The meaning gap in occupational therapy: Finding meaning in our
own occupation
Fran E. Aiken, Anne M. Fourt, Isabella K. S. Cheng, Helene J. Polatajko
Key words
Meaning
Occupational therapy
Professional practice
Qualitative research
Reflection
Abstract
Mots clés
Ergothérapie
Pratique professionnelle
Recherche qualitative
Réflexion
Sens
Fran E. Aiken, MEd, OT Reg. (Ont.)
was Professional and Education Leader
at the time of the study, now retired,
Occupational Therapy Services, Sunnybrook Health Sciences Centre, Toronto,
ON, Canada, M4N 3M5, and Associate
Professor in the Department of Occupational Science and Occupational Therapy,
University of Toronto. E-mail: maiken@
rogers.com
Anne M. Fourt, MEd, OT Reg. (Ont.)
is Trauma Therapy Program Coordinator, Women’s Mental Health Program,
Women’s College Hospital, 76 Grenville
St., 9th Fl., Toronto, ON, Canada, M5S 1B2,
and Assistant Professor, Department of
Occupational Science and Occupational
Therapy, University of Toronto.
Telephone: 416-323-6400, ext. 4859.
E-mail: [email protected]
Isabella K. S. Cheng, BHSc(OT), OT
Reg. (Ont.) is Professional and Education
Leader, Occupational Therapy Services,
Sunnybrook Health Sciences Centre,
DG-11B–2075 Bayview Ave., Toronto, ON,
Canada, M4N 3M5 and at the time of the
study, Occupational Therapist,
SunPACT—Sunnybrook Program of
Assertive Community Treatment, and
Lecturer, Department of Occupational
Science and Occupational Therapy,
University of Toronto.
Helene J. Polatajko, PhD, OT Reg.
(Ont.), OT(C), FCAOT, FCAHS is
Professor, Department of Occupational
Science and Occupational Therapy,
Graduate Department of Rehabilitation
Science, and Dalla Lana School of Public
Health, University of Toronto, 160–500
University Ave., Toronto, ON, Canada,
M5G 1V7.
294 Revue canadienne d’ergothérapie
Background. Occupation is a core concept of our profession, yet little is understood about how therapists use occupation in clinical practice. Purpose. This study
explores frontline clinicians’ experience with occupation-based practice in a large
academic health sciences centre. Methods. A qualitative constructivist study was
conducted using thematic analysis, following in-depth interviews with 12 occupational therapists. Findings. Participants described the existence of two realities:
Occupational therapy as they felt it should be practiced and as it actually is practiced. When the two were incongruent, participants experienced a meaning gap,
which was expressed through four themes to reveal that a personal sense of occupation guides practice and transforms the meaning of the job. Implications. The
exploration of personal occupational meaning through conscious self-reflection
and co-creation of meaning with clients and their health care teams may serve to
bridge the meaning gap.
Abrégé
Description. L’occupation est un concept de base de notre profession, et pourtant,
on connaît peu de choses sur la façon dont les ergothérapeutes utilisent l’occupation
dans la pratique clinique. But. Cette étude se penche sur l’expérience des cliniciens de
première ligne face à la pratique fondée sur l’occupation dans un grand établissement
d’enseignement en sciences de la santé. Méthodologie. Une étude qualitative
constructiviste a été menée à partir d’une analyse thématique, suivie d’entrevues en
profondeurs effectuées auprès de 12 ergothérapeutes. Résultats. Les participants
ont décrit l’existence de deux réalités : la façon dont l’ergothérapie devrait être exercée
de leur point de vue et la façon dont l’ergothérapie est exercée dans les faits. Lorsque
ces deux réalités étaient incongrues, les participants ressentaient un manque de sens,
qui a été exprimé au moyen de quatre thèmes ayant révélé que le sens personnel que
l’on attribue à une occupation oriente la pratique et transforme le sens de l’emploi.
Conséquences. Il est possible de combler un manque de sens en explorant le sens
personnel attribué à une occupation à partir d’une réflexion personnelle consciente
et de la création de sens avec les clients et leurs équipes de santé.
Citation: Aiken, F. E., Fourt, A. M., Cheng, I. K. S., & Polatajko, H. J. (2011). The meaning
gap in occupational therapy: Finding meaning in our own occupation. Canadian Journal of Occupational Therapy, 78, 294-302. doi: 10.2182/cjot.2011.78.5.4
Submitted: January 25, 2011; Final acceptance: August 10, 2011.
Funding for this project was provided through the Sunnybrook & Women’s Practice
Based Research Fund.
This manuscript was initiated under the editorship of Dr. M. Finlayson and accepted
under the associate editorship of Dr. C. Backman.
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Aiken et al.
ccupation has been a core concept of the occupational
therapy profession since its inception (Meyer, 1922).
