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Continuing Education Article
Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.
Earn .1 AOTA CEU
(one contact hour and
1.25 NBCOT PDU).
See page CE-7 for details.
CONTINUING EDUCATION ARTICLE
The OTPF-4: Continuing Our Professional
Journey Through Change
Debbie Amini, EdD, OTR/L, FAOTA 4. Describe the occupation of Health Management
Director of Professional Development 5. Describe how the addition of Health Management will help
AOTA advance the profession through greater attention to an import-
ant area of occupation in the 21st century.
ABSTRACT
The fourth edition of the Occupational Therapy Practice Frame- INTRODUCTION
work: Domain and Process (OTPF-4; American Occupational Since 2002, the Occupational Therapy Practice Framework (Frame-
Therapy Association, 2020b) was completed by the AOTA Com- work) has served to describe the common core of the profession,
mission on Practice (COP) and adopted by the AOTA Represen- highlighting both the domain of interest and service delivery pro-
tative Assembly in spring 2020. Having been initially published cesses. The fourth edition of this living document was published in
in 2002 after several years of work by the COP, this document volume 74 of the American Journal of Occupational Therapy (AJOT) in
has evolved and gained acceptance by the profession during its 2020 after being updated by the American Occupational Therapy
nearly 20 years of existence. Through the years and much like Association’s (AOTA’s) Commission on Practice (COP) and adopted
shaping of a bonsai tree, the OTPF-4 has been pruned where by the Representative Assembly (RA).
pruning was required and allowed to strengthen and flourish As the shepherding body for the Framework, the COP has been
in those areas that define the foundations of the profession it steadfast in its messaging that this document does not serve as
underlies. a taxonomy, theory, or model of occupational therapy; rather,
This article describes two recent and significant changes to it provides a structure or base on which to build a system or
the fourth edition of the Framework and discusses how they will concept. In other words, the Framework describes the central
support the practice of occupational therapy in the third decade concepts that ground occupational therapy practice and builds
of the 21st century. Among the changes described are (1) the a common understanding of the basic tenets and vision of the
addition of Cornerstones of occupational therapy practice and profession (AOTA, 2020b).
the complementary contributors, and (2) the addition of Health
Management as an occupation in the domain of occupational THE ANALOGY OF THE HOUSE
therapy. Both of these additions support and give voice to the core The Framework has often been described using the analogy of a
values and beliefs of the profession and guide practitioners in house to assist with understanding its purpose and place within
their understanding of what occupation is, how it is addressed in the profession of occupational therapy. The house analogy works
clinical practice, and how it affects those we serve. well with the definition of a Framework as an entity that pro-
vides a structure or base on which to build a system or concept.
LEARNING OBJECTIVES The Framework, like a house, is composed of building materials
After reading this article, you should be able to: (concepts of the domain and process) that are common to all
1. Describe the Cornerstones of occupational therapy that are areas of practice. This frame forms the structure to which the
part of the OTPF-4 design of the home (number of stories, type of roofing, type of
2. Identify the contributors to the Cornerstones of occupational siding, etc.) is added that makes it different from other homes
therapy and provides for the needs of the environment. In the case of
3. Discuss how the Cornerstones and contributors support prac- the occupational therapy profession, these are the types of cli-
titioners by providing a firm foundation for practice ents, approaches, outcomes, and interventions that are distinct
ARTICLE CODE CEA0221 | FEBRUARY 2021 CE-CE-1 1
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Continuing Education Article are also available ONLINE.
Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. Register at http://www.aota.org/cea or
call toll-free 877-404-AOTA (2682).
