Importance: There is increased attention on the role the physical home environment plays in successful engagement in occupation. Objective: To examine how home modification content is integrated into the core curriculum in entry-level OT programs in the United States. Design: Web-based survey research. Participants: Program directors or their representatives. Results: All respondents include home modification instruction in their curriculum, however instructional time, where content lies in the curriculum, and resources vary widely. Sixty-eight percent do not utilize content experts and 34% do not offer hands-on learning experiences. Conclusion and Relevance: There is a risk for disparity in the scope and quality of home modification education provided to OT students that could negatively impact service delivery in this increasingly in-demand area of practice.
Keywords: Competency, curriculum, home modification, occupational therapy, training
| Introduction|| |
Occupational therapy (OT) professionals understand that context influences participation in occupations. Prior to the COVID-19 pandemic, occupational performance in the home primarily centered around routine activities of daily living. However, with stay-at-home orders resulting in the closure of schools, businesses and many community-based programs, occupations previously engaged in outside of the home were now taking place within the home.
Even before the pandemic, the model for delivering healthcare services in the home was proving to be both cost effective for the insurer and preferred by the client.,,, The Department of Housing and Urban Development (HUD) recently awarded 30 million dollars in grant funding through the Older Adult Home Modification Program (OAHMP) to enable low-income elderly persons to safely remain in their homes through comprehensive home modifications provided by an OT. The OAHMP model relies on the expertise of an OT to exhibit knowledge in low-cost, high-impact environmental modifications and adaptive equipment to optimize the home environment and increase independence.
While there is support in the literature regarding the value of OTs role in home modifications, it is unclear how this material is covered in academic programs. One justification made for higher levels of education in the profession has been that this will allow academic programs to “have more opportunities for service learning, fieldwork experiences, or capstone projects that address the complexity of clients’ needs in their homes, schools, neighborhoods, and communities through a focus on the therapeutic use or adaptation of the objects and spaces of those environments”. The questions that arise are, to what extent are opportunities for learning in home modifications occurring and what do these opportunities look like?
Lack of clarity of constructs in occupation-focused theories and models of practice may account for what appears to be a void in published literature on the character and content of home modification education in entry-level occupational therapy programs. Varying interpretations of the Accreditation Council for Occupational Therapy Education (ACOTE) standards related to context(s) and/or environments in instructional content and how they are demonstrated may also result from this lack of clarity. Given the increasing number of people over 50 wanting to age in place, changes to the type of occupations occurring within the home for all ages as a result of the coronavirus pandemic,, and the recent increases in public funding for healthcare services delivered in the home including home modification, it is essential that occupational therapy programs clearly articulate their curricular content thus demonstrating that they are adequately preparing entry-level practitioners to meet these demands.
The purpose of this survey research was to explore three objectives related to how OT programs address home modifications in their curriculum: (1) extent to which home modifications is part of the core curriculum, (2) resources and instructor competency, (3) presence of measurable guidelines for student competency and confidence.
| Methods|| |
The authors, both of whom are occupational therapists with experience in academia and home modifications, developed the 16-question survey utilizing thirteen closed and three open-ended questions. Section B of the ACOTE Standards and Interpretive Guide was used in the identification of topic areas for questioning. Feedback on the initial survey was solicited from two occupational therapists who have more than thirty years combined experience in home modifications and are Certified Aging in Place Specialists with the National Association of Home Builders. The modified survey was approved through an Institutional Review Board. Surveys were distributed via Qualtrics to program directors of entry-level master and doctoral programs listed on the American Occupational Therapy Association (AOTA) website as accredited as of May 7, 2021. Up to three follow-up email reminders with the URL link to the survey were sent to programs who did not respond in order to maximize the number of responses. Participant consent was obtained.
Descriptive statistics, frequencies, and percentages were calculated for closed-ended responses using Microsoft Excel®. The open-ended responses were individually analyzed and coded by the authors who subsequently met to discuss their individual findings. Frequently used terms and similar reflections appearing in responses were grouped, color-coded and tallied. See [Table 1] for the open-ended questions.
| Results|| |
The survey was emailed to 194 program directors at 215 accredited entry-level occupational therapy programs within the United States. The survey remained opened from May 7, 2021 through June 15, 2021. A total of 36 people responded in part or entirely to the survey (19% response rate). All responses were included.