Over the years, however, the role and significance of
occupation has shifted, from what was initially a source of
diversion, through use as a therapeutic medium, to enablement (Polatajko, 2001). In Enabling Occupation II: Advancing
an Occupational Therapy Vision for Health, Well-Being & Justice through Occupation (Enabling Occupation II) (Townsend
& Polatajko, 2007), occupational therapy practice is viewed as
driven by theory and processes instead of method, and is envisioned to have a future that is occupation-based and focused
on enablement, so that all people may be engaged in meaningful occupation. That is, Enabling Occupation II defines our
practice not by tasks and procedures, but rather by the systematic series of enabling actions that are focused on occupation.
While exciting, this vision is a departure from the occupational therapy that had emerged over the years, an occupational therapy that was generally organized along clinically
defined programmatic areas (Baum, Berg, Seaton, & White,
2002; Jongbloed & Wendland, 2002) and had become focused
on a component approach to remediation of specific medical
problems (Wilcock, 1991; Yerxa, 1993), particularly in teaching hospitals where medical referral is still required.
This illness-focused perspective (Bryen & McColl, 2003;
Whiteford, Townsend & Hocking, 2000) led therapists to
translate an occupational perspective into medically measurable components, a practice that neither encompassed the
full scope of enabling occupation (Mattingly, 1991; Cockerill,
Scott, & Wright, 1996; Wilcock, 1998), nor was connected to
the meaningful occupations that our profession valued and
endorsed. As both Pierce (2003) and Fisher (2003) have noted,
the profession lost connection to occupation as it advanced
and aligned itself with outcomes-oriented health care. They
contend that if therapists improved their understanding of the
power of occupation to enable clients, therapists would use
occupation both as therapeutic means and therapeutic ends,
resulting in occupation-based practice.
The Enabling Occupation II guidelines for occupational
therapy practice endorse the enablement of meaningful occupations that optimize our clients’ engagement and performance (Townsend & Polatajko, 2007). This endorsement can
be extended to occupational therapists’ own occupation; that
is, we as occupational therapists should find our own occupation meaningful so we can be engaged and performing optimally at enabling our clients’ occupations. However, little is
known about occupational therapists’ experience of incorporating an occupational perspective into practice. The majority of the literature examining occupational therapy practice is
focused on specific client groups, specific treatment modalities
and client experiences. To date, only a few studies have examined therapists’ perspectives about their practice (see Kinn &
Aas, 2009; Wilding & Whiteford, 2008; Wilding & Whiteford,
2009). These studies have focused on the profession’s history
with developing and establishing a valued place among colleagues and within health care practice. They found that therapists struggled to find a consistent definition of their practice
and that they developed strategies to strengthen professional
identity and increase work satisfaction, such as changing lan-
guage use to reconnect with the core occupational therapy
philosophical values.
The Canadian occupational therapy vision for client-centred enablement through occupation (Townsend & Polatajko,
2007) is internationally espoused by leaders of our profession
(see American Occupational Therapy Association, 2002; Kielhofner, 2004; Wilcock, 2006), yet little is understood about
how this vision plays out in the practice arena. The purpose
of this paper is to describe the personal experiences of occupational therapists working in a major urban academic health
sciences centre with incorporating an occupational perspective into their work.
Context
In the year 2000, three large urban teaching hospitals with
distinct organizational structures and client populations were
merged into one academic health sciences centre (the Centre).
With this merger, three occupational therapy services were
also unified under the leadership of a professional practice
leader, the first author (FA). Since graduating in the 1970s,
FA witnessed the increasing trend towards disease-oriented
health care and a devaluing of activity-oriented interventions. Educated in an occupational perspective, FA found this
trend disturbing and welcomed the emergence of the then new
Canadian guidelines espousing the centrality of occupation
to our practice (see Canadian Association of Occupational
Therapists, 1997). FA seized the opportunity this document
presented and used occupation as a means of unifying the
occupational therapy services. FA implemented varied, ongoing strategies to foster a culture that promoted occupationbased practice. One key strategy was the development and
implementation of the study reported here.
Methods
This study uses a qualitative constructivist approach that posits
that knowledge, or meaning, is socially constructed and contextually dependent (Corbin & Strauss, 2008; Haverkamp &
Young, 2007). Thus, each person subjectively experiences and
gives meaning to her or his situation based on past experiences
and life events (Corbin & Strauss, 2008). This research study
follows the belief held by Corbin and Strauss (2008) that objectivity cannot be maintained by researchers because knowledge
and meaning are constructed within the social interaction of
the researcher and participant, and, thus, knowledge is fluid.
We, the authors, are ourselves occupational therapists with
many years of practice experience and our own understanding of occupation-based practice; we have used reflexivity as
a basis for broadening our interpretation of the constructed
knowledge. As suggested by Haverkamp and Young (2007)
and Holstein and Gubrium (2004), this infusion of assumptions and past experiences leads to a deeper and richer analysis
of meaning.
