Challenges and Opportunities to Work and Industry Practice in Occupational Therapy: A Practitioner Survey Open Access

Identified as a core occupation by Adolph Meyer (1922/1977) and stemming from the profession’s roots during World War I (Lohman & Peyton, 1997), work has since been consistently recognized as an integral performance area in every iteration of contemporary practice guidelines from the original release of uniform terminology (American Occupational Therapy Association [AOTA], 1979) to the most recent occupational therapy practice framework (AOTA, 2020a). Occupational therapy practitioners possess unique skills to assist people in engaging or reengaging in work activities by promoting the best fit among the worker, job tasks, and work environments (AOTA, 2017; Fisher, 2019). Occupational therapy broadly defines work as an occupation that fulfills people’s interests, habits, abilities, and intrinsic sense of productivity, including paid employment and nonpaid productive occupations, such as volunteering and resources seeking (Aldrich et al., 2017; Reed, 2019).

Despite being a core tenet, the current engagement of the occupational therapy workforce in work and industry (W&I) is unclear. Previous surveys on occupational therapy work practice focused solely on clinic-based work rehabilitation programs in the United States (Jundt & King, 1999), Hong Kong (Lo, 2000), and Australia (Deen et al., 2002). These studies do not reflect the contemporary evolution of this practice area toward the primary role of occupational therapy in workplace health and supporting other emerging perspectives of work as an occupation (Roll, 2023). There has not been an examination of W&I practice patterns or the W&I workforce in more than 2 decades. A contemporary understanding of occupational therapy’s contributions and challenges in W&I is crucial to promoting the recruitment and retention of the occupational therapy workforce.

Recent AOTA workforce survey results indicate a low involvement of occupational therapy practitioners in W&I (AOTA, 2020b), despite the deep historical roots of work in occupational therapy. Specifically, industrial rehabilitation or work programs, included under the “other” practice setting category within the survey, were selected by <3% of practitioners. To facilitate the future advancement of this practice area, in this study we investigate the current practice, challenges, and opportunities for W&I occupational therapy practitioners by addressing the following research questions: What are the current practice patterns in W&I occupational therapy? How important, abundant, and accessible are educational and research resources in W&I? What are the primary challenges and opportunities for occupational therapy practitioners specializing in W&I?

An online survey was conducted between June 12 and July 17, 2020, which consisted of 30 multiple-choice, Likert-type, and free-response questions (a total of 120 surveys had complete responses). Two researchers developed the survey items on the basis of their clinical expertise in W&I and used the Tailored Design Method (TDM) for internet surveys (Dillman, 2000). The TDM approach ensures maximum response rate and quality through survey item generation (e.g., question content, wording, survey structure). The survey items covered three broad areas: (1) practice trends, (2) training and resources, and (3) challenges and opportunities aligned with the three study questions. Two W&I experts outside the research team (one clinician and one researcher) pilot tested the survey questionnaire to establish face and content validity. A few refinements to the survey items were made after the expert review, primarily to clarify the terminology within the questions and answer choices. The University of Southern California institutional review board approved this study. Participants reviewed an informed consent page at the beginning of the survey, and compensation was not provided.

Licensed occupational therapists or occupational therapy assistants who self-identified as working in a W&I setting within the most recent 5 yr were eligible. We identified potential respondents through an extensive internet-based search using combinations of occupational therapy credentials (i.e., Occupational Therapist, Registered [OTR]; Occupational Therapist, Registered, Licensed [OTR/L]; Certified Occupational Therapy Assistant [COTA]) and 14 common W&I certifications (see Question 29 in the supplemental material for the full list of credentials, available online with this article at https://research.aota.org/ajot). Email invitations were sent to practitioners found through this search and to W&I practitioners within the research team’s network. A weblink was posted to LinkedIn and CommunOT, and respondents were asked to share the link with eligible people within their networks.

