A Curricular Renaissance:
Graduate Education
Centered on Occupation
Wendy Wood, Cathy Nielson, Ruth
Humphry, Susan Coppola, Grace Baranek,
Jane Rourk
Key Words: curriculum design • occupational science • professional growth
A 3-year project of curricular renaissance undertaken by the
faculty of an entry-level master’s degree program is described.
This project culminated in a thoroughly redesigned program
of study centered around the construct of occupation and
built on a foundation of knowledge in occupational science.
Described herein are three developmental and highly iterative domains of activity that were crucial to the project’s success: (a) environmental scanning and analysis, (b) creation
of a compelling future vision of occupational therapy, and
(c) curriculum planning. Also detailed are especially salient
assumptions and beliefs about graduate education as well as
seven themes that encompass the program’s academic content
and illustrate its defining emphases. These themes are (a)
occupation, (b) the human as an occupational being, (c)
occupation as a medium of change, (d) clinical reasoning,
(e) ethical reasoning, (f ) investigative reasoning, and (g)
occupational therapists as scholars and change agents in systems. The article concludes with reflections on innovation in
graduate education in occupational therapy today.
Wood, W., Nielson, C., Humphry, R., Coppola, S., Baranek, G.,
& Rourk, J. (2000). A curricular renaissance: Graduate education centered on occupation. American Journal of Occupational Therapy, 54,
586–597.
I
Wendy Wood, PhD, OTR/L, FAOTA, is Assistant Professor,
Division of Occupational Sciences, Department of Allied
Health Sciences, University of North Carolina at Chapel Hill,
Medical School Wing E, CB #7120, Chapel Hill, North
Carolina 27599-7120; [email protected].
Cathy Nielson, MPH, OTR/L, FAOTA, is Clinical Associate
Professor, Ruth Humphry, PhD, OTR/L, is Professor, Susan
Coppola, MS, OTR/L, is Clinical Assistant Professor, Grace
Baranek, PhD, OTR/L, is Assistant Professor, and Jane Rourk,
OTR/L, FAOTA, is Clinical Associate Professor, Division of
Occupational Sciences, Department of Allied Health Sciences,
University of North Carolina at Chapel Hill.
This article was accepted for publication December 13, 1999.
t is axiomatic that business as usual does not currently
exist in occupational therapy. To be sure, a preponderance of occupational therapists in the United States and
other countries around the world appear to embrace clinical practices that are occupation centered and delivered, as
much as possible, within persons’ lived environments
(Bontje, 1998). Likewise, the international community of
all health professionals concerned with disability, including
occupational therapists, now endorse, as best practice,
interventions that most efficaciously support persons’
meaningful and satisfactory participation in their real-life
activities (Law & Baum, 1998; World Health Organization
[WHO], 1997). Yet consistencies in these trends notwithstanding, occupational therapists in the United States have
not easily implemented optimally occupation-centered and
evidence-based practices nor have they developed services
for underserved populations in the community on a large
scale (Baum & Law, 1998b; Hasselkus, 1998). Moreover,
relatively recent changes in the economics of the U.S.
health care system have made it far more difficult to deliver robust programs of occupational therapy in traditional
medical settings while, paradoxically, also acting as powerful catalysts for the profession’s evolution. Practitioners in
the United States are thus challenged today, unlike ever
before, to think and act “outside of the box” in order to
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fully meet the occupational wants and needs of persons
receiving services. Practitioners must also think and act in
accord with newly emerging standards of evidence-based
practice and in financially viable ways that often require
diversification of traditional sources of reimbursement.
Due in large part to the changes now affecting practice,
a fundamental rethinking of professional education in
occupational therapy is also under way. Thus did Yerxa
(1998b) recently urge educators to engage in a curricular
renaissance of great magnitude. In Yerxa’s view, this renaissance ought to center professional education around the
construct of occupation, drawing on the perspectives of
multiple disciplines in so doing. Should such a renaissance
occur, Yerxa predicted that occupational therapy students
would graduate with the skills needed to meet the
unknown opportunities and needs of the 21st century,
while occupational therapy itself would become clearly differentiated from other fields. Matching the seriousness of
Yerxa’s call to action, the American Occupational Therapy
Association (AOTA) recently mandated postbaccalaureate
entry level for the profession. Thus, whereas all occupational therapy educators in the United States are being
called on to reconstruct their curricula in fundamental
ways, those educators in baccalaureate programs must also
soon meet the higher standards of academic rigor inherent
in graduate education.
The purpose of this article is to detail an experience of
curricular renaissance directed toward the existing entrylevel master’s degree program in occupational therapy at
the University of North Carolina at Chapel Hill (UNCCH). Beginning in 1995, we, the core faculty members of
this program, embarked on a formal process of thoroughly
redesigning our curriculum. That process attended to
diverse issues affecting practice and education, culminating
in a newly conceptualized and tightly integrated program
of study centered around the construct of occupation and
built on a foundation of knowledge in occupational science. Now in its third year of implementation, the new
curriculum is admittedly audacious in vision, having been
designed to graduate students who are simultaneously
scholars and change agents and who are educationally prepared to lead occupational therapy into a new era of human
service. In this spirit of optimism, we present our process of
curricular renaissance, guiding assumptions and beliefs
about graduate education, and academic content. We also
offer our reflections on academic innovation in occupational therapy today. In meeting these objectives, our hope
is to contribute substantively to the evolution of occupational therapy practice and education now evident around
the world.
