Why does professional attrition matter to occupational therapists?

Susanne MAK, PhD, OT(c), erg. [1]

As an Occupational Therapist (OT) with 25 years of experience involving diverse clinical and academic roles, I am still committed and passionate about my profession. This passion is informed by occupational therapy’s philosophies, values and the wide range of emerging roles and opportunities that are possible for us. I am always amazed by the strength demonstrated by OTs, for example, in the ways they prevail against adversity, find ways to innovate, or create new practice areas and roles for OTs to engage in to improve care. Contrarily, I am equally pained to learn about OTs exiting the profession (i.e., attrition). Factors such as, systemic constraints and repeated perceived negative work experiences, are some of the influences that may contribute to OT attrition.

One might ask why attrition matters. Attrition from a profession is commonplace, varying in proportion depending on the profession, timing, country, etc. (1). However, in the current context of global health human resource shortages (2) including OTs (3), attrition has become a problem that must be addressed. In 2022, the World Federation of Occupational Therapists (WFOT) reported a shortage of OTs in 62 countries (3). This shortage is anticipated to worsen over time, given the increasing demand for rehabilitation services due to aging populations, the growing prevalence of noncommunicable diseases, and persistent climate changes leading to natural disasters with devastating consequences on individuals and their families (4). Attrition, therefore, adds to an already serious health human resource issue and needs to be attended to, if we wish to provide high quality rehabilitation services to those who need them.

For the past seven years, I have studied the phenomena of attrition and retention in OTs, Physical Therapists (PT) and Speech-Language Pathologists (S-LP) from Quebec, Canada as part of my doctoral work. My research consisted of a scoping review on attrition and retention (1), followed by two qualitative studies in which I carried out individual interviews with current and former OTs, PTs and S-LPs (5). Focus groups were also conducted with professional associations and regulators, professional education programs and managers (public and private health sectors) (6). Below, I provide a brief summary of the main findings from this work and discuss the connection between work and meaning.

From the scoping review, I identified push factors (i.e., factors that drive individuals out of a profession) and pull factors (i.e., factors that draw individuals away from a profession) that pointed to different potential ways of exiting a profession. I also underscored stay factors (e.g., availability of support, positive working relationships) that shaped professionals’ decisions to remain in their profession (1). Based on the findings, I developed the questions for the interviews I conducted with professionals who remained in, or exited the profession. Drawing from the interview data, I developed six themes related to professionals’ perceived factors contributing to attrition and retention: 1) characteristics of work that make it meaningful; 2) aspects of work that practitioners appreciate; 3) factors of daily work that weigh on a practitioner; 4) factors that contribute to managing work; 5) relationships with different stakeholders that shape daily work; and 6) perceptions of the profession (5). Using the findings from the scoping review and the interviews, I conducted focus groups with different stakeholders (e.g., managers, professional regulators). I then carried out a combined analysis of the interview and focus group data, where I identified five sets of retention strategies: 1) ensuring that work aligns with values; 2) improving the alignment of work parameters with professionals’ needs and interests; 3) modifying physical, social, cultural, and structural aspects of a workplace; 4) offering informal and formal benefits; and 5) addressing how the profession is governed (6).

One particular finding from this research struck me profoundly. Namely, the meaning that we draw from our work, and how this is tied to whether our personal and/or professional values are reflected in our everyday work. This is not surprising in many ways. In a paper about contributing factors to occupational therapy values, Drolet and Désormeaux-Moreau explain that values are core to our professional identity (7). Professional identity is described as a person’s acknowledgement of the beliefs, values, ethical identity and roles that belong to a professional group, and how a person aligns with these (7). Drolet’s and Désormeaux-Moreau’s work therefore, highlights an important connection between our values and our practice/work. We might even consider that if we chose a type of occupational therapy work, there should be an alignment between our values and our choices. Alas, this alignment between our values and our choices only holds true if there are no other factors that influence the ways that our work unfolds in a given context. Multiple factors such as, adequate physical spaces, financial resources, access to support from managers and colleagues, the value and recognition of our contributions, and institutional discourses (8) can shape OTs’ experiences of practice (5). Even the predominant discourses and values in a health care team can influence this alignment between our values and our practice (9). Ashby et al. presented the findings of an investigation about the professional resilience of Australian OTs in mental health practice. (9) They described how OTs reported barriers to engaging in occupation-based practices when working in teams who valued other approaches (e.g., psychological theories). These work experiences challenged occupational therapy participants’ professional identity and led them to justify their use of occupation-based approaches (9).

The meaning that we derive from our work can also be influenced by factors beyond the work environment (5, 10). Contextual factors such as broader health care policies, professional regulation, the public awareness of our profession, can affect institutional practices and discourses, thereby driving practices that may lead us away from our profession (11). For instance, the lack of public awareness of the occupational therapy profession (12-14) may push OTs to describe their roles in comparison to other professions which may be more known (e.g., PT). These instances of misalignment can therefore, shape self-identification as authentic OTs, and the meaning that OTs derive from their everyday work.

