Running head: FIELDWORK PARADIGM CRITIQUE 1

Fieldwork Paradigm Critique

Gretchen Kempf
The University of Scranton


























FIELDWORK PARADIGM CRITIQUE 2
Introduction

This paper discusses the constructs of the Contemporary Occupational Therapy Paradigm
(Contemporary Paradigm), the Paradigm of Occupation, and the Mechanistic Paradigm in
relation to my level II physical rehabilitation fieldwork experience at Pine Run Rehabilitation
Health Center in Doylestown, Pennsylvania (Pine Run) during the summer of 2013. In addition
to an overview of the general concept of a paradigm, the paper sets forth the focal viewpoints
and core constructs of each of the three aforementioned paradigms. Following a critical
examination of my fieldwork experience at Pine Run, evidence will be presented to support the
conclusion that the occupational therapists at Pine Run rarely operationalized the constructs,
focal viewpoint and values of the professions Contemporary Paradigm in client treatment and
more often practiced under the constructs of the Mechanistic Paradigm. This paper also proposes
a design for a workshop that would allow an interdisciplinary team to be educated on the purpose
of occupational therapy (OT) through the lens of the Contemporary Paradigm. The proposed
design encompasses workshop objectives, delivery method, and methods of assessment to ensure
objectives are being met. Solutions for overcoming potential barriers to operationalizing the
professional paradigms constructs also will be presented. The paper concludes with an
examination of the connection between the Contemporary Paradigm and the Occupational
Therapy Practice Framework.
General Overview of a Paradigm
A paradigm serves as a common vision in a field of practice. It is made up of broad
assumptions and perspectives, which, in turn, unify the field and define the nature and purpose of
the particular field of practice as well as its primary concerns, methods, and values (Kielhofner,
2009). A paradigm also functions to create a professional culture with common beliefs and
FIELDWORK PARADIGM CRITIQUE 3
values that make sense of and guide professional action (Kielhofner). This allows practitioners
to gain a broad understanding of what they are doing when they practice (Boniface & Seymour,
2012). More specifically, OT paradigms allow occupational therapists to justify and define the
services they provide to clients. A paradigm is made up of core constructs, a focal viewpoint,
and values (Kielhofner). The core constructs identify the nature of the fields services and
provide an understanding of why the service is needed. The focal viewpoint directs
practitioners attention to certain aspects of therapy and offers a way of seeing those aspects.
Values are required to identify why practice matters and to determine what should be carried out
in practice. This is especially important for the profession of OT because practitioners are
constantly engaged in practical action, which requires them to keep in mind the good of that
action when selecting the proper techniques and methods to implement client service
(Kielhofner).
During its history and development in the United States, the profession of OT has had
three major paradigm shifts. The first paradigm, the Paradigm of Occupation, was prominent
from the early 1900s to the 1940s. This paradigm was founded on the principles of using
occupation to influence recovery from illness and adjustment to disability (Kielhofner, 2009). It
grew out of the arts and crafts movement as well as habit training. It was thought that humans
were occupational beings whose minds and bodies were shaped through the occupations in
which they were engaged. There was a great emphasis on the interrelationships of the mind,
body, and environment (Kielhofner). Despite this unifying paradigm, a crisis emerged in the
field due to many social/environmental factors (such as World War I & II, the Great Depression,
and scientific/technological advances) and the professions adoption of reductionism
FIELDWORK PARADIGM CRITIQUE 4
(Kielhofner). This major crisis culminated in the formation of the Mechanistic Paradigm, which
emerged during 1942 and governed the profession until 1960.
The Mechanistic Paradigm moved away from the use of arts and crafts and focused on
treatments for specific diseases. Occupational therapists believed that this practice shift would
bring OT recognition as a valuable, effective medical service and increase the professions
respectability within the scientific community (Kielhofner, 2009). This paradigm drastically
changed both the manner in which occupational therapists viewed their practice and the types of
services they provided to clients. Occupational therapists were no longer focused on the benefits
of occupation and the interrelationship of the mind, body, and environment; rather, they focused
on understanding and addressing impairments related to what was known as the
muscltrapsychic systems. OT interventions identified disrupted mechanisms within these
systems and attempted to fix what was broken (Kielhofner). This sudden change in the focus
of OT interventions from engagement in occupations to a more medical viewpoint created
identity confusion among occupational therapists and other healthcare professionals. This
identity crisis served to spur the development of another major paradigm shift within the
profession which resulted in the creation of the Contemporary Paradigm.
The Contemporary Paradigm came into being in the 1980s and is the paradigm governing