among practice settings. In other words, using this analogy Occupational therapy practitioners have distinct knowl-
reminds us that the profession is the standard house of the edge, skills, and qualities that contribute to the suc-
practitioner but that not all houses appear identical (Amini, cess of the occupational therapy process [and may be]
2020). described…as cornerstones. A cornerstone can be …
During the standard 5-year document review and update, something of great importance on which everything else
the COP made several changes to the OTPF-4 from the third depends. … cornerstones of occupational therapy help
version of the Framework (AOTA, 2014). Two significant distinguish it from other professions. (AOTA, 2020b, p. 6)
additions are the Cornerstones and Contributors and the
addition of a new occupation—Health Management (see The Cornerstones described in the OTPF-4 are:
Table 1). Core values and beliefs rooted in occupation (Cohn, 2019;
In keeping with the analogy of the house, the addition of Hinojosa et al., 2017)
the Cornerstones provides an important conceptual addition Knowledge and expertise in the therapeutic use of occupa-
to the grounding of the profession. A cornerstone can be tion (Gillen, 2013; Gillen et al., 2019)
thought of as an important and necessary part of the foun- Professional behaviors and dispositions (AOTA, 2015a,
dation of the house. Previously, the analogy helped us to see 2015b)
how the structure of the building supported and grounded Therapeutic use of self (AOTA, 2015a; Taylor, 2020)
the profession, but the Cornerstones actually go further and
ensure that certain elements of the profession are more deeply The Cornerstones are presented in a list form, but there is no hier-
embedded and supportive of the structure of the profession archy implied. Each Cornerstone has equal relevance and importance
itself. According to the OTPF-4: as part of the foundation of the profession, and each influences and
is influenced by the others (AOTA, 2020b). In addition, the required
Table 1. Health Management
Occupation Description
Health Management—Activities related to developing, managing, and maintaining health and wellness routines, including self-management,
with the goal of improving or maintaining health to support participation in other occupations
Social and emotional health promotion Identifying personal strengths and assets, managing emotions, expressing needs effectively, seek-
and maintenance ing occupations and social engagement to support health and wellness, developing self-identity,
making choices to improve quality of life in participation
Symptom and condition management Managing physical and mental health needs, including using coping strategies for illness, trau-
ma history, or societal stigma; managing pain; managing chronic disease; recognizing symptom
changes and fluctuations; developing and using strategies for managing and regulating emotions;
planning time and establishing behavioral patterns for restorative activities (e.g., meditation); using
community and social supports; navigating and accessing the health care system
Communication with the health care Expressing and receiving verbal, written, and digital communication with health care and insurance
system providers, including understanding and advocating for self or others
Medication management Communicating with the physician about prescriptions, filling prescriptions at the pharmacy,
interpreting medication instructions, taking medications on a routine basis, refilling prescrip-
tions in a timely manner (American Occupational Therapy Association, 2017c; Schwartz &
Smith, 2017)
Physical activity Completing cardiovascular exercise, strength training, and balance training to improve or maintain
health and decrease risk of health episodes, such as by incorporating walks into daily routine
Nutrition management Implementing and adhering to nutrition and hydration recommendations from the medical team,
preparing meals to support health goals, participating in health-promoting diet routines
Personal care device management Procuring, using, cleaning, and maintaining personal care devices, including hearing aids, contact
lenses, glasses, orthotics, prosthetics, adaptive equipment, pessaries, glucometers, and contracep-
tive and sexual devices
(AOTA, 2020b, p. 32) Note: the information in this table is reprinted from the OTPF-4 and cannot be shared in this form without permission.
CE-2 ARTICLE CODE CEA0221 | FEBRUARY 2021
Continuing Education Article
Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.
deep understanding of the Cornerstones is developed by practitioners In summary, we are at a critical point in our voyage
over time through their education, mentorship, and experience. For and development. As never before, our philosophical
this reason, the Cornerstones have the potential to evolve and reflect approach, the art and science that is occupational therapy,
changes and developments in the profession and the model of occu- and our normalcy are clearly being supported by our
pational science (AOTA, 2020b). scientific methods. [We] need to embrace it and integrate
The concepts of the Cornerstones have been embedded in all it. Let’s all promise to go back to work as change agents
editions of the Framework but have not been set aside and described embracing our roots, celebrating the amazing work and
individually, nor are they within the OTPF-4. The work of scholars the accomplishments of our young profession. [Let’s] put
and official documents of AOTA are cited and can be reviewed for the occupation back in occupational therapy. (p. 650)
greater understanding of the meaning of each Cornerstone to the
profession. One Cornerstone however, the therapeutic use of self, The Choosing Wisely campaign was born from the 2012 ini-
is part of the process section of the OTPF-4 and has been explicitly tiative of the American Board of Internal Medicine Foundation.
