapy as possible.

Typically, the students express ethical distress because they often believe that the recipients of these services are receiving marginal or no benefit from their participation.

As a population, OT students feel disempowered about expressing concerns in this area during their fieldwork experiences because

a) they perceive that they are 'just students' and don't want to make waves
b) they feel confused because their clinical preceptors are all engaging in the behavior
c) they have competing pragmatic concerns, like graduating on time, having to find a new fieldwork, etc

Students report that many practitioners 'go along' with the push for more therapy because they become concerned with job security or that they simply accept these practices as 'being the way things are done.'

The Wall Street Journal wrote an excellent investigative article on this issue that I encourage others to read fully and carefully.  The article can be found here: http://www.wsj.com/articles/therapy-is-for-helping-patients-not-the-nursing-homes-1440539579

The article describes massive increases in therapy that advantage Medicare payment rules:

"The ultrahigh-therapy rise stretches from small operators to chains. Genesis HealthCare Corp., among the largest nursing-home providers, cited ultrahigh therapy in 58% of days for which it billed the system in 2013, a Journal analysis of Medicare data shows, up from 8.1% in 2002.

Kindred Healthcare Inc., which runs nursing homes and provides therapy at other facilities through its RehabCare unit, did so 58% of the time in 2013 at its own facilities versus 7.6% in 2002. Kindred and Genesis declined to comment.

HCR billed for ultrahigh services 68% of the time in 2013, versus 8.8% in 2002. In December, the Justice Department joined a whistleblower lawsuit alleging HCR pressured employees to provide unnecessary therapy and overbilled Medicare."

The leaders of the speech, physical, and occupational therapy member associations responded to the article with this letter that can be found here: http://www.wsj.com/articles/therapy-is-for-helping-patients-not-the-nursing-homes-1440539579

The response pays appropriate concern to the problem, but I believe that the member associations need to do more than simply "dialogue with industry to address the issue of volume-based versus value-based care and to improve compliance" and "help clinicians navigate complex regulation and payment systems, emphasize their responsibility to report unethical care provision and promote value-based patient care."

Some therapy groups named in the Wall Street Journal Article declined to comment but they also have direct relationships with the member associations, including sponsorships, clinical affiliation agreements, and other opportunities where they 'partner' with the member associations.

I believe it is reasonable to suspend these kinds of partnership arrangements until there can be a more thorough investigation about the practices of these companies.  Membership associations can't claim to be concerned about possibly unethical or even possibly illegal practices that are discussed in the Wall Street Journal article while they are forming partnerships with these agencies at the same time.

Writing a letter in response to the article only pays lip service concern, particularly when partnership agreements with these agencies remain in force.  Temporarily suspending partnerships pending investigations is prudent and sends a much stronger message about the actual concerns of member associations.  Partnerships can be renewed if there is no wrongdoing.  If there is wrongdoing, the member associations should not be partnering with these groups.

Monday, August 17, 2015

The occupational therapy profession's indecisive step toward its Centennial Anniversary

The Accreditation Council for Occupational Therapy Education released an unexpected set of decisions last week.

In sum, the two decisions promote the concept of dual entry levels for OTA education and dual entry levels for OT education.  The OTA dual entry (associates and baccalaureate) is an entirely new concept while the OT dual entry (masters and doctoral) follows a year-long debate on whether or not the profession should adopt the doctoral level as a single point of entry.

The reason why each of these decisions was surprising is because they contradicted the publicized opinions of the American Occupational Therapy Association, the member group for the profession.

As such the 'problem' with the decisions doesn't rest with ACOTE alone, but rather represents a community of professionals that are at odds with themselves and unsure of how to move toward the future.

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Regarding OTA education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OTA education and came up with three recommendations.  Those recommendations were:

1. Keep OTA education at the associate level
2. Have only one level of degree entry for OTAs
3. Articulate strategies to succeed if the association ever decides to transition to a higher degree level for OTAs.