the profession of OT at the present time. This paradigm integrated useful concepts from both the
Mechanistic Paradigm and the Paradigm of Occupation and focused the profession on being
occupation-based, theory-based, evidence-based, and client-centered , while emphasizing the
importance of working collaboratively with clients, family members, and other professionals
(Kielhofner, 2009). The focal viewpoint of the Contemporary Paradigm reflects a return to
occupation as embodied in the original Paradigm of Occupation, but it seeks to steer a therapists
FIELDWORK PARADIGM CRITIQUE 5
intervention away from an emphasis on a clients impairments. The values integrated in the
Contemporary Paradigm relate to client centeredness, caring, and empathy, all of which serve to
create and strengthen the therapeutic relationship (Kielhofner).
Level II Experience
When reflecting on my twelve-week level II physical rehabilitation fieldwork experience
at Pine Run, I feel an overwhelming sense of regret in that I did not get to observe or participate
in the provision of OT services that were based upon the constructs of the Contemporary
Paradigm. Interventions at Pine Run more often than not lacked occupation-based components
and, in some instances, the goals of therapy did not appear to be client-centered. Consequently, I
was not often able to observe the dynamic, contemporary practice of OT. As will be discussed
below, in some ways, my fieldwork experience at Pine Run served as a time-capsule
experience of how the profession practiced during the heyday of the Mechanistic Paradigm.
Overview of Setting
Pine Run serves as both a sub-acute/outpatient facility and as a provider of skilled
nursing services for inpatients. The facility provides OT, physical therapy (PT), and speech
therapy (SLP) services for a wide range of diagnoses. The main diagnoses in my assigned
caseload were knee, shoulder, and hip replacements, stroke, ORIF, and dementia. The majority
of the patients I saw were 60 years old or older. This facility was very Medicare Resource
Utilization Group (RUG) level oriented, so it was essential that therapists from all three
professions (OT, PT and SLP) met with each patient for a set number of minutes. Most patients
received all three services once a day and professionals worked in collaboration to reach patient
goals. The average caseload varied between eight and thirteen clients and all Medicare Part A
and Part B clients were seen for roughly one hour and Health Maintenance Organization (HMO)
FIELDWORK PARADIGM CRITIQUE 6
clients were seen for only 30 minutes (and usually at the same time as another HMO client). The
facility provided therapists with a gymnasium that contained a wide variety of exercise
equipment and had storage for adaptive equipment. Direct access to two small bathrooms was
provided from the gym.
Paradigms Operationalized in Treatment
As mentioned previously, most therapeutic interventions at Pine Run appeared to be
within the realm of the Mechanistic Paradigm. Curiously, regardless of what the diagnosis was,
upper body strengthening and endurance always became a large focus of treatment. At times, I
had the sense that clients were not viewed as individuals and the intervention was focused
primarily on filling up the allotted time in order to meet RUG levels rather than being directed
toward a clients individualized functional needs. A typical OT session consisted of the use of
an arm bike and free weights, exercises utilizing Thera-Bands, and cone-reaching activities. This
type of treatment illustrates reductionism instead of a holistic approach to therapy. On my first
day, a patient asked my supervisor what OT was. My supervisor responded without hesitation
and said, [i]ts just like physical therapy only occupational therapists take care of the upper
body whereas physical therapists work more with the lower body. This statement unnecessarily
blurred the roles of therapists in the eyes of the client since it sought to define OT by using
another profession in the definition. This type of role blurring is congruent with the practice of
OT under the constructs of the Mechanistic Paradigm in which treatment was focused on specific
muscles that limited functional performance in the upper body. In contrast, the practice of OT
under the core constructs of the Contemporary Paradigm would address the importance of
occupation in health and well-being, would recognize the occupational problems/challenges, and
would be an occupation-based practice (Kielhofner, 2009).
FIELDWORK PARADIGM CRITIQUE 7
A key advocate in the shift from the Mechanistic Paradigm to the Contemporary
paradigm was Mary Reilly. Ms. Reilly called for a refocus on the theme of occupation and
provided the field with a broad and scholarly understanding of the complex parts of an
occupational therapists work (Kielhofner, 2009). This pioneering therapist envisioned
occupational behavior as the therapeutic framework for practice and I suspect she would strongly
oppose the intervention activities utilized by occupational therapists at Pine Run since these
interventions were not occupation-based and provided clients with very little meaningful activity.
Clients at Pine Run were referred to as patients in spite of the mandates of the
Occupational Therapy Practice Framework, 2
nd
Edition, which provides that OT is provided to
clients (AOTA, 2008). I have no doubt that the late Gail Fidler, a noted advocate for the
recognition of OT as a distinct profession, would disapprove of the treatment interventions at