Developmental Process of Curricular Renaissance
Since 1978, when our master’s degree program in occupational therapy first admitted students, curricular evaluation
and revision had been undertaken annually and formally.
Yet despite those efforts to build ever-stronger curricula, and
despite those curricula having always met the standards of
the Accreditation Council for Occupational Therapy
Education (ACOTE) and its graduates having typically
exceeded national averages on certification examinations,
the faculty members concluded in 1995 that more extensive
measures were in order. That is, every aspect of the program
was believed to merit meticulous and thorough reevaluation. In this reevaluation, moreover, the faculty allowed for
the possibilities of rejecting any one aspect of the curriculum, no matter how much of a historic “sacred cow,” and of
reinventing the curriculum in its entirety. Put on the table
as well were issues of faculty “ownership” of courses, including the conflict that can exist between academic freedom on
the one hand and provision of a well-integrated and internally coherent program of study on the other.
A curricular project of this magnitude was made possible by the faculty’s adherence to a systematic process of
development that encompassed three domains of activity
that we have defined as environmental scanning and analysis, creating a vision, and curriculum planning. Because
scanning and analysis of environmental trends had been
continuously undertaken by the faculty to facilitate annual
curricular revisions, this domain was not unique to the project initiated in 1995. Importantly though, activities in this
domain catalyzed the project’s initiation. In contrast, activities in the domains of creating a vision and curriculum
planning were unique to the project, spanning the period
from the fall of 1995 when the project formally began until
the fall of 1998 when the new curriculum was instituted.
Activities in these two domains were accomplished through
a rigorous schedule of weekly to biweekly 3-hour blocks of
time devoted to meeting as a full faculty, or to working on
our own, with respect to specific curricular assignments.
Also across these years, one faculty member acted as a
process manager, tracking progress, adjusting priorities,
and providing summaries of accomplishments periodically.
Finally, it is important to stress that although these
domains of activity followed a roughly linear sequence, in
actuality our process across them was highly iterative and
flexible.
Environmental Scanning and Analysis
It is clear from today’s vantage point that ongoing activities
of environmental scanning and analysis had culminated by
1995 in a sense of urgency among our faculty members
about the state of the profession in general and about
implications of that state for education in particular. We
had also by then interpreted problems within occupational
therapy in light of internal and external critiques of the
field, emerging research, considerations of health care policy and financing, and promising accomplishments by
occupational therapists around the world.
Analyses of student fieldwork experiences had revealed,
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for instance, that clinicians commonly devoted the bulk of
their treatment time to component-level procedures.
Studies had also emerged to suggest that this sort of narrowed practice domain was evident on a national scale
(e.g., Neistadt & Seymour, 1995; Pendleton, 1989; Rogers
& Masagatani, 1982). Nationally, many respected practitioners and educators had issued warnings by the early
1990s about the proliferation of philosophically incoherent
clinical practices (e.g., Florey, 1989; West & Wiemer,
1991; Yerxa, 1988). These internal critiques were consistent with external critiques of rehabilitation professionals
for being focused on “fixing” bodily deficits while all but
ignoring far more powerful environmental barriers to
societal inclusion (DeJong, 1979). Further, as payers and
policymakers called for evidence that therapy produced
meaningful functional outcomes (Foto, 1995), studies were
showing that component-driven therapy, in contrast to
more occupation-centered therapy, was ineffective in
achieving such outcomes (Trombly, 1995; Lin, Wu,
Degnen, & Coster, 1997). Also troubling was the
dwindling presence of occupational therapists in the U.S.
mental health arena coupled with few successes in creating
new community practices or expanding services to underserved populations (Nielson, 1994). Moreover, as the U.S.
health care system became more and more driven by economic interests, we anticipated that traditional sources of
funding would be severely curtailed in the near future.
The enormity of such problems notwithstanding, our
faculty members had also become convinced by 1995 that
promising courses of action were suggested wherever occupational therapy was thriving. For example, our students
were predictably bolstered by fieldwork experiences in
which they observed and delivered clinical practices congruent with the emerging paradigm of occupation described
by Kielhofner (1992). As already noted, research was also
substantiating the value of prioritizing attention to those
occupations that service recipients wanted and needed to
do. Similarly, occupation-centered practices evident in other
countries, such as the focus on client-centered practice in
Canada or on community practice in Sweden, offered
instructive examples of success. Likewise, the international
emergence of occupational science as an academic discipline
denoted not only a maturational milestone in occupational
therapy’s intellectual history, but also a vehicle for liberalizing and modernizing its scholarship and ways of serving
society (Wilcock, 1993; Yerxa et al., 1989). Ultimately, evaluation of this complex of problems, projections, and areas
of promise led to our conclusion that a strategy of yearly
curricular revisions guided by ACOTE standards had
become insufficient for preparing graduates to meet the
challenges of the near future. We thus felt compelled to
reject as well traditional indices of our program’s success if
we were to realize a much broader societal mandate.