The reports states that "While there may be some benefits to the two entry-level-degree model, they do not  outweigh the inconsistencies created when  there are  two different degree levels qualifying  graduates for a single set of entry-level competencies."

The full report is available at www.aota.org/.../OT-Entry-Level-Degree-ADHoc-Final.pdf

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Regarding OT education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OT education and came up with nineteen recommendations.  The most relevant regarding entry level was:

"AOTA adopt a mandate that entry-level-degree for practice as an  occupational therapist be a  doctorate by 2017 with a requirement for all academic programs  transition to the doctorate by 2020."

The full reports is available at http://www.aota.org/-/media/Corporate/Files/EducationCareers/Educators/Future-of-Education-Final-Report-2014.pdf

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The ACOTE decisions now recommend dual entry for both levels and apparently disregard concerns stated in the above reports in promoting what they are calling 'flexibility.'  ACOTE recognizes inherent difficulties with lack of differences in program outcomes between different levels, difficulties with infrastructure needed to support doctoral programs, and the paucity of fieldwork sites.  These are significant barriers that have been correctly identified.  The full statement is available at http://www.aota.org/Education-Careers/Accreditation/Announcements.aspx

Flexibility is certainly achieved by having dual entry points but also shows a profession that lacks leadership, direction, and ability to make definitive decisions and move toward a consensus.  In the parallel example of multiple entry points for the nursing profession, Smith (2009) states, "The requirements for entry into and completion of these programs vary by state and are controlled by forces within each state’s higher education system and healthcare-related interest groups, and the nursing profession itself."  This is what will also occur within the occupational therapy profession and is already on display in New York State.  A group of academicians, supported explicitly by the State OT board and tacitly by the State member association, is laying the groundwork for an eventual doctoral level entry point.  See here for details.

Not every state has interest groups that will powerfully drive the issue toward a conclusion.  There is a severe maldistribution of occupational therapy educational programs in the United States.  States with few or no programs and weaker State Associations might be among the last to promote a voluntary doctoral level entry point.  This will cause compounding problems with lack of consistency.

Smith (2009) lists several factors that likely contributed to the nursing profession's inability to agree on escalating degree requirements.  Use of a 'top down' decision making strategy was a major impediment that turned many nurses off of the idea of escalating entry level.  Also, the use of 'policy entrepreneurs' who were knowledgeable and well connected backfired on nurses because those people were not viewed as 'one of us' by the average nurse who would be impacted by the decision.  These same factors came into play for occupational therapy.

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Several actions are recommended in order to move the occupational therapy community to a consensus decision point.

1. Recognize that "flexibility" is a euphemism for indecision and confusion.  Study the nursing profession example to understand what "flexibility" has accomplished and not accomplished.

2. Place an accreditation moratorium on development of ALL entry level doctoral OT programs and baccalaureate level OTA programs.

3. Outline a process that will encourage a critical analysis of accreditation standards and align their minimal purpose with meeting evidence-based entry level occupational therapy practice competencies.

4. Develop profession-wide consensus on essential educational components based on practice analysis of entry level and advanced level skill sets through research.

5. Listen to and address the relevant concerns of the entire constituency that is impacted by such a decision: academia, clinicians, employers, the public, and other stakeholders.  Most importantly, don't drive this from a top-down perspective.

6. Develop final consensus based on a comprehensive consideration of ALL THE ABOVE.

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The current recommendation to promote dual entry levels will allow a condition of indecision to persist.  From a vacuum of indecision we can expect more special interest meddling from within different States.  We can expect a lack of uniformity that can complicate if not jeopardize third party reimbursements.  We can expect continued maldistribution of personnel.  We can expect uneven practice competency.

The occupational therapy profession is about to celebrate its Centennial Anniversary.  Confused and indecisive entry level education standards are not the way to put a best foot forward into a new century.
 

Reference:

Smith, T., (October 5, 2009) "A Policy Perspective on the Entry into Practice Issue" OJIN: The Online Journal of Issues in Nursing Vol. 15 No. 1. 