described in this and all previous editions of the Framework. The aim of the campaign is to encourage meaningful conversa-
tions between health care providers and clients to ensure that
THE CORNERSTONES appropriate and quality care is being provided and that wasteful
Core Values and Beliefs Rooted in Occupation (Cohn, 2019; Hinojo- health care spending is reduced (Gillen et al., 2019). As a result,
sa et al., 2017) AOTA formulated recommendations to the profession with
Ellen Cohn, OTR, ScD, FAOTA, presented the 2019 Eleanor regard to specific groups of treatment interventions currently
Clarke Slagle lecture at the AOTA Annual Conference & Expo being employed in the field. The first recommendation deals
in New Orleans. Her lecture, “Asserting Our Competence and with the use of purposeful activities [occupations] and states:
Affirming the Value of Occupation With Confidence,” is cited Purposeful activities—tasks that are part of daily routines
as part of the core values and beliefs rooted in the occupation and hold meaning, relevance, and perceived utility such as
Cornerstone of occupational therapy (Cohn, 2019). In her lec- personal care, home management, school, and work—are
ture, she describes the thoughts of several past leaders who have a core premise of occupational therapy. Research shows
written on occupation as the core. Cohn states, “Our strength that using purposeful activity (occupation) in interven-
is situated in our commitment to engagement in meaningful tions is an intrinsic motivator for clients. Such activities
occupation and how what we do helps clients achieve that can increase attention, endurance, motor performance,
engagement. Our focus on occupation is essential to the lives of pain tolerance, and engagement, resulting in better client
our clients and essential to our competence” (p. 2). outcomes. Purposeful activities build on a person’s ability
The late Jim Hinojosa, OT, PhD, FAOTA, and colleagues who and lead to achievement of personal and functional goals.
studied the construct of occupation through history and across the Conversely, non-purposeful activities do not stimulate
globe stated that the overall goal of occupational therapy is to ensure interest or motivation, resulting in reduced client partici-
that the individual can function within society so that they can pation and suboptimal outcomes. (Gillen et al., 2019, p. 5)
participate in purposeful activities and occupations (Hinojosa et al.,
2017). This further supports that the roots of occupation are part of As we see, the first two Cornerstones of our profession, both
the values and beliefs of the profession and reminds us of the close dealing with occupation as a core value and a therapeutic tech-
relationship between society and the ability to freely participate. nique, are well described in the literature. Of the four Corner-
stones identified, occupation serves as 50% of our foundation
Knowledge and expertise in the therapeutic use of occupation and distinct identity.
(Gillen, 2013; Gillen et al., 2019).
Glen Gillen, EdD, OTR, FAOTA, is a champion for occupa- Professional behaviors and dispositions (AOTA, 2015a, 2015b)
tion-based practice as evidenced by his 2013 Eleanor Clarke In many ways, the Cornerstone of professional behaviors and
Slagle lecture, “A Fork in the Road: An Occupational Hazard?” dispositions is not exclusive to occupational therapy, but cer-
He and others have also participated in the AOTA’s Top 5 Choos- tainly the behaviors and dispositions are highly important to the
ing Wisely® initiative. Both of these works support the second profession based on what we believe and with whom we work.
Cornerstone of the profession, which calls on practitioners to This Cornerstone is supported by the work of AOTA in the
understand occupation as the core of what we believe and do in official documents of the Association. The Standards of Practice
all facets of practice. Beyond occupation as a core belief is the for Occupational Therapy (AOTA, 2015b) and the Occupational
need for practitioners to actually use this construct as a means Therapy Code of Ethics (2015) (AOTA, 2015a) were both adopted
of assessment and intervention. In other words, it is not simply by the RA in 2015 and guide our understanding of this import-
a matter of belief, it is a matter of doing. ant Cornerstone.
At this end of his 2013 Slagle lecture, Gillen sums up his The Standards of Practice for Occupational Therapy are require-
thoughts and challenge to the professional body with regard to ments for occupational therapists and occupational therapy
knowledge and expertise in the therapeutic use of occupations assistants for the delivery of occupational therapy services.
when he states: According to the preface, “The practice of occupational therapy
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Continuing Education Article are also available ONLINE.