Creating a Vision
With the faculty’s analysis of environmental trends as a
foundation, the pivotal activity in the domain of creating a
vision consisted of developing a future image of occupational therapy that overcame barriers to best practices in
existing clinical settings and created new ways in which
occupational therapists could serve society. As observed by
Bandrowski (1990), “The future will be invented by those
who see it today” (p. 33). Accordingly, our faculty members
adapted a visioning process of Bandrowski’s that enabled us
to take creative leaps into the future in order to imagine
occupational therapy as it could be if its fullest potential
was realized. We constructed an image of occupational
therapy that was, in our estimation, so compelling and rich
that it continuously acted as a source of inspiration
throughout all subsequent work, helping us overcome
numerous obstacles to change. Although this image concluded with our ideal of a best possible world, it embraced
many doable objectives that could be realized on small and
local scales in the foreseeable future (see Appendix).
Curriculum Planning
Curriculum planning was guided by our prior visioning
work and consisted of seven steps that, while seemingly discrete, were in fact highly iterative (see Table 1). This
domain marked an intensive period of study, reflection,
and debate during which we immersed ourselves in relevant disciplinary and interdisciplinary literature. Our sustained exchanges about this literature served to coalesce our
faculty as a community of scholars who were not only capable of productive scholarly disagreement, but also became
committed to a certain view of education and practice. As
a function of such discourse, we developed our mission
statement and philosophical views of occupation, the occupational human, and occupational therapy. These documents were critically important in defining our identity
and purpose and can be accessed via our program’s Web site
(www.alliedhealth.unc.edu/ocsci).
Emerging directly from this foundational work were
seven curriculum themes that encompass all academic content and educational outcomes for each theme. Expert
educators within and outside of occupational therapy consulted with the faculty at this juncture, culminating in the
integration of themes within a conceptual model of our
educational process. This model is visualized as a spiral to
emphasize the curriculum’s developmental nature in revisiting content in each theme in greater depth and breadth
across 2 years of study. Our conceptual model in turn guided development of course objectives and preliminary
syllabi that began to explicate how content would be introduced and then systematically deepened and expanded.
Evaluative strategies were developed so that problems could
be identified and corrected in a timely manner. During our
final year of work, we arranged for a series of seminars by a
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Table 1
Domain Three: Curriculum Planning Cycle
Step
Definition
Developing mission and Writing statements that describe the
philosophy statements
program’s “reason for being” and
core values as educators and occupational therapists and scientists
Key Activities
• Faculty study groups
• Literature review and study
• Scheduled discussion
• Individual writing followed by
group critique and development
Outcomes
Mission statement
Definition of occupation
View of humans as occupational
beings
View of occupational therapy
View of the educational process
Time Frame
Focused work in
1995–1996
Planning objectives and
outcomes
Describing the knowledge, skills,
and attitudes of entry-level occupational therapists
• Theme and content analysis of
Curriculum content themes and
philosophy documents
areas
• Development of student learning Curriculum objectives
outcomes for each theme and content area
• Faculty discussion, critique, and
development of outcome statements
• External consultants
Focused work in
1996–1997
Constructing conceptual frameworks
Integrating content themes into a
visual model of sequential development and learning within and
across themes
• Synthesis of themes and content
areas into visual models
• External consultants
Formulating course
emphasis and sequence
Using the conceptual framework
and learning outcomes as a guide
for defining and chunking content
into courses across the structure of
semesters and years
• Generation of content lists and
An outline view of curriculum years Focused work in
identification of the progression of
1 and 2: preliminary course titles,
1996–1997
learning
credit hours, and descriptions
• Synthesis of lists into content
Preliminary syllabi for each pro“chunks”
posed course
• Individual faculty development of
“courses I would like to teach”
• Faculty review; discussion and
adoption of preliminary courses
• Incubation of curriculum plan
• “Essentials” review of mini-syllabi
Designing course objectives, content, learning,
and evaluative activities
Assigning course development and
• Faculty work on courses
teaching responsibilities to individu- • Refinement of individual courses
als and faculty teams
and overall curriculum plan
• Internal consultation on teaching
and evaluative strategies
Implementing the cur riculum design
Educating students, colleagues, and
ourselves in the new curriculum
Evaluating curriculum
process and results
Reviewing all aspects of the curricu- • Course evaluations: mid-term and Curriculum changes involving any
An ongoing activity
lum from student, faculty, and
final
step of the planning phase of
external perspectives
• Fieldwork Level I and II evaluavarying degrees of complexity
tion: existing and newly developed
from within course changes to
formats
alteration of outcomes to addition
• National Board for Certification
or deletion of courses
in Occupational Therapy exam
performance
• Scheduled discussion and review
by faculty members
Spiral model of curriculum
An approved curriculum
New courses
Name change approved by
University of North Carolina at
Chapel Hill, Division of
Occupational Science
• Orienting current and future stu- Clinical educator conferences about
dents to the curriculum
the curriculum and about key
• Orienting key clinical educators to
content and concepts
the curriculum
Scheduling and teaching newly
• Faculty study and development of
developed courses
courses
• Teaching new and transitional
curricula
respected educational reformer. These seminars were devoted to many pedagogical issues, such as classroom management, instructional methods to maximize participatory
learning, and integration of academic content with “realworld” experiences.