How do we drive changes in occupational therapy practice which are intimately influenced by broad systems, like health care, education and professional regulation? More specifically, how do we promote the alignment between an OT’s values and their work, to retain OTs? A first step may be to identity institutional processes to ask OTs about their values and to consider the fit between their values and occupational therapy work. For this to occur, a thorough examination of the actual occupational therapy work, and an in-depth discussion with the interested OT, preferably prior to accepting the position, is necessary. Work parameters, such as the urgency within the work, the number of clients seen daily, the diversity of work tasks and responsibilities and the availability of clinical and administrative support, also need to be part of an OT’s reflection and discussion with the institution’s administrators (5). This is a necessary step that can take place at individual and organizational levels provided that the institution believes in the importance of aligning one’s values with their work.

Opportunities to engage OTs in designing retention strategies are also needed. This can happen at multiple levels (6). At an organizational level, various institutional elements are likely needed to create spaces for such engagement. Examples such as a champion to bring different stakeholders together, liberation of OTs from their clinical duties for this purpose and the participation of decision-makers who value OTs’ perspectives, can elevate the authenticity of these conversations and shift efforts towards shared goals and concrete actions. Systemically, OTs can be involved in consultations with policy makers, regulators, associations and professional education programs to ensure that their interests are represented. However, perhaps what is needed most, is a vision about how we can collectively address retention issues with concrete actions and timelines, through our organizations, in the various systems where we work (6, 15).

While we are embarking on organizational and systemic changes, how do we support OTs individually? Remembering that empathy and collegiality (10) are also values in our profession, we can help by communicating and checking in with our colleagues to support building a sense of community in our local environments. Communities where OTs can be with each other, use occupational therapy terms and ‘feel like OTs’, can help to strengthen each other’s professional identities (16). In turn, being part of a community that helps to reinforce one’s professional identities, can contribute to career longevity and retention in the long term. I strongly encourage all OTs to find their ‘home’; reflect and act to find where you may feel understood, where your values are upheld, and where you can find the support you seek.

Acknowledgements

My heartfelt thanks to my OT colleagues, Barbara Shanklandand Caroline Storr, fortheir feedback on this guesteditorial.

References

1. Mak S, Hunt, M., Riccio, S. S., Razack, S., Root, K., & Thomas, A. Attrition and Retention of Rehabilitation Professionals: A Scoping Review. J Contin Educ Health Prof. 2023a. Epub 20230307. doi: 10.1097/ceh.0000000000000492. PubMed PMID: 36881451.

2. Côté N, Denis JL. Situations of anomie and the health workforce crisis: Policy implications of a socially sensitive and inclusive approach to human resources. Int J Health Plann Manage. 2024;39(3):898-905. Epub 20240215. doi: 10.1002/hpm.3785. PubMed PMID: 38358841.

3. World Federation of Occupational Therapists. WFOT Human Resources Project 2022. 2022.

4. World Health Organization. Rehabilitation 2030 Initiative 2023 [March 15, 2023]. Available (11/04/2024): https://urlz.fr/sTBT

5.  Mak S, Thomas, A., Razack, S., Root, K., & Hunt, M. Unraveling attrition and retention: a qualitative study with rehabilitation professionals. WORK: A Journal of Prevention, Assessment & Rehabilitation. 2023b;Advance online publication. doi: 10.3233/WOR-230531.

6. Mak S. An Investigation into Attrition and Retention of Rehabilitation Professionals [Doctoral dissertation]: McGill University; 2024. Available (11/04/2024): https://escholarship.mcgill.ca/concern/theses/3n204458j

7. Drolet M-J, Désormeaux-Moreau M. The values of occupational therapy: Perceptions of occupational therapists in Quebec. Scand J Occup Ther. 2016;23(4):272-85. doi: 10.3109/11038128.2015.1082623.

8. Hammond R. The construction of physiotherapists' identities through collective memory work [Doctoral dissertation]: University of Brighton; 2013.

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10. Sogomonian T, Hoang, M.A. Part II: Certified Somatosensory Therapist of Pain and Master of Science in Occupational Therapy (Guesteditorial). Somatosens Pain Rehab. 2024;21(1):2-8. Available (11/04/2024): https://urlz.fr/qy3O

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12. Houtrow A, Murphy N, DISABILITIES COCW, Kuo DZ, Apkon S, Brei TJ, et al. Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities. Pediatrics. 2019;143(4). doi: 10.1542/peds.2019-0285.

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14. Darawsheh WB. Awareness and Knowledge about Occupational Therapy in Jordan. Occup Ther Int. 2018;2018:2493584. Epub 20180521. doi: 10.1155/2018/2493584. PubMed PMID: 29950955; PubMed Central PMCID: PMC5987337.

15. World Federation of Occupational Therapists: Jesus T, Zweck C, Mani K, Kamalakannan S, Ledgerd R. Global Strategy for the Occupational Therapy Workforce2024.

16. Mak S, Hunt, M., Boruff, J., Zaccagnini, M., Thomas, A.,. Exploring professional identity in rehabilitation professions: a scoping review. Adv Health Sci Educ Theory Pract. 2022. Epub 2022/04/26. doi: 10.1007/s10459-022-10103-z. PubMed PMID: 35467304.

[1] Associate Director (Occupational Therapy program) School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Québec, Canada. Susanne.mak@mcgill.ca