Pine Run and the manner in which occupational therapists misrepresented their profession to
clients (Fisher, 1998). The professional identity blurring promoted by occupational therapists at
Pine Run between occupational therapists and physical therapists mistakenly suggests that the
OT services being provided were not unique and that they could have been provided just as
easily by a PT.
Although Pine Run provided many examples of treatment practices that I do not wish to
follow in my future career as an occupational therapist, my experience there was not completely
negative. Although it was rare, Pine Run therapists did touch upon some of the core constructs
of the Contemporary Paradigm in their practice. Clients often were given a functional diagnosis
of generalized muscle weakness and muscle strengthening, therefore, was addressed. This
strengthening was accomplished through the use of free weights and Thera-Band exercises, but it
was also addressed through transfers. This would include either a shower/tub transfer or a toilet
FIELDWORK PARADIGM CRITIQUE 8
transfer. Although he was not always successful, my fieldwork supervisor did strive to
incorporate something functional in every treatment session and that indicates his recognition of
occupational challenges and the importance of an occupation-based practice. Activities of daily
living (ADL) also were addressed when it became apparent in an evaluation that a client was
unable to dress themselves without the use of adaptive equipment. The sessions that I spent
educating clients on the use of adaptive equipment or practicing the use of such equipment with
them always felt very productive and seem to give the clients a sense of regained independence.
Many of them subsequently were able to decline the assistance of an aide when dressing
themselves. These interventions were congruent with the Contemporary Paradigm since they
were occupation-based and recognized individual occupational challenges and difficulties.
Another intervention utilized at Pine Run that seems to be congruent with the Contemporary
Paradigm was having the client make a cup of tea. Although the activity required every client to
make tea without regard to whether the client even liked that beverage, it nevertheless was an
occupation-based activity that also served to address safety concerns in the kitchen.
The core values at the heart of the Contemporary Paradigm did not appear to be
uppermost in the minds of many of the occupational therapists I observed in practice at Pine
Run. Their interventions did not seem to be designed to stress the importance of supporting
clients desires to integrate themselves into the mainstream of life through participation in
occupation or the importance of the therapeutic relationship. In addition, a lack of a client-
centered practice, as well as a generalized lack of a caring and empathetic attitude, was evident
among occupational therapists throughout the facility.
During the era when the Mechanistic Paradigm was prominent, therapists came to realize
that two primary shortcomings of the paradigm were that it did not permit a client to be seen as a
FIELDWORK PARADIGM CRITIQUE 9
whole person and that it promoted therapy that was impersonal and not meaningful to individual
clients. These two flaws were addressed during the professions shift to the Contemporary
Paradigm, but therapeutic practice at Pine Run continues to lag behind in this regard. For
example, I observed my supervisor treat two HMO patients at the same time with identical
strengthening exercises in spite of the fact that the two patients had completely different
diagnoses. The occupational therapists at Pine Run seemed to function on autopilot throughout
their work day, appearing to put little thought into treatment interventions and merely recycling
the same mundane interventions each day. Treatment also appeared not to be evidence-based
since I never observed the administration of any assessments to track clients progress. Once
again, this serves as evidence that the practice of OT at Pine Run is not in line with the constructs
of the Contemporary Paradigm.
Contemporary Paradigm Workshop
To address the aforementioned issues and to encourage a more contemporary practice of
OT at Pine Run, an interdisciplinary workshop may be helpful. The purpose of such a workshop
would be to educate an interdisciplinary team on the purpose and practice of OT congruent with
the Contemporary Paradigm. The workshop would be presented to occupational therapists,
physical therapists, and speech therapists so that all team members can understand the true
definition of OT and can learn how their particular profession can work toward client goals in a
collaborative manner with other therapists. My experience at Pine Run illustrated that there are
still misconceptions about OT as a profession among healthcare practitioners, including
occupational therapists themselves (as demonstrated by my supervisors horrific definition of
OT). The objectives of this workshop would include: (1) the ability to define occupational
therapy and the services occupational therapists provide; (2) the ability to define paradigm, core
FIELDWORK PARADIGM CRITIQUE 10
constructs, focal viewpoint, and values; (3) the ability to identify Contemporary Paradigm core
constructs, focal viewpoint, and values and to describe differences between the current
Contemporary Paradigm and past paradigms; and (4) the ability to apply the Contemporary
Paradigm to various healthcare professions.
The workshop would be presented utilizing PowerPoint so that it can present important