Core Assumptions and Beliefs About Graduate
Education
Throughout the curriculum project, our faculty grappled
with its core assumptions and beliefs about graduate edu-
Focused work in
1996–1997
Focused work in
1997–1998
Year 1 of new curriculum:
1998–1999
Year 2 of new cur riculum:
1999–2000
cation. Although some premises were clear from the project’s initiation, others became obvious only after implementing the curriculum and then reflecting on what we
had accomplished and how.
Perhaps the most compelling assumption guiding the
project itself was that “the proof of education is practice”
(Presseller, 1984, p. 5). In other words, while recognizing
that practice is shaped by much more than education, we
agreed that how a program’s graduates typically go on to
practice constitute that program’s truest outcome measure.
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Similarly, we thought that educators were obligated to
ensure that their own curricula did not incubate in students
distinct patterns of future clinical deficiencies or shortfalls
in professionalism. Further, we confronted the question of
whether the kind of innovation in graduate education that
we envisioned could truly help occupational therapy realize
its full potential in the foreseeable future. Ultimately, we
agreed with Bruner (1996) who argued that educational
innovations—contrary to what is often reflexively
assumed—have, in fact, often been powerful and lasting in
impact.
To be catalytic, we assumed that graduate education
had to hone sophisticated critical thinking abilities in students. We agreed with Reilly’s (1958) observation that the
hallmark of professional education is curricula that are
“built from a constellation of conceptual understandings
that support practice” (p. 294). On grounds that it was dangerously regressive to do so, we thus rejected the position
that we were obliged to sanction, or to teach students how
to perform, most every entry-level technique used in practice. Rather, we thought it far more important that students
develop the requisite critical thinking capacities to evaluate
specific techniques—and entire clinical programs—in light
of the best available science, theory, and consensus expert
opinion. We also agreed that only clinical approaches that
advanced best practice would be targeted for development
of performance competencies. For example, given current
evidence, we do not teach students how to elicit righting
and equilibrium responses or how to “normalize” muscle
tone in children with central nervous system disorders; we
do teach them how to assess and adapt multiple occupational contexts in order to increase meaningful participations of such children in their everyday lives.
Additionally, to be catalytic, we assumed that graduate
education had to affect students’ emotions just as deeply as
it did their intellects; graduate education also had to deal
with issues of personal character. We therefore decided to
create a selection process that favored applicants who
showed courage and leadership, that is, those who not only
met UNC-CH’s academic standards, but also had
immersed themselves in substantive service projects,
researched the field extensively, showed awareness of current changes in the field, and demonstrated credibility in
their respect for scholarship and research. Once admitted,
we resolved as well to attend closely to issues of professional behavior and leadership in classroom and student advising contexts (Fidler, 1996). Key areas of attention in these
regards were identified as effectiveness of work habits and
standards, responsiveness to feedback, commitment to selfdirected learning, capacities for cooperative and small
group work, or emotional comfort in presenting and
defending one’s work in public forums.
Another core assumption of our program is that cognition and learning are always contextually and culturally situated. As Bruner (1996) observed, “Meaning making
involves situating encounters with the world in their appropriate cultural contexts” (p. 3). Accordingly, we believed
that we needed to create a variety of learning experiences
that required students to integrate, explicitly and systematically, academic content with direct experiences outside the
classroom. This assumption guided numerous programmatic decisions, such as those to expand Level I fieldwork, tightly integrate course content with all fieldwork, embed multiple educational objectives within community projects, or
create continuing education events in which students interacted with clinicians in accord with course objectives.
All together, our core assumptions and beliefs infuse
our curriculum in numerous ways—most obviously by
guiding concrete decisions about admissions, instructional
methods, course content, fieldwork assignments, or student–faculty relationships. Adherence to these premises has
also helped to create, we believe, a culture in our division in
which students responsibly commit both to their own learning and professional maturation and to that of their peers.
Curriculum Themes and Academic Content
Academic content in the program is organized around
seven curriculum themes, all of which include basic and
applied content. Rather than translating into separate
courses, each theme is addressed, to varying degrees of
emphasis, in many courses across the program of study.
Consistent with our spiral curriculum model, students are
immediately immersed in the study of all themes, with
content systematically developed in much greater breadth
and depth over 2 years. Comprising the core of the curriculum are three curricular themes that center around the
defining philosophic traditions of occupational therapy
and that are supported by occupational science: occupation,
the human as an occupational being, and occupation as a
medium of change. Three more supporting themes reflect
reasoning processes, specifically, clinical, investigative, and
ethical reasoning, that inform core content by representing
indispensable ways in which occupational therapists enact
best practice and achieve optimal professionalism. The final
theme, occupational therapists as scholars and change agents
in systems, addresses content pertaining to leadership and
innovation and represents the program’s ultimate educational goal.
The reader should note that the citation style in the
next section refers to readings from course syllabi that
reflect the described academic content as accurately and
comprehensively as possible. However, each theme covers
more content than can be cited or described herein.