We conducted descriptive analyses for all questions and used t tests to compare responses between experienced (>5 yr) and novice (<5 yr) practitioners and between respondents with high (>50%) and low (<50%) W&I workloads. We used Levene’s test to assess the equal variance assumption of t tests. When Levene’s tests were nonsignificant and the ratio between the variances of two groups was <4, a two-sample test was used; otherwise, Welch’s t test was used. We conducted analyses using IBM SPSS Statistics (Version 28.0) and set significance at p < .05. For brevity, only significant group differences are reported.

The total number of complete survey responses was 120. Seventy-five complete responses from 179 invitations resulted in a reasonable response rate of 41.9% (Wu et al., 2022), and 45 additional responses were obtained from the secondary recruitment method through internet-based posts. All survey respondents self-identified as licensed occupational therapists or occupational therapy assistants. Table 1 summarizes the demographics of the 120 respondents, who were from 35 states within the United States (n = 112) and multiple countries outside the United States (n = 8). Approximately 70% of respondents identified as female. Most respondents were experienced practitioners with an average of 17.2 yr (SD = 9.4) of experience; novice practitioners had an average of 2.0 yr (SD = 1.5) of experience. Most respondents had at least one W&I certification (>80%); 9 respondents (7.5%) had ≥3. Among 22 different certifications, the most common were Certified Ergonomics Assessment Specialist (CEAS I, II, and III; 34.2%), Certified Ergonomic Evaluation Specialist (CEES; 10.5%), Certified Work Capacity Evaluator (CWCE; 9.6%), and Certified Professional Ergonomist (CPE; 8.8%). Ergonomics consultation, acute injury management, and worksite evaluation were the most frequently provided services. The least frequently provided services were health, wellness, or psychosocial consulting and employment tests (Figure 1).

On average, respondents attributed 37.3% of their W&I knowledge to on-the-job training, 26.6% to continuing education, 14.6% to mentorship, 9.6% to occupational therapy school, and 7.7% to peer- reviewed research articles. Experienced practitioners attributed more to continuing education (M = 29.1%) than novice practitioners (M = 17.7%), t(118) = 2.69, p = .004. Figure 2 displays perceptions of importance, abundance, and accessibility of training and resources. Most respondents considered continuing education, mentorship, certification-based training, and research as very to extremely important; yet, <20% rated these resources as very to extremely abundant. Internet resources were most accessible but least important, whereas mentorship was the least accessible and second-most important. Mentorship and textbooks were significantly more important to novice practitioners—that is, novice (M = 4.2, SD = 0.8) versus experienced (M = 3.6, SD = 1.2) practitioners, t(114) = 2.35, p = .01, and novice (M = 3.1, SD = 0.9) versus experienced (M = 2.6, SD = 0.8) practitioners, t(116) = 2.65 p = .005, respectively.

Respondents’ perceptions of W&I research are presented in Figure 3. More than half of the respondents disagreed that the occupational therapy voice and perspective are represented in research related to W&I (n = 65; 54.2%), and most respondents agreed that they rely on evidence from other professions to support their work (n = 102; 85.0%), including occupational health and medicine (n = 95; 79.2%), human factors (n = 85; 70.8%), biomechanics and kinesiology (n = 75; 62.5%), physical therapy (n = 72; 60.0%), and industrial engineering and hygiene (n = 67; 55.8%). Respondents felt prepared to contribute to the evidence for W&I (n = 71; 59.2%), but only one-third were aware of opportunities to contribute to evidence for W&I (n = 41; 34.2%).