terms and visual aids (such as diagrams) to illustrate the concentric layers of knowledge within
the conceptual foundations of the Contemporary Paradigm. The presentation would touch upon
previous paradigms and identify each paradigms key characteristics, as well as relevant
historical events that directly influenced paradigm shifts. After this historical review, the
Contemporary Paradigm would be introduced and its core constructs, focal viewpoint, and values
would be discussed in depth. This discussion would allow the workshop participants to
understand the development of the Contemporary Paradigm and have an understanding of the
flaws of previous paradigms that the Contemporary Paradigm aimed to overcome. After the
PowerPoint presentation, interdisciplinary workshop participants would be divided into groups
and provided with a case study. Working together, they would be asked to develop intervention
plans that are true to their professional domains and that contribute to a common goal among the
all the healthcare professionals on the team. This exercise would allow them to understand the
importance of collaboration in the workplace.
In order to evaluate and assess that workshop objectives were met, audience members
would be asked to take a pre- and post-workshop quiz. After the post-quiz has been
administered, questions would be posed to the audience as a whole in order to facilitate a group
discussion. Three possible questions would be: (1) How can using the Contemporary Paradigm
benefit your profession? (2) What are some barriers to operationalizing the Contemporary
FIELDWORK PARADIGM CRITIQUE 11
Paradigm and what are some solutions to overcoming these barriers? (3) How well is this facility
operationalizing the Contemporary Paradigm and what areas or aspects of practice need to be
improved? At the end of this group discussion, journal clubs among team members would be
recommended to assist them in keeping abreast of the current literature and the relevant research
in the sphere of each profession. This activity is designed to increase evidence-based practice
within the facility and to increase practitioners awareness of the latest intervention techniques.
Barriers and Solutions to Operationalization
When it comes to the lack of operationalizing the professional paradigms constructs at
Pine Run, one primary contributing factor appears to be the lack of awareness of current
literature and research within OT. The profession of OT requires a constant striving for the best
possible practice and awareness that research is ongoing. A successful and effective
occupational therapist must commit to being a lifelong learner. Although it is time-consuming, it
is crucial to stay up to date on current literature to better enable the justification of services and
to benefit the clients recovery by encouraging the development of interventions that are
evidence-based, occupation-based, and the best possible practice. Working occupational
therapists have learned that journal clubs can greatly assist them with this mandatory obligation
of their profession. The club members, usually co-workers at the same health care facility,
typically designate one day a week as a journal club day. The meeting often takes place over the
designated lunch time. Each week, a different club member is assigned to bring in a current
article from a professional research journal such as American Journal of Occupational Therapy
or OT Practice and present it informally to the group. After the short presentation of the articles
facts and main points, a group discussion of the relevant information and the ways in which it
FIELDWORK PARADIGM CRITIQUE 12
can be implemented in practice is encouraged. This is an easy way for practitioners to keep
knowledgeable about the current literature being published in their profession.
Another barrier at Pine Run that seemed to contribute to the negligence of the
Contemporary Paradigms constructs was the overemphasis on meeting RUG levels. Meeting
the time requirements in a treatment session took precedence over the well-being of the client.
The OT interventions at Pine Run were rarely occupation-based since setting up such an
intervention was time consuming. Another related barrier to the implementation of a
contemporary OT practice at Pine Run was the limited availability of supplies. The gym was
filled with different exercise equipment and, thus, it was quicker to set someone up on an arm
bike than it was to set up a craft or gardening activity for them. In summary, the easy
accessibility of exercise equipment (such as free weights and Thera-Bands) and a misplaced
focus on the number of minutes that treatment lasted both served to discourage therapists at Pine
Run from using occupation-based activities. A possible solution would be to create pre-made
occupation bins for the facility which would be readily accessible in the gym. Each bin would
contain materials for a different occupation-based activity such as gardening, dressing, sewing,
medication management, money management, nail care, grooming kits, and cosmetic
application. This would eliminate the set-up time from the treatment session and enable the
therapist to meet time requirements. Placing the bins in the line of sight of the therapists would
have them serve as a visual reminder that treatments should revolve around the engagement of
meaningful occupations.
Relationship of Contemporary Paradigm and OT Practice Framework
The Contemporary Paradigm and the Occupational Therapy Practice Framework 2
nd