Tuesday, August 04, 2015

OTD 45 day comment period coming to a close next week


This post represents continuing analysis of the process to change the entry level educational requirements for practicing occupational therapy from the masters level to the doctoral level.  The analysis is offered as a public critique of the occupational therapy profession's methodology for enacting such a change.

The 45 day comment period on a new rule that will authorize the conferral in New York State of the degree of Doctor of Occupational Therapy (O.T.D.) will come to a close at the end of next week.

The American Occupational Therapy Association reports:

In June 2015 AOTA staff also surveyed the 152 accredited master’s-degree-level programs, with 131 (86%) responding to the survey. Of the 131 programs that responded, 106 (81%) indicated that they had started working on a transition to the doctorate and planned to have this completed within 10 years (86 within 5 years). 

As I stated recently, "In my opinion the American Occupational Therapy Association Board of Director's 'recommendation' to move to the entry level doctorate is a dog whistle call to academicians to begin readying for a change to an entry level doctorate."  Looks like my analysis was spot on.

The American Occupational Therapy Association also reports:

What is clear from the data collected is that overall, the occupational therapy community is split on this issue, and that the overwhelming majority of participants in the dialogues see both potential threats and opportunities in moving the entry-level degree requirement to the clinical doctorate. 

I note the careful use of the word 'split,' which casually implies equal or near equal parts - but we are living in Orwellian times where words are carefully used this way.  A more accurate representation of this 'split' opinion in OT is probably near 75% in opposition and 25% in support.  Most of the support comes from academicians.

I based this on my own reading of the OT Connections forums and other social media sites and from the expression of opinion in the Town Hall at the AOTA National Conference.

The word-crafting does not end with the word "split."  It is also notable that in the Representative Assembly discussions nearly all the commentary from reps was negative.  On March 31 I posted the following in the RA feedback forums: (link is restricted to AOTA members)

AOTA members should take careful note of the strategies employed in the discussions about the move to an entry level doctorate. In several of the threads discussion was started - and that discussion was almost universally negative or hesitant about the move to an entry level doctorate. Then the Task Group Leaders in a couple threads suggested that Reps use a SWOT analysis in order to express their opinions, because "It will help when gathering and organizing the comments from the four task groups." Use of a SWOT analysis format FORCES reps into making statements that they were not naturally making. Prior to the directive, reps were responding naturally with perceptions of weakness and threats associated with the change. Now their comments are being naturally counterbalanced because they are being asked to include Strengths and Opportunities. Someone made the decision to ask for SWOT, and reps should all wonder where that request came from and why it was made. SWOT does not make data gathering any easier - all it does is balance out the feedback and artificially promote positive comments. That is how the thumb is placed on the scale and influences feedback. It is a detail that does not escape the notice of the membership who is watching this process closely. 

ACOTE will release the results of a survey of 3000 respondents sometime later this month.  It will be interesting to see the results of that poll, and an analysis will be posted here.

One refreshing point of honesty from AOTA was mentioned in their latest statement when they reported "It is likely that student debt will increase, and that continues to be a concern"

The debt issue alone should mobilize some students and parents to write a letter to NY State Department of Education and offer some feedback about the rising cost of higher education and whether or not there is evidence to continue escalating degree requirements and subsequent costs.

I posted a question on the NYSOTA Facebook page two weeks ago asking for their public comment on the OTD proposal.  That question remains unanswered.  According to NYSOTA documents from a couple months ago, there were 1308 student members, which constitutes approximately 65% of their membership.  Perhaps that is why they don't want to answer this question?

This change will probably happen anyway primarily at the whim of academics who have decided the issue for everyone else.  Readers have until next week to register an opinion with the NY State Department of Education.  Write to:

Office of the Professions,
Office of the Deputy Commissioner
State Education Department 
State Education Building 2M
89 Washington Ave.
Albany, NY 12234
(518) 486-1765
email: opdepcom@nysed.gov