Most respondents (n = 104; 86.7%) noted at least one of six common workplace issues as harming their health and well-being, with a median of two per respondent; nearly one-quarter experienced ≥4 (n = 27; 22.5%). Among the participants who responded to this item (n = 104), the most prevalent issues were workplace stress (n = 71; 68.3%), cognitive fatigue (n = 63; 60.6%), emotional fatigue (n = 54; 51.9%), and work-related musculoskeletal discomfort or injury (n = 50; 48.1%). Other workplace issues reported in text responses included productivity concerns when working from home, fatigue from traveling to clients, and bureaucratic workplace culture. Respondents with <50% of daily work in W&I identified more negative effects (M = 2.9, SD = 1.4 vs. M = 2.0, SD = 1.6), t(118) = 2.81, p = .003, and they were more likely to report cognitive fatigue (p = .002), emotional fatigue (p < .001), and workplace stress (p = .018). Nearly all respondents were at least moderately confident in managing work-related health (n = 112; 93.3%) and these workplace issues (n = 96; 80.0%). Experienced practitioners were significantly more confident in managing their health (M = 4.0, SD = 0.8) than novice practitioners (M = 3.5, SD = 0.9), t(118) = 2.47, p = .007; moreover, practitioners with >50% work in W&I were more confident in managing workplace issues (M = 3.5, SD = 1.1) than their peers (M = 3.1, SD = 1.0), t(118) = 2.15, p = .017.

Challenges most frequently rated as very to extremely significant included responding to emerging trends (n = 59; 49.2%), maintaining a referral and client base (n = 25; 20.8%), and managing relationships between clients and their employers (n = 23; 19.2%). Practitioners with <50% W&I tasks considered accessing tools and assessments more challenging (M = 3.5, SD = 1.0 vs. M = 3.1, SD = 1.0), t(116) = 2.53, p = .006. Novice practitioners reported lower confidence in accessing necessary tools and assessment (M = 2.8, SD = 1.0) and communicating with other disciplines (M = 3.7, SD = 0.8) compared with experienced practitioners: M = 2.4, SD = 1.0, t(117) = 2.78, p = .003, and M = 4.1, SD = 0.9, t(117) = 2.07, p = .02, respectively. Practitioners with a lower W&I workload reported lower confidence in maintaining a referral and client base (M = 3.0, SD = 0.9), t(117) = 2.27, p = .012, and meeting productivity standards (M = 3.3, SD = 0.8), t(117) = 3.37, p < .001, compared with practitioners primarily providing W&I (M = 3.4, SD = 1.0; M = 3.8, SD = 0.8, respectively). The most commonly reported challenges in free-text responses were competition from other professionals (e.g., physical therapy) and lack of recognition and support from occupational therapy organizations (e.g., AOTA, National Board for Certification in Occupational Therapy [NBCOT]). Other concerns included reimbursement, lack of W&I content in occupational therapy school, lack of evidence-based assessments and interventions, and unique struggles of private practice owners.

The top opportunity for occupational therapy in W&I identified as very to extremely important by 90% (n = 108) of respondents was participating in workplace injury prevention measures. More than three-quarters also identified providing support for changing worker demographics (e.g., aging population, immigrants; n = 101; 84.2%), integrating technological advances into practice (n = 95; 79.2%), and addressing psychosocial issues of the workplace for clients returning to work (n = 93; 77.5%) as very to extremely important. Two other opportunities were rated as top priorities by at least one-quarter of respondents: leadership in employee wellness programs in the workplace (n = 36; 30.0%) and providing support for workplace integration for people who are neurodiverse or have developmental and intellectual impairments (n = 32; 26.7%). Experienced practitioners rated marketing to referring physicians, workers’ compensation managers, and industries (M = 4.1, SD = 0.9) as significantly more important than novice practitioners (M = 3.6, SD = 1.1), t(118) = 2.16, p = .016. Additional opportunities that respondents identified in the free-text response included office space redesign, safe patient handling programs, collaboration with human resources (HR), legal and legislative support, and Americans With Disabilities Act of 1990 (ADA) modification.

The findings of this survey provide insight into current practice patterns, opportunities, and challenges in W&I. Most W&I services are now provided onsite, whereas clinic-based work rehabilitation services have decreased over the past 2 decades. Notably, the services ranked as the most frequent in the last practice survey conducted in 1999 (Jundt and King, 1999)—work conditioning and functional capacity evaluations (FCEs)—were among the least frequent in this study. Wellness programs and psychosocial consulting had low frequency but were rated as the top opportunities for occupational therapy practitioners in this practice area. Similarly, physical therapists, who are qualified health providers for administering FCEs and other employment tests, have also recognized the emerging trend of onsite consultation and workplace health promotion (McMenamin et al., 2021). The findings highlight significant challenges in W&I practice, including adapting to emerging trends, such as workplace technologies and changing worker demographics; maintaining consistent referrals; and facing competition from other professions.