The research team consisted of two co-principal investigators and five staff occupational therapists, including the
third author. The five staff occupational therapists were the
members of the education council representing practice areas
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Aiken et al.
across the three campuses of the newly merged Centre; all had
been invited to participate in the study as co-investigators. The
co-principal investigators were not study participants because
of their extensive administrative and limited clinical roles. All
investigators collaborated in project design, interview-tool
development, research-project planning and launch, initial
data analysis, and data presentation at conferences. The Centre’s Research Ethics Board granted ethics approval.
Recruitment began in 2003 at a departmental retreat focused
on occupational therapy and occupational science. All members of the department, including the five co-investigators,
were given both written and verbal information about the
study and invited to participate. Participation was voluntary
and anonymous; attendees were asked to complete a study
participation form, place it in an envelope, seal it, and, at the
end of the retreat, place the sealed envelope in a drop box.
The sealed envelopes were then given to an external research
assistant, who opened them and created a master list of participants. Investigators did not have access to this list.
Of 50 clinicians in the Centre, 13 agreed to be interviewed. Participants may or may not have included study coinvestigators: co-investigators were never asked to self-disclose
participation, nor was their participation tracked in any way.
One participant subsequently withdrew; those data were not
included in the analyses. The 12 participating therapists represented the various practice areas of the Centre (see Table 1).
Participants were all female and English speaking, three had
worked for less than 2 years, three had worked between 2 and
5 years, two had worked between 5 and 10 years, and four had
worked for over 10 years.
cal-care scenarios to describe their occupation-based practice.
Major probes included the participant’s definition of occupation and occupational science; team members’ perception of
occupation; vision of best occupation-based practice; and the
enablers, barriers, and strategies used to incorporate occupation within practice.
Over the course of the study, two external research-assistant interviewers, both recently graduated occupational therapists with no previous or current employment at the Centre,
were hired and trained to conduct the semi-structured interviews. The first interviewer completed the pilot interview in the
fall of 2003 and conducted the first four interviews. Remaining
interviews were conducted by the second interviewer between
January 2004 and March 2005. The interviewer arranged the
interviews, which were held at private locations within the
Centre that the participant chose. Interviews ranged from 30
to 90 minutes and were audio-taped. As the tapes were completed, the interviewer numbered them and gave them to a
professional transcriptionist for verbatim transcription. The
transcripts were verified by the interviewer for accuracy and
anonymized. The anonymized transcripts were securely stored
in a locked cabinet.
The investigators only had access to anonymized transcripts. And while, at times, interview content was suggestive
of whom the participant may have been, the number of therapists and the degree of workload overlap was large enough
that anonymity was essentially maintained; that is, it was never
entirely clear which transcript belonged to which therapist.
Pseudonyms were applied post hoc for the purposes of publication. Names were assigned to the numbered transcripts in
alphabetical sequence, with interview 1 being assigned a name
beginning with the letter A.
Data Collection and Handling
Data Analysis
An interview guide was prepared by the research team, piloted
with an occupational therapist at another facility, and refined
for clarity. The interview was semi-structured, each question in the interview guide was asked, and participants were
encouraged to provide additional comments and to use clini-
Data analysis was initiated in 2003 by all seven members of
the research team. Analysis was initially approached using
an open-coding process, as described by Lincoln and Guba
(1985): The data were broken into units of meaning and then
grouped under categories, resulting in well over 50 categories
(Aiken et al., 2004). In an attempt to structure the analysis and
reduce the categories, the Person-Environment-Occupation
model (Law et al., 1996) was applied to the data. This proved to
be too limiting a structure, failing to capture significant components of the data. An open-coding process was again initiated: Transcripts were re-read, categories were re-affirmed,
and new categories were created. This time 5 themes and 12
subthemes emerged (Aiken et al., 2005, 2006).
Manuscript preparation for submission was undertaken
by the first three authors. During preparation, these three
authors continued to reflect and immerse themselves in the
data. In the process of reviewing new literature for manuscript
preparation, Enabling Occupation II (Townsend & Polatajko,
2007) in particular provided a new perspective on the data
and, therefore, the process of data coding was reinstated. All
transcripts were re-read, coding was reaffirmed or modified,
and a new synthesis of the data was undertaken, resulting in a
new set of themes that the authors felt fully captured the rich-
Participants
Table 1
Demographic Information*
Participants (pseudonyms)
Area of Practice
Ava
Brooklyn
Chloe
Daphne
Emma Florence
Gabrielle
Hanna
Jessica
Kiera
Lily
Megan
Medical ambulatory
Medical acute
Medical acute
Mental health
Mental health
Medical ambulatory
Mental health
Long-Term care
Mental health
Medical acute
Medical acute
Medical ambulatory
*To protect anonymity, only aggregate data are presented.
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ness of the data. A fourth member (author) was invited to join
the team to facilitate the process of project completion. She
did not complete primary re-coding or participate in thematic
development.