Additionally, content that is available in books on occupational therapy, although prominent as a classroom resource,
is generally not cited. Finally, it is important to stress that
citations reflect just one snapshot in time, as content is continuously updated. (Current syllabi may be downloaded
from our Web site.)
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A Foundation of Occupational Science
Occupational science is an emerging academic discipline
akin in scope to, say, psychology or economics and not a
practice model, “umbrella” theory, or particular perspective
of occupational therapy as is sometimes thought. Having
grown from the philosophic, intellectual, and humanitarian
traditions of occupational therapy, the science’s defining
focus is that of the study of occupation, including its observable forms, functions during evolution and ontogeny, and
meanings at person and sociocultural levels (Clark, Wood,
& Larson, 1998). To develop the richest possible body of
knowledge about occupation, occupational scientists are
strongly committed to interdisciplinary discovery and
enrichment (Wilcock, 1998a; Zemke & Clark, 1996). This
commitment to interdisciplinarity enables occupational scientists to inform, and be informed by, classic and contemporary views of human behavior extant within the
global health and scientific community. Yet more than just
synthesizing existing knowledge through the “lens” of occupation—an activity that does not justify claims of a distinct
academic discipline—occupational scientists are generating
new knowledge about occupational behavior across the life
span, in diverse cultural contexts, and with persons with and
without disabling conditions (Larson, 1998; Pierce, 2000;
Segal & Frank, 1998; Townsend, 1997).
In portraying our curriculum as built on a foundation
of occupational science, we mean essentially two things.
First, we mean that the defining focus of occupational science explicitly and implicitly comprises our academic content. Explicitly, our three core curriculum themes address
basic and applied knowledge pertaining to the form, function, and meaning of occupation. Our curriculum consequently frames the study of occupation and its applications
to health care, education, and well-being across the life
span—and not the study of biomedical sciences or generic
rehabilitation techniques—as constituting occupational
therapy’s vital base of knowledge. Implicitly, the curriculum is constructed to ensure that none of its tacit messages
work at cross-purposes to its ultimate educational objectives. Our remaining curriculum themes, therefore, are
constructed to prepare students to address current and
emerging areas of occupational need in individuals, social
systems, and society as skillfully as possible. Accordingly, all
educational experiences and sequences have been designed
to ensure that students develop clear and confident identities as occupational therapists. For instance, biomedical
content is taught directly in the first year of study as it
relates to the form, function, and meaning of occupation.
After having gained a sufficient corpus of knowledge about
occupation with which to contribute optimally to, and
benefit optimally from, interdisciplinary discourse, students take an elective in their second year in the humanities, social sciences, public health, health policy, or a specialty clinical focus.
The second way in which our curriculum is based in
occupational science concerns how we expect our students
to think as occupational scientists and to recognize when
they are doing so. Occupational scientists use, we believe,
divergent thinking when exploring the perspectives of
other disciplines and convergent thinking when critically
evaluating those perspectives in order to broaden or deepen understanding of human occupation. Correspondingly,
if students are to explicate how content in the humanities
enriches their understandings of the occupational experiences of families caring for loved ones with disabilities or
how knowledge of public policy helps them address the
occupational needs of disenfranchised minority persons,
they must think as occupational scientists, employing both
divergent and convergent thinking. As these examples
hopefully illustrate, to think as an occupational scientist, a
core of knowledge in occupational science is necessary as is
the meta-cognitive ability to recognize when and how one’s
thinking as an occupational scientist offers a distinctly
unique perspective of human behavior.
Core Curriculum Themes
Occupation. The theme of occupation addresses conceptual and clinical capacities pertaining to (a) occupational form,
or objectively observable units of behaviors that constitute
occupations; (b) occupational functions, or identifiable
effects, consequences, or outcomes of occupational engagement; and (c) dynamic interrelationships between occupational form and function (Clark et al., 1998). This theme
emphasizes, although not exclusively, the usefulness of synchronic (immediate time) and etic (objectively observable)
perspectives in being able to conceptualize, observe, and
analyze units of behavior that do or do not constitute discrete occupations (Christiansen, 1994). In this emphasis,
the theme reflects that dimension of occupational therapy’s
history concerned with using and adapting singular occupations for the purpose of realizing positive outcomes in
persons.
To grasp what does or does not constitute an occupation, students investigate various approaches to conceptualizing and researching occupation that have informed and
catalyzed the field’s evolution. The curriculum heuristically
defines occupations as the ways in which people orchestrate
time to fulfill their needs and wants in everyday environments. While highlighting people’s agency in the context of
lived environments and cycles of time, this definition offers
a liberal foundation for appreciating other perspectives.
Students accordingly pursue in-depth study of the social
movements and philosophies that gave rise to the idea of
occupation as therapy (Addams, 1990; Dewey, 1944; Meyer,
1957) in addition to modern approaches to studying occupation (Christiansen, 1994; Gray, 1997; Trombly, 1995).
Various forms of occupation and of other non–occupationbased media that have been used as therapy are likewise
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explored from historical and cultural perspectives.
