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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 53  |  Issue : 1  |  Page : 15-22

Scope of practice boundary violation in occupational therapy: An online survey of practitioners' perceptions in India


Department of Occupational Therapy, University of Texas Medical Branch, Galveston, TX, USA

Date of Submission24-Dec-2020
Date of Acceptance03-Apr-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
Karthik Mani
1572, Harvest Vine Ct, Friendswood, TX - 77546
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_44_20

Rights and Permissions
  Abstract 


Background: Occupational therapy (OT) practice in India is yet to be regulated at the national level. This presents a significant challenge to the OT community in India as it would be difficult for them to defend themselves if other professionals violate the scope of practice (SOP) boundaries. Objectives: The aim is to explore the views of occupational therapists (OTs) related to the issue of SOP boundary violation in OT practice in India. Study Design: An online survey research design was chosen to conduct this study. A 10-item electronic survey (9 with response options and one open ended) was developed based on the research question. Methods: An online survey link generated through SurveyMonkey was E-mailed to 760 OTs in India, identified through convenient sampling. The survey link was also shared on four WhatsApp Messenger groups (TNAIOTA Official Group, OTist Group, Clinic OT, and IPOTPDG1) with many Indian OTs (snowball sampling). Data were collected from January 29, to February 29, 2020. Results: The number of responses received was 126. One hundred and nine (87%) respondents believed that other professionals encroach OT's SOP boundaries knowingly or unknowingly. This belief is strong among all OTs across the nation, regardless of gender and practice experience. Conclusions: Many OTs in India believe that individuals belonging to other professions step into the domain of OT knowingly or unknowingly. Enacting an OT practice legislation, establishing a regulatory body at the national level and increasing them at state levels, endorsing an official SOP document, educating stakeholders, and engaging in awareness promotion initiatives would help mitigate the issue to a great extent. Ongoing and strategic efforts by the OT community in India are warranted.

Keywords: Awareness, Occupational Therapists, Surveys and Questionnaires, Workforce


How to cite this article:
Mani K. Scope of practice boundary violation in occupational therapy: An online survey of practitioners' perceptions in India. Indian J Occup Ther 2021;53:15-22

How to cite this URL:
Mani K. Scope of practice boundary violation in occupational therapy: An online survey of practitioners' perceptions in India. Indian J Occup Ther [serial online] 2021 [cited 2021 Oct 18];53:15-22. Available from: http://www.ijotonweb.org/text.asp?2021/53/1/15/318985




  Introduction Top


In the healthcare arena, professions continue to evolve with new practice opportunities, evidence informed treatment modalities, and technology. Hence, it is critical for healthcare professionals to be aware of and act within their profession's scope.[1] Professional regulation assists professionals' practice within their scope.

Occupational therapy (OT) in India is largely unregulated. Currently, only two jurisdictions (Maharashtra and New Delhi) regulate the profession through a state-level council.[2],[3] In addition, the national association, through its academic council, offers registration to its members. Lack of regulation, limited awareness, and dearth of workforce coupled with increased demand for services have paved the way for quacks to enter the health care industry, including the field of OT.[4],[5]

Several occupational therapists (OTs) in India expressed concerns about non-OT professionals violating OT's scope of practice (SOP) boundaries (OT professionals, personal communication, 2/3/2019). The first step in resolving this concern is to explore and document the reasons behind the violations. The aim of this study was to explore the issue of OT SOP boundary violations (BVs) in India from OTs perspective.


  Methods Top


This online survey-based research study was conducted adhering to the principles of Declaration of Helsinki guidelines. The guidelines were reviewed before the survey being sent to the participants. In addition, the survey invitation that was sent to and shared with participants clearly identified that participation in the survey was “strictly voluntary and the responses will be kept anonymous.”

Sample

The study's targeted population was OTs in India. The participants were identified through convenience and snowball sampling. The author found 760 E-mail addresses belonging to OTs in India from E-mail archives. The possibility of two or more E-mail addresses belonging to the same practitioner cannot be ruled out. Further, the survey invitation was also shared on four different WhatsApp groups of Indian OT practitioners (TNAIOTA Official Group, OTist Group, Clinic OT, and IPOTPDG1).

Instrumentation

The author developed the survey by reviewing the literature and following survey-writing guidelines.[5],[6],[7],[8] The survey tool consisted of ten items [Appendix A]. The first few items gathered information on participants' demographics (age and geographical location), practice experience, practice setting, and practice area. Subsequent items explored participants view on (i) SOP BV, (ii) professionals who violate boundaries knowingly or unknowingly, (iii) potential reasons behind BV, and (iv) strategies to overcome BV. The final open-ended item asked participants to express any other related thoughts.