Trustworthiness
Detailed notes were kept throughout, as was an audit trail of
actions, decisions, and the investigators’ reflexive thoughts.
Participants also experienced satisfaction and excitement from
the reciprocity, mutuality, and collaboration in their relationships with the client; when they were able to focus on the occupational narrative; with the team when they could negotiate
the team environment; and within themselves when they were
able to see the power to make a difference. These four themes
intertwine to reveal that a personal sense of occupation guides
practice and transforms the job into meaningful occupation.
Doing “Real OT” versus doing “The Job”.
Findings
The Meaning Gap
Participants in this study revealed living a meaning gap. They
described the existence of two realities: occupational therapy
as they felt it should be practiced and occupational therapy as
it actually is practiced. Brooklyn explained this:
I don’t really see much of a connection, actually, because
in theory occupation . . . is an indicator of health. But I
think that here, or where I work, I don’t really see occupation is so important. I think I facilitate people to become
independent but maybe not necessarily in occupations
that are significant or important to them. . . . [The] ideal
OT job in this setting would be just the possibilities to
really . . . or the freedom to just really talk with the patient
and really get a sense of what it is in their life that … limits them beyond just getting dressed … so really just to
get a bigger picture of the person’s life and really help.
Where the two realities were congruent, participants
talked about their practice being meaningful, “Seeing the confidence that’s built from engaging in occupation, seeing that
[the client’s] self-esteem and overall quality of life was improved
from engaging in occupation, really—that’s the point to being
an OT” (Gabrielle).
Where the two realities were incongruent, participants
experienced a meaning gap. In the words of Florence:
We are focused on the occupation of work, you know, or
paid employment, whereas as an occupational therapist
you want to look at occupation much more broadly . . .
And usually at the end, the way I try and make myself feel
better as an OT, that I feel like I’m doing more than just
assessing people and giving an opinion, . . . [I] usually
spend some time afterwards and talk with them, some
tips on how they could increase their participation in
various activities so that they’re not limiting themselves
more than they need to, and they usually appreciate that,
because that’s one way I sort of do it outside of, you know,
the regular part of the job.
This overarching theme of a meaning gap had four
themes: doing “real OT” versus doing “the job”; meaning
transforms doing; finding occupational meaning is personal;
and co-creating occupational meaning. Participants described
a clash of expectations between their ideal practice and program demands, time constraints, medically focused care, and
expectations of other staff. Nonetheless, they also found ways
to ascribe meaning to their work through making meaning
visible and seeing the big picture. This meaning making was
evolving, internally motivated, and created by use of language.
Participants discussed a clash of expectations inhibiting the
realization of occupation-based practice. These included
expectations of other staff, constraints of the work environment, and hospital policies. Daphne stated that there were
“ongoing cutbacks, so funding and access to funds to purchase
updated materials and assessments” necessary for practice
were limited. Brooklyn identified multiple constraints: “We
don’t have enough time to properly go and enable occupation
beyond self-care, look at productivity, and leisure. Length of
stay is really short … actually the mandate of the hospital,”
adding, “I think the priority is more of the medical needs of the
patient, so other professions may not be aware of, you know,
occupation and its importance.”
Similarly, Lily spoke of challenges to focus on occupation
within the dominant medical model: “In acute care, especially
when it’s a very medically focused injury-related type of arena,
this type of activity isn’t first, not even second, sometimes not
even in the whole scope of the day.” She described the resistance she meets from some acute-care staff when encouraging acutely ill patients to begin to participate in washing
themselves instead of being given a bed bath: “So that makes
it always a battle, sort of, ‘Well what are you doing? Why are
you making this harder for us?’ is all around.” While she saw
an opportunity for patients to regain occupation, staff did not
share her occupational focus and priorities.
Ava summarized the clash: “We always struggle with
being true to our profession and yet being true to the programme . . . it’s hard to say that I’ve been able to balance both
in my clinical practice.”
Meaning transforms doing.
Participants ascribed different meanings to the same intervention, such as self-care. One clinician described her interventions as tasks: “We set up equipment, we teach people
how to transfer in and out; it’s very mechanical . . . it needs
to be done, but it’s not occupation” (Brooklyn). Another clinician (Kiera) described her interventions in acute trauma as
enabling actions: “stretching the right way” because clients are
“not going to be able in the long run to do any other functional
activities”; acknowledging that “people that have great outcomes can often go back to work, can lead a normal life”; and
patients with more complicated outcomes, they tend to
not want to get out in public and they tend to not be able
to go back to their job, and often times they’ll even need
more help at home, along with the scarring [that] can
also limit function of that joint (Kiera).
Similarly, while Chloe acknowledged her “acute care”
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role meant she would “never really see that end goal,” she
saw her interventions as “not always improving the person’s
occupation but just sort of giving them things to help them to
manage [toward] that end goal of their improved occupational
performance.”