Two unique demographic features of W&I practitioners, gender and specialty certification, were noted in the survey findings. Although men are historically underrepresented in occupational therapy (Maxim & Rice, 2018), we found that 29.2% of respondents identified as male, which is more than 3 times higher than the representation of men in the AOTA workforce survey conducted at a similar time (AOTA, 2020b, p. 9). The percentage of practitioners with specialty certification was remarkably high (>80% had at least one), indicating a diverse range of knowledge and expertise requiring specialized training in W&I practice (Buys, 2007). The findings illuminate distinct characteristics of the W&I occupational therapy workforce that present an opportunity for increasing the profession’s diversity.

Despite the high rate of specialty certifications, respondents expressed concerns regarding the availability and accessibility of mentoring, training, and profession-based research evidence. Mentoring was considered essential, yet lacking, which is vital for advanced practice areas (Cusick et al., 2010); the growing number of practitioners in private practice may pose difficulties for novice practitioners to access these mentorship opportunities (Jackson et al., 2023). Content at professional conferences, a critical training opportunity, was the second least available resource; of 261 published abstracts from the 2022 AOTA annual conference, <10 were related to W&I (https://research.aota.org/ajot/issue/76/Supplement_1). This barrier was reflected in many comments and concerns regarding a lack of support from professional organizations for W&I practitioners. Although it is encouraging that many respondents felt prepared to contribute to research, most were unaware of research opportunities; moreover, practitioners primarily relied on evidence from other disciplines. Given the importance of evidence-based resources in supporting clinical practice (Dirette et al., 2009), the low availability of occupational therapy–specific W&I content and the need to rely on sources from other disciplines are worrisome.

Although the number of W&I occupational therapy practitioners who responded to our survey was the largest compared with previous reports, the sample size limited the power to perform comparative analyses across all demographic factors. Specifically, we could not compare practitioner responses among work settings, which likely have differences in clinical service provision, challenges, and opportunities. Additionally, respondents in this survey may not represent the broad range of work-related practices in occupational therapy. For instance, practitioners in school-based or adolescent transition programs who provide job training are not represented in this study. We used a self-developed survey method for descriptive and exploratory purposes because no existing survey instrument aligned with our study’s purpose; numerous efforts were made to maximize the validity of the questionnaire. Despite these design features that limit the ability to draw broad conclusions, the findings of this study provide insights into contemporary W&I occupational therapy practice.

The results of this study have the following implications for occupational therapy practice:

• ▪ Psychosocial consulting and workplace wellness programming are two opportunities for increased engagement of occupational therapy practitioners in W&I, potentially by leading interprofessional intervention approaches, such as applications of Total Worker Health®.

• ▪ It is important to develop mentorship programs and increase knowledge mobilization at professional conferences to address the paucity of training and resources to support novice occupational therapy practitioners in W&I.

• ▪ Research incorporating the occupational therapy perspective on work participation and worker health and wellness is needed. A sufficient amount of occupational therapy–focused literature can aid in the development of professional identity (Walder et al., 2022), which is crucial for W&I practitioners given their small number within the occupational therapy profession and competition from other professionals in this practice area.

• ▪ Recognition of W&I practices (e.g., workplace wellness promotion, worksite evaluations) as essential curriculum content areas within the Accreditation Council for Occupational Therapy Education (ACOTE) standards is needed to maintain the profession’s foothold in this practice setting.

This survey study met its objectives by describing the current practice trend and identifying key challenges and opportunities in the W&I occupational therapy practice area. Compared with previous evidence, our results indicate a shift in practice trend from clinic-based work rehabilitation to ergonomic consultation and worksite evaluation services. This study also highlighted a lack of accessible training resources, mentoring opportunities, and research evidence in the field of W&I. To advance the future of W&I practices, increased recognition of work as a core area of occupation and structured support from occupational therapy professional and research organizations are essential.