Additionally, dynamic systems theory is examined in depth
to generate competencies in accurately analyzing occupational behavior as it emerges and comes to be expressed in
immediate action contexts (Thelen & Smith, 1998).
Concern with the functions of occupation includes
considerations of adaptation (Frank, 1996; Kielhofner,
1977; Wood, 1998b), health-related quality of life (Muldoon, Barger, Flory, & Manuck, 1998), function in activity and participation (WHO, 1997), and new explorations of
multifold effects of occupation on individuals, communities,
societies, and the environment (Wilcock, 1998b; Yerxa,
1998a). Keen attention is paid to studies that substantiate
favorable effects of occupation, such as those by Clark et al.
(1997) in occupational science and therapy or by
Csikszentimihalyi and LeFevre (1989) and Glass, Mendes
de Leon, Marottoli, and Berkman (1999) in psychological
and public health perspectives. To help students identify
interrelationships between engagement in occupations and
consequences stemming from such engagements, considerable attention is given to the theory and practice of
top–down approaches to functional assessment (Coster,
1998).
The human as an occupational being. The theme of
humans as occupational beings encompasses four main
content areas: (a) biological basis of the occupational human,
(b) occupational meaning, (c) historic and sociocultural contexts of occupation, and (d) temporal orchestration of occupational patterns. As these content areas suggest, the theme
emphasizes, although again not exclusively, diachronic
(across time) and emic (subjective) perspectives in its study
of the occupational human (Christiansen, 1994).
Moreover, a biopsychosocial view of the occupational
human is sustained throughout this theme, as is a life span
perspective.
Study of the biological basis of the occupational
human encompasses considerations of biological requirements for occupation (Greenough & Black, 1992; Wood,
1998a) and the effects of variations in performance components, such as sensory processing, on daily activities
(Baranek, 1999; Baranek, Foster, & Berkson, 1997).
Transformations in occupational behavior are also related
to issues of maturation, aging, illness, congenital or
acquired disabilities, and sources of individual differences
affecting multiple trajectories of development. Study of
various psychological and sociocultural perspectives on
activity and agency further enrich understanding of the
occupational human (Atchley, 1989; Bandura, 1989;
Bateson, 1996). The importance of attending to issues of
occupational meaning is stressed by directly tying biomedical content to the phenomenological study of disability
and compelling first-person accounts of living with various
heath conditions (Klein, 1997; Monette, 1994).
Recognizing the power of context, students are also
immersed in evidence that occupations and their related
effects and meanings are embedded in varying social histories and sociocultural contexts (Humphry & ThigpenBeck, 1997; Jackson, 1995; Larson, 1998; Primeau, 1996).
The life span perspective of this theme stresses continuities and discontinuities of multiple levels of change in
embedded systems (Smith & Baltes, 1999). Similarly,
dynamic systems thinking is expanded to encompass consideration of how occupational behavior evolves through
transactions of persons with a multiplicity of interdependent systems over time (Gray, Kennedy, & Zemke, 1996;
Kielhofner & Forsyth, 1997). All together, this theme is
designed to help students value the centrality of occupation
to daily existence across multiple transitions of growth,
development, maturation, aging, illness, and disability.
Occupation as a medium of change. An important educational outcome of our curriculum is that students will be
able to interweave a rich complex of etic and emic as well
as synchronic and diachronic perspectives in designing and
delivering interventions that maximally support persons’
participation as defined by the WHO (1997). This complex of proficiencies includes, among others, the use of systematic strategies to generate keen observations of occupational behavior in immediate action contexts, explicate
salient influences on occupational behavior across multiple
contexts, attend to both phenomenological and biomedical
dimensions of health conditions, and grasp the essential
historicity of people as related to past and present occupational patterns as well as future possibilities and hopes. To
hone such proficiencies, the theme of occupation as a
medium of change emphasizes (a) conscious cataloging of
treatment mechanisms, that is, those aspects or qualities of
an occupation—or of an entire program of intervention—
to which positive outcomes are directly attributable; (b)
application of contemporary process models of occupational
therapy; (c) environmental approaches to maximizing life
participation; and (d) clinical problem solving in context of
real-life case studies.
It is critically important that occupational therapists be
able to articulate and then put into play that which makes
occupation a powerful tool for inducing favorable subjective experiences and desired outcomes (Pierce, 1998;
Trombly, 1995). To this end, students analyze therapeutic
situations in which occupation was pivotal in instituting
beneficial changes as gauged by recipients of service themselves (Clark, 1993; Gray, 1998). Students are similarly
challenged to distinguish truly empowering alliances
among occupational therapists and service recipients from
associations that may be friendly yet are essentially nontherapeutic (Davidson & Peloquin, 1998). Likewise, they
identify criteria distinguishing truly therapeutic groups
centered on occupation from the mere gathering of aggregates of people for treatment. Also examined is how a broad
temporal approach to lifestyle redesign helps people orchestrate rounds of occupations over time that are self-satisfying and health promoting (Jackson, Carlson, Mandel,
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November/December 2000, Volume 54, Number 6
Zemke, & Clark, 1998). Considerations of these and other
key catalysts of change are integrated in the study of new
process models of occupational therapy that instill individualized occupation-centered practices from initial point of
contact through termination of services (Fearing, Law, &
Clark, 1997; Fisher, 1998).