Nine experienced OTs who had practiced OT in India and abroad reviewed and commented on the survey tool. The following changes were made to the original survey tool based on the feedback. First, the response options to item 8 were rearranged so that two response options begin with “lack of clarity” do not appear next to each other. Second, one of the response options to item 8 was changed from supply-demand imbalance to therapists' shortage to make it easier for respondents to understand. Third, an additional response option (Introduce OT assistant educational programs to increase workforce in the field) was included in item 9.

Procedure

The survey was conducted through SurveyMonkey™.[7] In January 2020, all identified participants were sent an E-mail invitation to participate in the survey. The survey link was also shared via four WhatsApp groups with February 29, 2020 as the response deadline. Two reminder E-mails were sent during the open survey period.[8] The reminder E-mail message with the survey link was also posted on the WhatsApp groups. At the end of the survey response period, all data were exported and tabulated for statistical analysis.

Data Analysis

Descriptive statistics were used to summarize and report the responses received. Data are reported as percentages and aggregate numbers to protect the identity of respondents. Chi Square test was performed to determine the association between the variables as needed. The association was deemed significant if the P < 0.05. The data were clustered logically when the frequency values were low. For instance, states were clustered into South, West, and other regions; “strongly agree” and “agree” responses were grouped; “strongly disagree” and “disagree” responses were combined; etc., When the data were aggregated for statistical analyses, neutral responses were eliminated. All analyses were conducted using Microsoft Excel 2016. The responses to the open-ended question were analyzed for themes using qualitative content analysis. In this method, the responses are clustered to generate conceptual categories.


  Results Top


By the response deadline, 126 responses (78 via E-mail and 48 via social media) were received. Of 126 respondents, 67 (53%) were female OTs and 59 (47%) were male OTs; 57 (45%) respondents practiced OT in Tamil Nadu, 19 (15%) in Maharashtra, 15 (12%) in Karnataka, and 8 (6%) in Delhi-National Capital Region. Five or less responses were received from 13 other states and two union territories (UTs). The survey failed to generate responses from 12 states and five UTs. Twenty-three (18%) of respondents reported that they are in the field of OT for more than 20 years, 49 (39%) reported 10–20 years, 17 (13%) reported 5 to 10 years, 11 (9%) reported 3 to 5 years, and 26 (21%) reported <3 years.

[Figure 1] and [Figure 2] present the practice settings and practice areas of the respondents respectively. Respondents who chose the “other” option for the item on practice setting identified settings related to academia (college, university, medical college, etc.) and one respondent mentioned “government” in the text box. Respondents who chose the “other” option for the item on practice areas identified “cardiopulmonary rehabilitation, occupational rehabilitation, rheumatology, and rehabilitation as their practice areas.
Figure 1: Practice Settings of Respondents

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Figure 2: Practice Areas of Respondents

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Of 126 respondents, 55 (44%) strongly agreed and 54 (43%) agreed to the statement of other professionals providing interventions that fall under the OT SOP. [Figure 3] and [Figure 4] present respondents view on who (which other professional) steps into OT's SOP and why they do so either knowingly or unknowingly. Respondents who chose “other” as their response for item 7 identified psychotherapist, nursing staff, prosthetist and orthotist, preschool teachers, ayurvedic doctors, developmental therapists, and parents of children with disability in the comments. The comments of those respondents who opted “other” as their response for item 8 reflected the following themes: profit mentality, viable unfilled practice opportunities, increasing demand for OT services, professional hierarchy, multi-professional continuing professional development activities, and lack of unity among OTs.
Figure 3: Respondents View on “Which Other Professionals Step into Occupational Therapy Domain Knowingly or Unknowingly”

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Figure 4: Respondents View on “Why Other Professionals Step into Occupational Therapy Domain Knowingly or Unknowingly”

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[Figure 5] presents respondents view on what the OT community in India can do to overcome the issue of SOP BV. The comments of respondents who chose the “other” as their response reflected the following themes: united efforts, quality OT education, national qualifying examination, improved competence, ongoing professional development, change in OTs attitude, and ethical practice.
Figure 5: Respondents View on How Occupational Therapists in India Can Overcome the Issue of Encroachment of Other Professionals into the Scope of Practice

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Seventy-five (60%) of the respondents responded to the final open-ended items. The following themes emerged from the analysis of their responses: Professional regulation can be mitigated through professional regulation; professional BV affect patient care; awareness promotion is paramount; change must begin from OTs; assertive and united actions from OTs are critical; OTs should improve their knowledge, skills and competency; and overlap between professional domains is expected.