Emma saw her interventions as discovering options:
My role is helping [clients] look at what they can do . . .
to look at what it is they’ve lost . . . to use possibilities and
finding meaning in what they can do . . . getting them to
see where their passion is and what they feel they’d love
to pursue . . . to help them functionally.
Participants who appeared to bridge the meaning gap
framed their interventions in meaningful occupation. They
noted that meaningful occupation cannot always be observed;
it has to be made visible. Being able to see and articulate meaning in clients’ occupations appeared to be a strategy used by
clinicians to find meaning in their own work as occupational
therapists. Hanna described a teachable moment:
I’m getting [someone] a wheelchair, and [the student]
sees for [someone else] that I’m getting him a wheelchair,
and then [the student sees for] another resident I’m getting them a wheelchair; she’s [the student] thinking “my
God, all this woman does is wheelchairs.” But then I had
to take her aside and say, “This person, how are we helping her occupations? What are the things that they are
wanting to do?”
Finding occupational meaning appeared to affect and be
affected by personal values, and be supported or hindered by
language used in practice.
Participants frequently described the process using
leading words such as “personal bent,” “personal perspective,” “individual sense,” “different view,” and “my experience.”
Meaning is personal, so it follows that finding meaning is a
personal process. Megan noted that her “individual sense of
occupation is very different,” stating, “We learn the same stuff,
the same theory, but within each person is what your view of
occupation is. . . . So I think it’s your individual sense of occupation that sort of guides you where you want to go.”
Participants offered personal definitions of occupation
that revealed unique thinking, and which, in turn, informed
how they reflected on their practice. Brooklyn viewed occupation as “anything that we do as human beings. It can be self-care,
productivity, or leisure.” Chloe viewed occupation as “anything
that people do throughout the day, throughout their lives . . .
it can be very broad.” When asked if there was anything in her
daily work that was not related to occupation, she replied, “Not
really. It all eventually ties back.” Florence introduced another
perspective, that occupation “can also be more passive reflection, although we tend to think of occupation as doing; I think
there’s also those passive things like reflecting on life.”
Participants’ personal processes with developing an
occupational perspective also differed. Various strategies were
employed, including participating in “monthly reflective practice sessions” and “informal networking” (Daphne); “starting
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interest group meetings” (Kiera); carrying out funded research
on how her work “is actually making a difference to these individuals” (Ava); attending “rounds,” “in-services,” and “reading
on my own time” (Chloe); “spend[ing] more time with therapists just talking through why we are doing what we are doing
and not going with the status quo” (Florence); “spend[ing] a lot
of time looking at the latest topics” (Emma); and dedicating a
concerted effort to “translate [occupation] . . . and incorporate
it . . . as a team effort” as well as educate her clinical team about
other roles she could fulfill (Hanna).
The desire to find meaning also emerged as personal.
Gabrielle remarked that her “own understanding of occupation has evolved over time” through a desire to “learn more
about occupation” because of “interest and motivation and initiative” that “exists from within.” She reflected:
I think that it has to come from that participant . . . if that
person is really wanting to learn more about occupation,
then they’re going to learn more about occupation. If
conferences, teleconferences, in-services, focus groups,
newsletters, articles, discussion groups, interest groups,
e-mail listings, pamphlets, etc., exist, they’re resources
unless someone is really willing to, ahm, has a need to
take in and want to take in that information, it possibly
can get wasted.
Several participants identified the role of language in creating meaning for their practice. Daphne recalled that when she
graduated, she was “still struggling how to explain to other people what an occupational therapist is and what we do.” Ava spoke
about the need to “take advantage of opportunities” through
“educating colleagues and sort of sliding that term ‘occupation’
. . . if you use the lingo often enough, then they kind of become
accustomed to it and know that’s something that’s fundamental
or part of your practice.” Chloe identified the “systemic” role of
language “even [in] the assessment form”:
When I’m assessing, I’ll like think of what’s the next thing
on the form . . . and if the assessment form used those
terms . . . then I think it influences the way I would kind
of, like, think on a daily basis because it’s hard to really in
your daily practice to, like, infuse that into it.
Gabrielle stated:
I see a lot more exposure to the idea of occupation even
in everyday language, replacing a word like functioning
with occupational performance. Say what you mean, and
if you don’t mean occupation and you mean activity or
task, say what you mean . . . we don’t use, as occupational
therapists, across the board, consistent language. We
don’t use occupation when we mean occupation. We say
“OT” when we should be saying “occupational therapist”
to describe who we are to people.
Brooklyn discussed the challenge with incorporating occupational language:
The terminology and the lingo of all that is not really
there, you know, we don’t talk about that. Occupation is
more like the performance [components] and . . . I don’t
necessarily see this occupational view in health because
it’s not really established.
While participants experienced different levels of ability
and comfort in using occupational language in practice, occu-
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Aiken et al.
pational language seemed significant to their everyday practice and the meaning that they found in practice. As Lily said,
“Until there’s a language and terminology that’s commonly
used, there isn’t going to be an understanding within the OT
field. . . . It’s hard to have that language sitting at the bedside
trying to make it up.”