Also with respect to this theme, students are repeatedly engaged in clinical problem solving relative to case studies selected from a wide range of life circumstances and disabling conditions across the life span. These case studies
constitute a crucible in which content from all curriculum
themes and fieldwork experiences is progressively integrated into pragmatic interventions for individuals, social systems, and institutions. Specific to this theme, case studies
require numerous occupational analyses of persons across
differing contexts of living. Along with emphases on treatment mechanisms and process models, these analyses provide a foundation for learning how best to elicit or support
engagement in occupations to beneficial ends. Case studies
are also designed to inculcate a fundamental shift in thinking away from dated, component-driven practices that
mainly target deficits internal to the human body and
toward far more holistic and evidence-based practices that
target elements of person–environment transactions that
significantly affect performance capacities and well-being.
Accordingly stressed are clinical competencies relevant to
key environmental issues such as the availability of opportunities for meaningful time use; the usefulness of technology, adaptive living aids, community networks, or social
interdependence; the value of universal design and accessible public transportation; or the indispensability of collaborative partnerships with family caregivers.
Supporting Curriculum Themes
Clinical reasoning. The theme of clinical reasoning addresses strategies for thinking and self-reflection needed to
become an expert, client-centered therapist as expeditiously as possible. Works that illuminate the reasoning processes of occupational therapists are studied in depth and then
woven into other curriculum themes and related to clinical
experiences. For instance, as related to the theme of occupation, diagnostic reasoning is presented as a systematic
strategy for analyzing barriers to and enablers of occupational performance in immediate action contexts (Rogers
& Holm, 1998). As related to the occupational human,
narrative reasoning is presented as a tool for accessing persons’ phenomenological experiences of illness and disability (Mattingly & Fleming, 1994). As related to occupation
as a medium of change, procedural reasoning is examined
with respect to whether and to what degree various
enabling procedures do in fact enhance functioning in real
life and, hence, are therapeutically justifiable. With respect
to the theme of ethical reasoning, pragmatic reasoning is
used to examine the skills needed to respond to, from an
empowered stance, external constraints that threaten to
diminish the quality of one’s services (Schell, 1998). As
synthesizing exercises, students critique multiple fieldwork
experiences relative to the forms of clinical reasoning in
which they engaged, addressing how services might have
been improved by alternate or more comprehensive reasoning processes.
Investigative reasoning. The theme of investigative reasoning addresses (a) the values, attitudes, and skills to endorse
and enact evidence-based practice (Law & Baum, 1998) and
(b) the capacities to contribute, as coinvestigators, to research
in occupational science and therapy. Starting in their first
semester, students study, apply, and write about, using rules
of scholarship, various works that critique and guide practice relative to current theory and research. Once some
scholarly sophistication has matured, students are challenged to become sophisticated consumers of research by
such experiences as writing discussion sections and clinical
interpretations of studies (Coppola, 1998), debating the
profession’s research priorities (Parham, 1998), or analyzing
assumptions of post-positivist, constructivist, and critical
theory paradigms of research and their manifestations in
clinical practices (Guba & Lincoln, 1994). Corresponding
to intensive study of research methods, students complete
faculty-mentored research projects along with one to two
other students during their second year. These projects are
designed to build knowledge in occupational therapy or
science and, as feasible, to act as springboards into students’
careers by being of sufficient quality for submission to refereed forums (Humphry & Thigpen-Beck, 1997). Other
integrating experiences include critiquing practice during
fieldwork from an evidence base and critically evaluating
occupational therapy relative to factors that historically
have driven its treatment methods.
Ethical reasoning. Ethical reasoning is defined in the
curriculum as processes of enacting the highest standards of
ethical conduct and of generating solutions to problems on
the basis of a systematic study of morality. While encompassing attention to ethical issues in practice and research
(Hasselkus, 1991; Rogers, 1983), the theme also heavily
stresses the ethics of professionalism (Freidson, 1994). For
example, the concept of what it means to be a “principled
ideologue” of one’s profession is used to examine many
examples from occupational therapy and other fields of various innovations and advancements that occurred despite,
and sometimes due to, a “shaking up” of the status quo
(Colman, 1992). Conversely, current threats to the field are
examined in light of past compromises that weakened
occupational therapy’s sociopolitical position and diminished its power to meet the occupational needs of people
and society (Friedland, 1998).
Ultimate Educational Outcome
The final theme of occupational therapists as scholars and
change agents in systems addresses content pertaining to
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change, leadership, and current and potential environments
for practice. Scholars are defined as those who, at minimum,
continually inform and refine their work through ongoing
study of credible theory, research, and scholarship. Change
agents are defined in three ways: (a) change generators, or
those who initiate desired change; (b) change recipients, or
those who evaluate imposed change and respond with support and positive action; and (c) change resistors, or those
who evaluate imposed change and respond with deliberate
and strategic opposition. Decisions to act as change generators, recipients, or resistors are predicated on whatever best
supports both one’s professionalism as an occupational therapist and one’s capacity to enact best practice.