The test of association performed between the “level of agreement to the statement of other professionals violating OT SOP” and “gender” (χ2 = 2.23; P = 0.13; odds ratio [OR] =2.5417; 95% confidence interval [CI] =0.72, 8.95) and “years of practice” (χ2 = 0.69; P = 0.41; OR = 1.69; 95% CI = 0.48, 5.96) yielded nonsignificant probability values. No test of association was performed for other variables due to low frequency values.

Some of the themes emerged from respondents' comments to items 8–10 were elaborated in the subsequent section.


  Discussion Top


The results of this study suggest that many OTs in India, regardless of gender, experience, geographical region, practice setting, and practice area, believe that individuals who belong to other healthcare professions violate OT's SOP boundary either knowingly or unknowingly. (The author respects and values the contribution of all healthcare professionals. As the survey item had the phrase “knowingly or unknowingly,” this statement should not be deemed accusatory. One of the intentions of this study was to document the beliefs of OTs in India related to professional boundary violation so that the OT leaders and advocates can engage in a productive conversation with other stakeholders. Further, the findings of this study can also be used to advocate for a professional regulatory body for OT at the state/national level.) Given the low number of responses, no analysis was performed to determine the perception of practitioners in the states (Maharashtra and New Delhi) where the profession has already been regulated and yet to be regulated.

Encroachment into Occupational Therapy Domains of Practice

Except three respondents, all respondents believed that one or more (other) professionals stepped into the OT's domains of practice knowingly or unknowingly. Other professionals performing interventions that fall under the traditional domains of OT have been reported in the literature.[9] The reasons behind this could be lack of role delineation/clarity,[10],[11] existence of role overlap,[12] sharing of a common knowledge base, similarity in the service delivery processes, commonality between diagnoses treated, overlapping treatment goals, commonality between therapeutic approaches, and professionals' zeal to help patients/clients in resource limited settings.[13]

Many respondents perceived that physiotherapists (PTs) (n = 102) and special educators [SEs] (n = 97) encroach into the OT domain, knowingly or unknowingly. This perception could be due to the common goals these professionals may have for the clients they co-treat with OTs.

The professional overlap between OT and PT professions has been documented in the literature over the past five decades.[9],[10],[14],[15] Although the literature on professional overlap between OTs and SEs is scant, since many respondents in this study identified “pediatrics” as their practice area, it is highly likely that they work with teachers and SEs to achieve common goals. The efforts made by teachers/SEs to achieve positive student outcomes may have contributed to OTs perception of SEs stepping into the OT practice boundaries. Literature advocates for the collaborative efforts between SEs and OTs to achieve positive outcomes. Ottenbacher stated that OTs who work with the SEs in the school system are in a unique position to help SEs combine various treatment models to assist education and habilitation of developmentally disabled individuals.[16] Barnes and Turner supported the collaboration between teachers and OTs by stating that it augments positive student outcomes.[17]

Interestingly, 54 respondents believed that psychologists stepped into OTs domain of practice, despite only three of them reported their primary practice area as psychiatry. Another interesting observation is that 37 respondents who identified their practice area as pediatrics also identified psychologists as one of the professionals who step into the domain of OT. The literature on professional overlap between OT and psychology is scant and limited to professional opinions.

Reasons for Boundary Violation

Many respondents believed that lack of awareness, role confusion, and lack of professional regulation as the major reasons behind the SOPBV. Understandably, lack of awareness of OT may lead other professionals unknowingly encroach into OT domains of practice. Conner-Kerr et al. reported the existence of practice role confusion between OT and PT students and OT and speech language pathology students.[11] As professional regulatory organizations monitor and regulate professional activities through disciplinary actions,[18] it would be wise to assume that lack of such a regulatory mechanism may lead to BV.

Many OT activities may appear basic from an overt view despite the inherent sound theoretical foundations and clinical reasoning. This superficial perspective may have encouraged other professionals and nonprofessionals to perceive OT, incorrectly, as something that anyone can deliver with little training/observation. In addition, the BV by OTs may also lead to role confusion.

Respondents' comments indicated that others may enter the OT domain of practice if there are viable unfilled practice opportunities. Clemence stated that “if there is still a demand for service, the vacuum left by the withdrawal of therapists will be filled by another professional group.”[19] (p. 274) In India, it is evident from continuous OT job postings on social media that the demand for OT services is increasing rapidly.[20] This supply-demand imbalance may have favored the BV. Respondents comments also echoed that profit mentality may be a reason that might motivate other professionals violate OT SOP boundaries. One respondent commented “Economic gains far superior to their own” and another respondent commented “management is not bothers who does it for less pay [sic].