Co-creating occupational meaning.
The process of finding occupational meaning for each participant was expressed through co-creation with their clients,
their health care teams, and within themselves. The co-creation
of occupational meaning was described as moments when the
ideal of enabling occupation is most fully realized. Those who
experienced co-creations discussed fulfillment in their work,
and satisfaction and excitement from the reciprocity, mutuality, and collaboration of those moments.
Experiencing the power to make a difference through
occupation was important in co-creating occupational meaning within oneself. Florence reflected on a client who wanted
to return to a physically demanding job:
Even for me as an occupational therapist I was going, “I
don’t know that I want to send this guy back to a heavy
job.” I was questioning it. But this guy was so motivated
and it really challenged me in my thinking of what can a
person do. . . . So it was kind of neat, that one, in sort of
challenging even me that I was questioning should we be
doing this, and yet a highly motivated client can transform your thoughts on occupation.
Focusing on clients’ occupational narratives created a
sense of mutual engagement and reciprocity between clinicians and clients. Jessica shared several stories about connecting with individual clients:
together assessing what her strengths are, what her interests are, in terms of . . . helping them find meaningful
occupation and help them through the process. ; . . . He
wanted to live more independently, have his own room,
have more privacy, live in a smaller house, and so we supported him through that and it’s amazing how just being
involved in these self-care occupations how it had a huge
impact, not only on his health, his well-being, but his
quality of life. . . . And his quality of life, I have to say,
has tripled.
For others, co-creating meaning occurred at times with
difficulty, and at times with ease. Lily contrasts both elements
through the following examples of two clients:
If the client isn’t totally engaged in that as well, that’s what
I mean about if the motivation isn’t there, then I’m the
only one who seems to be trying to engage somebody
in an occupation. So I find that difficult … I have a lady
right now who’s had quite a traumatic injury. . . . but she
lives independently in the community. She’s got lots of
clubs and social activities. . . . and suddenly [her life is]
interrupted [by an] event that she isn’t sure will allow her
to do any of these things again. . . . [This situation] really
[brings me back to] see what drives people, what their
passions are, why they do those things that they do.
Participants identified that their ability to enable occupation was affected by their role as part of a team. Their perception
of support, value, and understanding of an occupational focus
within the team environment varied. Gabrielle experienced a
“strong cohesive, trusting community that I can rely on . . . if
I’m not there that day, and I wanted to explore something that
came out of the COPM [Canadian Occupational Performance
Measure] … someone else on the team will follow through.”
Ava, on the other hand, felt her team members did not understand her focus on occupation: “I think [the team’s] understanding is very much [safety] and independence in function,
but that’s not what occupation is all about.” Not being understood by the team affected how participants saw themselves.
Megan reflected, “With OTs, some of our things that we do
are very common sense things. So it’s almost like you have to
validate yourself, you have to validate your profession.”
To co-create occupational meaning within their teams,
clinicians initiated creative strategies. Ava developed and documented the scope of her role. Hanna felt “pigeon-holed,” so
she expanded her role, stating, “I didn’t want to just do wheelchairs, and I felt that I could do more,” and engaged the team,
offering that
If you guys are having difficulty I can come in and maybe
see if there are some strategies that we can try, or, you
know, adapting to the environment, like different things
that have to do with occupation. And so now I’m actually
getting a lot more referrals.
Lily preferred to “educate one-on-one”:
We . . . corral some of the nurses. “Oh yeah, he’s got a great
nurse today; let’s get this pattern going,” and then somehow it’s harder to change a pattern back if the pattern’s
existing. So we’ll post things behind beds “up daily, up
and out of the room to see OT, likes to be by the lounge,”
so we’ll push a lot of that. And usually when the pattern is
rolling, then it’s hard then for one nurse who has them for
three days to suddenly say, “Well, they don’t really get up
on my shift.” Because then everybody says, “Well, they do
on mine, and they have been for the last two weeks; what
do you mean they’re not getting up on your shift?” So we
try to do it that way, more of a one-to-one.
Kiera acknowledged that assuming “our educational
role” was necessary to develop understanding within the team.
Jessica concurred, stating that while her “team is definitely
well-educated and have [sic] a really good understanding of
. . . the role we bring forward to the team,” it has been through
“an ongoing process of educating.”
Discussion
This study set out to explore how occupation is incorporated
into everyday clinical practice. Through the experiences of
practicing therapists, meaning emerged as the central theme.