Objective 1 – Extent to which home modifications is part of the core curriculum
All respondents indicated their curriculum included content specifically related to modification of the home environment, with 82% (28/34) reporting home modification content was addressed within another course [see [Figure 1]]. When instructing on home modifications in OT programs, all those responding (100%; 33/33) stated a focus on the older adult population with some programs additionally addressing young adults (52%; 17/33) and children (48%; 16/33). This tendency to address home modifications more often with older adults was supported by the identification of medical conditions linked to instruction in home modification (stroke, Parkinson’s disease, falls, dementia/Alzheimer’s, low vision, chronic obstructive pulmonary disease, and osteoarthritis). Seventy-seven percent (24/31) of respondents reported from six to more than 15 hours of total instruction time spent on home modifications [see [Figure 2]].
|Figure 2: Relationship of hours spent teaching content and credentials of those teaching content|
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Responses of entry-level skills needed in home modification were categorized into theory and advocacy or hands-on skills [see [Figure 3]].
Objective 2 – Resources and instructor competency in home modification curriculum
No one single resource was used in instruction; rather respondents reported using a variety of learning content including textbooks/chapters in textbooks, formal and informal assessments, guest speakers, journal articles, AOTA fact sheets and simulation. Most frequently cited texts included Ainsworth and Jonge (2018), Pendleton and Schultz-Krohn (2018), Radomsky and Trombly (2014), and Christianson and Chase (2011).,,, Sixty-eight percent report that the instructor has no specialty training or certification in home modifications.
Objective 3 – Presence of measurable guidelines for student competency and confidence
No one single assessment either informal or formal appears to be preferred by those programs that responded (Safety Assessment of Function and the Environment for Rehabilitation - SAFER = 21%; In-Home Occupational Performance Evaluation - I-HOPE = 15%; AARP HOMEFIT Home Safety Checklist = 15%; Rebuilding Together Safe at Home Checklist = 12%).,,, Sixty-eight percent report that the instructor has no specialty training or certification in home modifications. Of those that do report specialty training or certification, [Figure 2] highlights the type of training or certification. Sixty six percent (19/29) of responding programs provide students with the opportunity for hands-on educational experiences. [Figure 4] depicts the hands-on student experience reported.
| Discussion|| |
Ten years ago, most OT practitioners working in home modification did not have specialty certifications and the use of standardized measurement tools to document changes in functional performance as a result of home modifications was lacking., With a consideration for public expectations regarding competence, it was recommended at that time that varying levels of education and training for OT practitioners in home modifications was needed, and that skill development needed to have both an academic foundation and experiential learning component. It appears that within current OT programs instructional time, type of instruction, resources and assessments utilized, how content is woven in the curriculum, and level of experiential learning opportunities are not uniform.
There are benefits of experiential learning in the health sciences compared with didactic teaching. These benefits include an enhanced ability to apply learned concepts along with improved confidence, clinical reasoning and professional behavior skills, and perception of fieldwork readiness.,, A recent article by dos Santos et al., (2021) highlights some home modification experiential learning opportunities being developed for students ranging from fieldwork opportunities to community outreach activities. If the occupational therapy profession is to secure its position in this new and emerging field, it is imperative that programs continue developing experiential learning opportunities to provide students with the opportunity to put learned concepts into action.
Experience levels for those teaching home modification content seems to indicate that most instructors do not have specialty certifications. It is speculated that there are benefits to students and programs when specialized content is taught by experts. What respondents report as required entry-level knowledge differs than what is delivered in OT programs, with most content being covered through other courses and by faculty without expertise. Thus, there is value to encouraging programs to work with faculty to obtain specialty certifications when delivering this content.
Generalization of findings across programs is limited due to response rate and inclusion of incomplete responses. It is challenging to know if respondents are a true representation of the entire population surveyed or are in some way systematically different. The diversity in answers, especially related to instructional time, instructor knowledge and opportunity for hands-on experience may suggest that there is broad representation reflected in the response rate. Another survey with higher participation is needed to truly understand how well these findings represent the population.
Additional considerations for limits to this study include the fact that occupational therapy assistant programs (OTA) were not included. Future studies exploring the scope of instruction in home modification within OTA programs may provide further justification for OTs role in this practice area. Both authors have received home modifications training and certifications and thus bias may have been evident.
Implications for practice
As future trends in healthcare delivery and reimbursement continue to show a shift away from hospital-based settings to less expensive, more personalized home settings, clearly articulating within the profession and to the public a more uniform understanding of the education and training provided to entry-level practitioners in home modification will be essential to securing OTs position and value in this field. Prospective occupational therapy students interested in the practice of home modifications may want to seek out programs that provide expert instruction and hands-on experience. Establishing mentorship programs and in-person course instruction for those seeking higher level skill achievement in the execution of home modification from simple to more complex projects should be encouraged.
Financial support and sponsorship
Conflict of interest
There are no conflicts of interest.
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Occupational Therapy Program, University of Vermont, College of Nursing and Health Sciences, 106 Carrigan Dr Burlington, VT 05405
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]