One respondent believed that the hierarchy in the healthcare system prevailing in India could be a reason for SOP BV. He/she commented “Stong[sic] desire to dominate OT practice. For e.g. they wanted to prescribe/Control how many times/to what duration (per week) OT should treat a patient and what assessment should be done.”

One respondent commented “Certification courses done by other professionals,” which indicates that those professionals who attend certificate courses on a topic related to OT practice may knowingly or unknowingly begin practicing OT interventions.

Overcoming Boundary Violations

According to respondents, the most effective way to address the SOP BV issue is by advocating for a professional regulatory body at the national/state level. Logically, this would be the best solution to mitigate the issue. It is important to underscore here that India has made progress in terms of regulating OT, such as establishing OT councils in two jurisdictions and including OT in the recently introduced National Commission for Allied and Health Care Professions Bill.[21] However, it is important to note that 23 (85%) respondents from regulated jurisdictions either agreed or strongly agreed to the statement of 'other disciplines providing services that fall under the scope of OT'. This shows the need for more efforts in addition to establishing a regulatory body.

Seventy-six respondents supported the idea of publishing and disseminating official SOPs to mitigate the BV issue. Some efforts have been made related to the development of the official SOP pertaining to the Indian context of practice. Indian OTs Think Tank, a voluntary organization made of highly skilled likeminded OTs from India, has drafted and recently adopted an official SOP document, which is awaiting publication at the time of this writing.[22]

Other responses endorsed by at least 72 respondents were educating employers of OT on the importance of hiring qualified OTs and publicizing the harms involved in receiving OT services from individuals who are not OTs. Professional organizations may develop materials such as brief videos, evidence-based handouts, etc., to support these ideas.

The OT community in India must also focus on addressing the supply-demand imbalance by increasing workforce in the field by establishing new OT programs in all parts of the country. India has made good strides on this front in recent years with the establishment of four new OT educational programs in Tamil Nadu.[23],[24]

Educating the stakeholders on the science and reasoning behind OT interventions may help stakeholders appreciate the value OT. It is important to note that clients, often, expect high quality service from health care providers regardless of their professional titles or SOP.[9] If OTs continue to deliver high quality services, understandably, clients will be more inclined to seek services from them, which may help the OT community mitigate the issue of BV.

Metcalfe stated that acknowledging the professional overlap between healthcare practitioners as inevitable is another strategy to handle the issue of SOP BV.[12] Brown and Greenwood also advised that OTs may need to “accept the fact there will be some professional boundary overlap with other professional groups and in turn, focus on what is best for the client”[9] (p. 168).

Only 29 respondents selected the response option of developing OT-assistant programs to mitigate the workforce issue in the field. This shows that the many respondents were not in favor of the idea of developing two levels of OT education. However, it is essential to note that, globally, the trend toward recognition of OT assistants by providing professional membership in the national association and establishing OT-assistant education programs has been on the rise.[25]

Other comments by respondents suggested OTs to practice their profession ethically (we should not appoint other professional or nonprofessional to give OT to patients”), improve their competence and role clarity (”OT themselves should have an absolute clarity what they are capable of in real sense”), and engage in united efforts (OTs have to be assertive and authoritative. We need to have unity and harmony within us”) to address the issue of SOP BV. One respondent called for a multi-faceted approach to deal with the issue. He/she commented:

”… a piecemeal, fragmented approach will not work. Our practice needs to look different from others, not just superficially, but in deep surface levels also…It needs change first from within OT and probably a major overhaul on all fronts-education, clinical practice and research.”

Implications for the Profession in India

This study reveals that OTs in India strongly believe that their boundaries are encroached by other individuals. This may affect the image and growth of their profession and cause harm to the public. To allay the issue, OTs shall:

  • Accelerate the advocacy efforts to form a regulatory body at the national/state level
  • Acknowledge the concerns related to possible duplication of skills
  • Communicate the holistic approach they use, which is beyond addressing the physical impairment[26]
  • Demonstrate assertiveness while establishing their professional identity in practice settings such as hospitals and national institutes
  • Educate stakeholders on OT SOP
  • Encourage discourse on professional boundaries among students
  • Engage in ongoing awareness promotion initiatives
  • Fight for what is uniquely theirs[10]
  • Promote their unique identity through education, practice, and public communications[26]
  • Publish high quality research to support OT practice in the Indian context
  • Report BV to employers, professional agencies, and regulatory bodies as relevant
  • Share the rationale behind “why they did what they did” to stakeholders
  • Update OT curriculum in an ongoing manner reflecting traditional and emerging areas of practice and student feedback
  • Uphold ethical practice and avoid recruiting trained personnel in their practice
  • Work with other professional groups, through their national and state level professional agencies, to establish clear professional boundaries suitable to the local context.