In our experience, entering students often require convincing that it is their professional obligation to challenge
forces internal and external to occupational therapy that
can adversely constrict its practice. To instill this mind-set,
an early Level I fieldwork is examined relative to how features of a particular setting shape the services delivered
therein. Examined somewhat later is how national policy,
reimbursement, interdisciplinary dynamics, and organizational culture affect the practices and status of occupational therapists (Crepeau, 1994; Townsend, 1996) as well as
how various systems of practice undergo change (Rourk,
1996). Students subsequently develop skills as change generators by means of conducting needs assessments and then
planning model community-based programs of occupational therapy (Baum & Law, 1998a). Diverse sources of
reimbursement are explored and integrated in comprehensive business and funding plans designed to support these
programs (“SBA Classroom,” 1999; The Foundation
Center, 1999). Skills in consultation, marketing, and program evaluation are also applied (Jaffe & Epstein, 1992).
All together, these projects are designed to help students
create their own positions in service of underserved populations in the community.
As the program’s ultimate educational objective, the
occupational therapist who is a scholar and change agent is
viewed as one who confronts complex problems with innovative solutions that are grounded in sound clinical, ethical,
and investigative reasoning and that manifest sound practice skills. Further, the scholar and change agent, even at
the entry level of practice, possesses the requisite capacities
to assume multiple professional responsibilities, including
those of advocate, program planner, administrator, community organizer, collaborative researcher, consultant, and
entrepreneur. In asking our students to think of themselves
in such “large ways,” they become ready, we believe, to see
their unique leadership profiles and to believe in their abilities to act as change agents on many levels within their
profession and communities.
Reflections on Innovation in Graduate Education
in Occupational Therapy
Having now implemented our new program of study, it is
possible to reflect on its “birthing” process, focusing on
those aspects that were crucial to the project’s completion.
To begin, we believe that our project would not have been
brought to fruition had we not committed ourselves to a
consistent schedule of curriculum work and eventually
become willing to engage in a true curricular renaissance.
Designating one person as a process manager was also key
to keeping the project on course, inducing flexibility and
structure as needed, and offering periodic reviews to take
stock of our progress and become energized anew.
Additionally, the 3 years that our project took allowed key
ideas to gestate and an enormous amount of work to be
accomplished while still managing other responsibilities.
Paying heavy attention to pedagogic issues and concerns
also proved to be critically important. We believe too that
we made the right decision in not starting the project
with course development. Rather, by collectively engaging in a visioning process and sustained period of study,
the curriculum grew to be far richer, more exciting, and
more reflective of our respective values, commitments,
and strengths than any that we had initially imagined.
Lastly, we should note that our work is unfinished. We are
continuing our consultations with the aforementioned
educational reformer in order to develop consistency,
across courses and assignments, by which quality of scholarly writing as well as various professional behaviors like
attendance, participation, timeliness in meeting external
deadlines, accuracy in following written instructions,
among others, are integrated into assigned academic
grades. Additionally, we are explicating developmental
progressions of learning objectives for each content area
in each curriculum theme on a semester-by-semester
basis. By tying these objectives to specific units of study
and markers of achievement, we can evaluate whether and
how well we teach what we think we do and, furthermore,
how to go about filling in gaps or otherwise improve our
efforts.
Ultimately, the most important question is not what
facilitated our curricular renaissance, but what its lasting
aftermath will be. That answer will reveal itself slowly as
we watch the professional commitments and contributions of our alumni take root and grow over time—or
not. Yet whatever transpires, on this we now wholeheartedly agree: Today’s educators must become far less concerned with preparing students to fit into preexisting
niches and far more concerned with empowering them to
invent their own futures as well as that of occupational
therapy. ▲
Acknowledgments
We thank Wendy Coster, PhD, OTR/L, FAOTA, Betty Hasselkus, PhD, OTR,
FAOTA, Ed Neal, PhD, Martin Rice, PhD, OTR/L, Barbara Schell, PhD,
OTR/L, FAOTA, Eve Taylor, PhD, OTR/L, Jenny Womack, MS, OTR/L, and
Elizabeth Yerxa, EdD, OTR, FAOTA, for their vital contributions to our curricular renaissance.
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November/December 2000, Volume 54, Number 6
Appendix
Guiding Vision of Occupational Therapy
We envision a future where
• occupational therapy is neither bounded by institution walls
nor compromised by artificial boundaries that preclude it from
addressing the vital activities of life for all persons in need,
regardless of their abilities to pay;
• occupational therapy is an integral component of all health
care, educational, welfare, wellness, and social systems that support persons with disabling conditions and the poor and disenfranchised members of our society;
• occupational therapy is recognized by society as having vital
contributions to make in helping people experience a high quality of life, whether they have disabling conditions or not;
• occupational therapy is available in all places where people carry
on their lives;
• researchers in occupational science and occupational therapy
play a lead role in formulating new understandings of the relationship of occupation to human development, adaptiveness,
resilience, health, and well-being; and
• the humanitarian values of occupational therapy are embraced
by society at large such that every person of any age, fully well
or with a disabling condition of any type, rich or poor, has the
opportunity to lead a life that is complete and full and contributory to others—a life of meaningful occupations.
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