Edition (OTPF-II) are closely related. The OTPF-II was published to guide occupational
FIELDWORK PARADIGM CRITIQUE 13
therapists in practice by articulating OTs contribution to promoting the health and participation
of people, organizations, and populations through engagement in occupation (AOTA, 2008).
Both the Contemporary Paradigm and the OTPF-II emphasize the centrality of occupation to
health and well-being and recognize that engagement in occupations structures everyday life and
contributes to health and well-being (AOTA; Kielhofner, 2009). Another congruency between
the OTPF-II and the Contemporary Paradigm is that they both value the interrelationship
between the person, environment, and occupational factors. The OTPF-II clearly states that
occupational therapists must deliver service with a holistic perspective and address all aspects of
performance when providing interventions (AOTA). The Contemporary Paradigm core
constructs, focal viewpoint, and values are expressed through the OTPF-II overarching statement
supporting health and participation in life through engagement in occupation (AOTA, p.626).
Both the Contemporary Paradigm and the OTPF-II serve to unify the professions identity and
clearly articulate the nature, purpose and domain of practice. The content of the OTPF-II and the
Contemporary Paradigm both allow therapists to justify services and provide focus for service
delivery to support a clients health and participation. The structured outline provided by the
OTPF-II allows practitioners an easy way to implement the Contemporary Paradigm into
practice. It provides for an evaluation through use of an occupational profile and the analysis of
occupational performance, an intervention process consisting of a plan, implementation, and
review and an assessment of treatment outcomes (AOTA).
Conclusion
As the future generation of occupational therapists, it is fundamental that we continue to
embark on a journey of continued learning in order to implement the most current research and
literature into our own OT practice. This paper has given a general overview of the three
FIELDWORK PARADIGM CRITIQUE 14
paradigms and the factors precipitating paradigm shifts. The Contemporary Paradigm has been
discussed in depth and the core constructs, focal viewpoint, and values of the paradigm have
been identified and examined in relationship to the OTPF-II. A design for a workshop to educate
an interdisciplinary team on the purpose of OT through the lens of the Contemporary Paradigm
has been proposed and the design includes objectives, delivery method, and methods of
assessment. Lastly, barriers and potential solutions for operationalizing the Contemporary
Paradigms constructs at Pine Run have been identified.
The Contemporary Paradigm has become the paradigm of current times because it aims
to address the shortcomings of the previous paradigms. It is essential that therapists strive to
implement the core constructs, focal viewpoints, and values of the Contemporary Paradigm to
ensure that clients are receiving the best possible treatment, which entails clinical reasoning,
research, and evidence-based interventions. Analyzing my fieldwork experience at Pine Run
through the lens of this paper has enabled me to better identify the qualities of an effective
occupational therapist, has provided me with a stronger foundation upon which to base my future
practice and has renewed my commitment to operationalize the Contemporary Paradigm in
whatever therapy setting my career may lead me.







FIELDWORK PARADIGM CRITIQUE 15
References
American Occupational Therapy Association. (2008). Occupational therapy practice framework:

Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625683.

Boniface, G., Seymour, A., & Taylor, M.C. (2012). Using occupational therapy theory in
practice. Chichester, West Succesx, UK: Wiley-Blackwell.

Fisher, A. G. (1998). Uniting practice and theory in an occupational framework- Eleanor Clarke
Slagle Lecture. America Journal of Occupational Therapy, 52, 509-521
Kielhofner, G. (2009). Conceptual foundation of occupational therapy practice. (4 ed., pp. 108-
126). Philadelphia: F.A. Davis.