Meaning may be understood as a sense of value, purpose, and
fulfillment in what we do and how we exist, interact, contribute, and envision possibilities (Hammell, 2004; Hasselkus,
2002; Reed, Hocking & Smythe, 2010; Wilcock, 1998). The
experience of meaningful professional work is well documented in health care practice. Interestingly, until recently,
in the occupational therapy literature, meaning has been
discussed primarily in relation to the experiences of our cliCanadian Journal of Occupational Therapy December 2011 78(5) 299
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Aiken et al.
ents (see Hammell, 2004; Hasselkus, 2002; Reed et al., 2010;
Wilcock, 1998). Meaning associated with the practice experiences of occupational therapists has only recently been investigated (see Robertson & Finlay, 2007; Trenc Smith & Kinsella,
2009), and there is essentially no research discussing meaning
associated with the occupation-based practice experiences of
clinicians.
This study revealed that searching for meaning in the
occupation of providing occupational therapy was a core
experience. When clinicians struggled to find personal meaning and value in their occupation of being an occupational
therapist, they experienced a meaning gap. Whether clinicians
found meaning in their own occupation did not appear as an
all–or–nothing experience; it could fluctuate depending on a
variety of personal and contextual factors.
Clinicians identified that environmental constraints
affected their work—job pressures, time, budgets, medical
models, and systemic issues—which have been previously
reported (see Baum, Berg, Seaton, & White, 2002; Jongbloed
& Wendland, 2002; Wilcock, 1991). Clinicians experienced
meaningful occupational therapy work when there was a congruence of values and support in the workplace, which corresponds with other study findings (see Robertson & Finlay,
2007; Trenc Smith & Kinsella, 2009). When clinicians do not
experience meaningful work, we might assume the meaning
gap follows from the converse. However, our findings suggest
the meaning gap is due to more than contextual factors; it is
also due to personal factors.
Clinicians expressed that their sense of occupation and
the meaning ascribed to their work was very personal. The
meaning gap was not necessarily related to the specifics of
practice; rather, clinicians interpreted the significance of their
interventions differently. Similar work was experienced differently, depending on the meaning ascribed by individual clinicians. For example, two clinicians providing acute medical
care, working in similar service areas and with similar workplace constraints, were found to perceive the same intervention
as either a rudimentary task or as an enabling action towards
meaningful occupation. In turn, each clinician’s interpretation of his or her own actions affected his or her own sense
of meaning as an occupational therapist. It is this uniquely
constructed personal sense of occupation that guided practice
and transformed doing “the job” into meaningful occupation;
it enabled some clinicians to bridge the meaning gap.
This study provides insight into how meaning is derived.
Clinicians relayed different strategies for overcoming the
described constraints of “acute care,” feeling “pigeon-holed,”
wanting to “do more,” and discovering how they were “actually making a difference.” Florence described going outside her
hospital-mandated role to offer suggestions that enable clients
to engage in occupations they perceive as important in their
daily lives. This is reminiscent of underground practice, as discussed by Fleming (1991, p. 1010), which denotes unreported,
interactive practice focused on the phenomenological person
as an individual.
Whereas Price and Miner (2007) observed the interactions of one occupational therapist and interpreted that occupation-based practice emerged through the process of creating
300 Revue canadienne d’ergothérapie
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meaning with a client during therapy, the clinicians in this
study articulated the meaning-making in their work through
stories not only about their interactions with clients, but
also with colleagues, team members, and students. Through
this reflection and narrative, they made visible the meanings
embedded in clients’ occupations and aligned these with their
personal sense of occupation-based practice. In turn, they also
became aware of how clients’ engagement in meaningful occupation affected their own engagement. The device of reflecting on practice stories and discovering how they connect a
clinician’s intention and ability to do good work has been eloquently exemplified (see Wood, 2004), and it is recommended
as a method of developing an occupation-based perspective in
practice (Schell, 2009).
Meaning was also derived through negotiating the team
environment, a strategy reportedly used by other clinicians
when faced with not living up to personal and professional
expectations (Kinn & Aas, 2009; Robertson & Finlay, 2007).
Moreover, clinicians identified the significant role that language plays in practice—the conscious use of occupational
language in verbal and written interactions—that has long
been promoted in theoretical literature (Townsend, 1998) and
more recently corroborated by clinician experiences (Kinn
& Aas, 2008; Wilding & Whiteford, 2008). Participation in
reflective opportunities, collegial consultations and conversations, and educational opportunities to appreciate and develop
occupation-based practice also served to assist clinicians to
derive meaning in their work. Wilding and Whiteford (2009)
suggest that reflective practice and dialoguing and critiquing
practice experiences within communities of practice also serve
to enable occupation-based practice. The process of discussion
and debate about occupation-based practice may also serve to
strengthen the profession through improved practice (Pierce,
2003).
Perhaps the most important personal factor and strategy employed by clinicians who experienced meaning in their
work was the conscious connection between their actions
and the future occupational performance and engagement
of clients. They had a clear idea about their personal sense of
occupation and placed their interventions in the context of
meaningful occupation. They envisioned how their interventions fit into a big picture of enabling occupation. In this era
of fragmented, medical-model-based health care practice, the
ability to extrapolate enabling actions and incorporate them
into clients’ future occupations is valuable.