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call toll-free 877-404-AOTA (2682).
means the therapeutic use of occupations (everyday life activ- they interact and communicate with clients, and within society.
ities) with persons, groups, and populations for the purpose of One of the seven standards of conduct is: “Professional Integ-
participation in roles and situations in the home, school, work- rity, Responsibility, and Accountability: Occupational therapy
place, community, or other settings” (AOTA, 2015b, p. 1) personnel maintain awareness and comply with AOTA policies
The language is clear that the minimum standard for the prac- and Official Documents, current laws and regulations that are
tice of occupational therapy is the use of therapeutic occupations relevant to the profession of occupational therapy, and employer
with those we serve for the purpose of participation within their policies and procedures” (AOTA, 2020a, p. 5).
particular context. This document, as well as those forming the This example again reiterates the fact that ethical practice
basis of the first two Cornerstones, is steadfast in the belief that places occupation, laws, and regulations as the solid foundation
occupation and occupational participation are at the heart of the on which the profession and practitioners exist. A list of all the
profession. The remainder of the Standards document provides ethical Standards of Conduct can be found in the AOTA 2020
for the understanding that practitioners shall practice under state Occupational Therapy Code of Ethics document.
and federal laws; obtain education from ACOTE®-accredited
institutions; pass an entry-level examination as approved by the Therapeutic use of self (AOTA, 2015b; Taylor, 2020)
state regulatory board; and fulfill state requirements for licensure, As stated previously, the construct of the therapeutic use of self
certification, or registration (AOTA, 2015b). has been described in each edition of the Framework to date. The
There are four actual standards set forth in the document. concepts that underlie this often implicit and tacit intervention
The first is Professional Standing and Responsibility, which is are not specific to the profession of occupational therapy and
described through 13 subcomponents. The first subcomponent are also used by other professions, such as nursing and counsel-
of Standard I states, “An occupational therapy practitioner ing. However, for many decades, the profession of occupational
(occupational therapist or occupational therapy assistant) deliv- therapy has taught, researched, and used the term therapeutic
ers occupational therapy services that reflect the philosophical use of self to denote an intervention technique derived from the
base of occupational therapy and are consistent with the estab- profession’s client-centered and humanistic beliefs and values.
lished principles and concepts of theory and practice” (AOTA, Table 2. Ethical Principles
2015b, p. 3). The other three standards pertain to the practice of
occupational therapy: Standard II: Screening, Evaluation, and Principle Description
Reevaluation; Standard III: Intervention Process; and Standard
IV: Transition, Discharge, and Outcome Measurement. These Principle 1. Beneficence Occupational therapy personnel
standards make reference to the many facets of occupational shall demonstrate a concern for the
therapy and health care practice in general and contain several well-being and safety of persons.
references to occupation and occupational participation.
Since the adoption of the OTPF-4, the AOTA 2020 Occupational Principle 2. Nonmalefi- Occupational therapy personnel shall
Therapy Code of Ethics (AOTA, 2020a) was adopted to guide prac- cence refrain from actions that cause harm.
titioners. There are few differences between the 2015 document
and the 2020 document when it comes to supporting the third Principle 3. Autonomy Occupational therapy personnel shall
Cornerstone. In the interest of sharing the most up-to-date infor- respect the right of the person to
mation, the 2020 ethics document will be discussed here. self-determination, privacy, confiden-
Of significance when considering the third Cornerstone are tiality, and consent.
the seven longstanding core values of Altruism, Equality, Freedom,
Justice, Dignity, Truth, and Prudence. These values are not unique Principle 4. Justice Occupational therapy personnel shall
to the profession of occupational therapy but do serve to support promote equity, inclusion, and objec-
our beliefs that clients can only have equal access to resources that tivity in the provision of occupational
support their ability to engage in their life fully when these values therapy services.
are upheld by the profession and society. We have an ethical respon- Principle 5. Veracity Occupational therapy personnel shall
sibility as practitioners to ensure that these values are upheld. provide comprehensive, accurate,
According to the AOTA 2020 Occupational Therapy Code of Eth- and objective information when
ics, ethical principles guide ethical decision making and inspire representing the profession.
occupational therapy personnel to act in accordance with the
highest ideals. As with core values, principles are not hierarchi- Principle 6. Fidelity Occupational therapy personnel shall
cal but may need to be balanced and weighed against competing treat clients (persons, groups, or
professional values, individual and cultural beliefs, and organiza- populations), colleagues, and other
tional policies. The principles are provided for review in Table 2. professionals with respect, fairness,
The ethical standards of conduct found within the Code of discretion, and integrity.
Ethics that are tied to the ethical principles illustrate the specific
behaviors expected of occupational therapy practitioners as (AOTA, 2020a, pp. 34)
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