Limitations

The major limitation of this study is the low number of responses, which limits the generalizability of the findings. Further, there were no responses from many states and union territories. This limits the generalizability of the findings nationwide. A mail or telephone survey may have increased the number of responses. An in-depth survey with more questions may have yielded additional insights.

Recommendations

The survey tool could be elaborated with additional questions to generate more insights. Conducting focus groups exploring the professional overlap between OT and PT, OT and SE, and OT and psychology in the Indian context of practice may generate valuable insights. A study can be performed to learn the impact of professional regulation where the profession has already been regulated in India.


  Conclusions Top


OTs in India are concerned about the issue of professional BV. Lack of regulation and role confusion between OT and other disciplines complicates the issue and fuels the concern. A multi-pronged approach targeted toward professional regulation, role delineation, and stakeholder education is needed to mitigate the concern.

Acknowledgment

The authors express his sincere gratitude to all participants and those who reviewed the survey tool for face validity.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.


  Appendix Top


Appendix A

This survey aims to explore the views of occupational therapists related to the issue of scope of practice boundary violation in occupational therapy practice in India. This survey is intended only for occupational therapists who practice occupational therapy in India. Your participation in this survey is strictly voluntary and your responses will be kept confidential. Completing the survey indicates your consent to participate in this study. Please DO NOT complete this survey if:

(i) you practice occupational therapy outside India

(ii) you live in India, but work in another field

Please do not provide your name or contact details anywhere on this survey. Should you have any queries or comments regarding this survey, please write to me at [email protected] co. in.

Glossary:

Scope of Practice: Scope of practice helps to identify procedures, actions, and processes an individual in the given profession is permitted to perform. It is based on specific education, experiences and demonstrated competence.

Boundary Violation: Practicing outside one's scope of practice.

1. Please identify your gender.

Male

Female

2. Please identify the state/union territory in which you practice occupational therapy.

(Drop down menu of states and union territories in India)

3. How long have you been an occupational therapy practitioner?

0-3 years

3 years 1 day-5 years

5 years 1 day-10 years

10 years 1 day-20 years

20 + years

4. Please identify your primary practice setting.

Acute care hospital

Subacute care/Rehabilitation center

School/Special School

Nongovernmental organization

Outpatient clinic

Home health

Private practice

Other (please specify)

5. Please identify your primary area of practice.

Pediatrics

Neurology

Orthopedics

Geriatrics

Oncology

Psychiatry

Other (please specify)

6. In my view, professionals belong to other disciplines provide interventions that fall under the scope of occupational therapy practice.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

7. In your view, which of the following professionals' step into the occupational therapy scope of practice (In other words, use techniques and procedures from the OT toolbox), knowingly or unknowingly? (Select all that apply)

Physical therapist

Physician/Medical specialists

Special educator

Psychologist

Speech language pathologist

Multipurpose rehabilitation therapist

Social worker

None

Other (please specify)

8. Why do you think other professionals enter into the occupational therapy profession's scope of practice in India? (Select all that apply)

Lack of professional regulation

Lack of awareness about occupational therapy among patients

Lack of clarity about occupational therapy domains of practice among occupational therapists

Lack of a publicly available official scope of practice document pertaining to occupational therapy practice in India

Therapists' shortage (less therapists-more patients)

Occupational therapy domains of practice overlap with several other professions

Lack of clarity about occupational therapy domains of practice among other professionals

In my view, other professionals do not enter into the OT's scope of practice in India

Other (please specify)

9. In your view, how can occupational therapists in India overcome the issue of encroachment of other professionals into the OT scope of practice? (Select all that apply)

Advocate for a regulatory body (e.g. council) at the national level

Advocate for a regulatory body (e.g. council) at the state level

Educate stakeholders on the OT scope of practice

Publish an official scope of practice document in multiple Indian languages and make it publicly available

Increase workforce in the occupational therapy workforce in India by opening new occupational therapy educational programs

Publicize the harms related to receiving occupational therapy services from unqualified individuals

Educate employers of occupational therapists on the importance of recruiting qualified professionals

Introduce OT Assistant educational programs to increase manpower in the field

No action needed-it is not at all an issue or the issue will resolve by itself over time

Other (please specify)

10. Please share any other thoughts you may have related to professional boundary violation in OT practice in India.



 
  References Top

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2.
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    Figures

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