Implications for Clinicians
These findings encourage clinicians to reflect upon their practice experiences and their own sense of occupation-based
practice. The process of identifying and articulating a potential
meaning gap and then implementing strategies to address it
may assist clinicians to find meaning in their work. Reflective
practice (Denshire, 2002; Driscoll & Teh, 2001; Kinsella, 2000)
can assist clinicians to identify those moments when they feel
they are practicing as a “real OT,” to articulate a personal sense
of occupation, and to make visible the occupational meaning
in their work. Similar to findings by Kinn and Aas (2008), it
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Aiken et al.
may be worthwhile to consider that occupational language
offers a way to frame and explain clinical experiences and the
potential value of integrating language into the assessments
and documentation that provide structure to most clinicians’
work. Comparing “real OT” with personal practice experiences, making visible the link between practice actions and
client occupations, envisioning future possibilities for clients,
co-creating meaning, and sharing stories of success and learning with others are all strategies that may help clinicians identify meaning in their work.
the practice of novice to experienced clinicians and practice
in generalist and expert roles. Additional research into how
to explicitly address the meaning gap will contribute to our
understanding of occupation-based practice.
The future of occupation-based practice requires every
occupational therapist to explore personal occupational meaning through conscious reflection within him- or herself and
co-creation of meaning with clients and with their health care
teams. Sharing these stories of finding meaning and bridging
any meaning gap may serve to assist others to do the same.
Conclusion
Implications for Education
It is necessary to prepare students for ideal occupational therapy practice as well as provide them with tools to recognize
and bridge any meaning gaps that arise in clinical practice.
In their learning experiences, students may benefit not only
from developing knowledge about occupation-based practice
but also from their skill and comfort in incorporating occupational language and their ability to use it effectively. Therapists
need to model negotiating the differing contexts of the team
environment for students and need to mentor them on how to
co-create meaning within themselves, with clients, and with
team members. Just as meaning is not inherently evident in
occupations and must sometimes be consciously articulated,
as in the example of Hanna prescribing wheelchairs, students
need to learn a repertoire of strategies to reveal meaning and
make meaning in clinical practice.
Limitations
This study was limited to findings from a single, albeit large,
urban academic health sciences centre and the perspectives of
a relatively small number of participants. While participants
came from different practice areas, the experiences of occupational therapists in community or rural settings might be very
different; transferability, as always, is left to the reader.
The original interviews were recorded several years ago;
however, this allowed for extensive iterative analysis of the
data. The period of time between interviews and publication
allowed for peer review and confirmability of findings through
sharing and discussion of emerging themes with the occupational therapists at the Centre, at a Canadian Occupational
Science symposium (Aiken et al., 2004), at a practice-based
research symposium (Aiken et al., 2005) as well as at a Canadian Association of Occupational Therapy conference (Aiken
et al., 2006).
This study explored the experience of occupation-based practice, a perspective not typically investigated. A major finding of
this study is that it demonstrated how clinicians struggle to live
up to the ideals of occupation-based practice as espoused by
the professional literature. At times, frontline, academic, hospital-based therapists experience a meaning gap in their work;
they bridge the gap with a wealth of specific strategies learned
and incorporated into everyday clinical practice.
It is suggested that enabling meaningful occupations
is the essence of our profession. As occupational therapists,
it behooves us to understand how we make meaning of our
own occupation. Sharing our clinical stories and reflecting on
our own experiences of the meaning gap can lead us to identify both personal and contextual elements. Strategies such as
using occupational language, co-creating meaning with clients, negotiating the team environment, and making meaning
visible are useful in this endeavour and can assist in deepening
our reflective practice and fulfilling the ideals of our professional practice.
Key Messages
• Occupational therapists who value occupation-based
practice may experience a meaning gap between “real”
occupational therapy and “the job.”
• A personal sense of meaning can be an important element contributing to the experience of meaning-making across different practice contexts.
• Strategies to bridge a meaning gap, such as reflective
practice, incorporation of occupational language, and
co-creating meaning with clients and team members
exist and should be explicitly imparted to occupational therapists and students.
Acknowledgements
Future Directions
This is the first study to identify a meaning gap for occupational therapists in the practice of occupation-based, occupational therapy. Further research should explore some specific
aspects of the meaning gap: whether and how it is experienced
in specific contexts, including different practice areas and
urban and rural practice settings; the nature of the gap, including essential identifying qualities or characteristics to recognize it and the personal attributes that may determine it; and, if
there is any relationship to the professional journey, including
Parts of this paper were presented at conferences, as referenced
in the text. Co-investigators from the Occupational Therapy
Education Committee were Tamara Baron, Dawn Lawrence,
Lisa Menaker, and Azeena Ratansi. Most important, we thank
the occupational therapists who shared their experience and
perspectives. A special thanks to Jane Davis for her comments
on methods.
Canadian Journal of Occupational Therapy December 2011 78(5) 301
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Aiken et al.
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