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Culture, Equity, & Justice in Occupational Therapy Practice



Applying Culture, Equity, and Justice in Practice

Culture, equity, and justice are represented in occupational therapy practice in ways that are complex and varied by settings and roles. Navigating this requires openness, reflection, and flexibility. Successfully handling the challenges of practice and meeting the needs of the diverse public seen in practice will require occupational therapists to critically and continuously reflect on how to provide equitable access to their services.

Occupational therapists can create inclusive and welcoming environments for clients, and in workplaces that promote belonging and respect for all human rights. Despite the changing conversations and language used around culture, equity, and justice, occupational therapists should view this learning as an ongoing process. Unlearning biases while relearning how to be truly open to the uniqueness of the client in front of them will contribute to safe, effective, and ethical care.

For questions about this content, please contact the College’s practice team at practice@coto.org.

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Introduction

Clients benefit when their healthcare providers are sensitive to their unique needs and experiences. The process of deepening our understanding of how to best to provide service to clients requires the hard work of self-reflection, insight, and learning about the emerging trends in practice that are driving change.

These pages are intended to explain to occupational therapists how culture, equity, and justice impact practice, and to inform registrants about what they can do to provide culturally safer practices. The College recognizes that the process of questioning personal and professional views can be difficult, but also knows that occupational therapists can be champions of this work.

Clients benefit when their healthcare providers are sensitive to their unique needs and experiences. The process of deepening our understanding of how to best to provide service to clients requires the hard work of self-reflection, insight, and learning about the emerging trends in practice that are driving change.

These pages are intended to explain to occupational therapists how culture, equity, and justice impact practice, and to inform registrants about what they can do to provide culturally safer practices. The College recognizes that the process of questioning personal and professional views can be difficult, but also knows that occupational therapists can be champions of this work.


Background

Like most Western healthcare, the profession of occupational therapy was founded on, and remains grounded in, White, Western ideologies. It continues to include mainly female-identifying clinicians and students. This has resulted in historically excluded equity-deserving groups being unintentionally and unknowingly disadvantaged and discriminated against when receiving services.

Changing the reality that equity and justice are not always present in practice is the responsibility of us all. The College, in its own position of power and privilege, has the important role of protecting the public from injustices by setting the expectations for competent, safe, and ethical occupational therapy practice in Ontario.

While data is lacking to indicate the type of diversity that may exist amongst those practising the profession, the College acknowledges that diversity does exist. A survey and conversations with self-identified Indigenous and equity-informed registrants revealed that occupational therapists are at different stages of learning, understanding, and applying the concepts of this document. Those with lived/living experience as members of equity-deserving groups may be more knowledgeable than others about injustices in practice, but they should not be tasked with explaining or having to “fix” them. If real change is to be made, the responsibility of learning and growing must be shared amongst us. 


The framework of intersectionality is a useful foundation for understanding culture, equity, and justice, and how these concepts can be applied to practice.

Intersectionality explains that people view and experience the world from unique social locations (that is, social positions, positionalities). Social locations are shaped by both the identities an individual holds and the contexts in which they live. 

When practising, occupational therapists should be aware of the positionality, values, and beliefs both they and their clients hold, as these will influence a client’s experience with the therapeutic process.

The intersecting and interdependent identities are outlined as follows. 



Oppression is systemic and is reinforced and challenged in everyday practice


The dynamic intersections between social identities and contexts over time compound to create systems of privilege and systems of oppression.

Institutions and organizations may uphold and perpetuate systems of oppression through legislation, policies, and other structures. There are many examples of how these systems may influence an individual’s experiences with health and occupation.

For example, the social determinants of health are intrinsically linked to social identities and positionalities. Lower socioeconomic status is correlated with many social identities due to systems that create privilege and disadvantage through law, policy, and other institutions.

Importantly, occupational therapists working in Canada must recognize that ongoing legacies of “colonization and colonialism cross-cut and influence all other social determinants of health of First Nations, Inuit and Métis individuals, families and communities” (National Collaborating Centre for Indigenous Health, 2021, para. 2, emphasis added). 

Occupational therapists have an opportunity to model the change needed in systems of oppression where a power imbalance exists.

Occupational therapists should be mindful that practice tools reflect the worldviews of those that developed them and that these tools are not always normalized with a representative sample. Therefore, it would be incorrect to assume that all practice theories, assessment tools, and therapeutic approaches are applicable to all clients.

Further, occupational therapists are to understand that language used in practice and the workplace can also affect oppression. When talking to or about their clients and colleagues, occupational therapists should refer to others respectfully. This includes learning about, avoiding, and not silently condoning microaggressions in the workplace.



Bias is inevitable and harmful


Biases refer to the views that individuals consciously and/or unconsciously hold toward diverse groups of people because of their own unique social location.

Biases can be emotional (causing prejudice), cognitive (causing stereotypes), and behavioural (causing discrimination).

Implicit biases are views that an individual holds unconsciously, whereas explicit biases are views that an individual is aware they hold. All people, including occupational therapists, have biases that inform their actions, behaviours, and judgements.

Occupational therapists’ biases can intentionally and/or unintentionally impact clinical decision-making and client interactions, at times perpetuating discrimination.

While it is difficult to completely remove all biases, occupational therapists can take steps to identify and challenge their biases to reduce the impact these have on their practice.


“Available” and “Accessible” are not synonymous


The World Federation of Occupational Therapists (2019) has clearly articulated that occupational rights are human rights.

Specifically, all people have the right to participate in occupations that are meaningful, necessary for survival, and contribute to personal and community well-being; to “[c]hoose occupations without pressure, force, coercion, or threats”; and to “[f]reely engage in necessary and chosen occupations without risk to safety, human dignity, or equity” (p. 1, emphasis in original).

Occupational therapists can promote occupational rights by facilitating equitable access to both participation and services. But practitioners must understand that the availability of occupational opportunities and services does not guarantee accessibility for all clients.

Barriers to access may be systemic (for example, affordability of services) or practical (for example, culturally insensitive or inappropriate). Considering the barriers that may impact access and taking steps to mitigate or alleviate them contributes to improved client outcomes.


Trauma is prevalent


Occupational therapists in Ontario should have a basic understanding of the prevalence of trauma and its potential effects on the clients and communities they work with.

Research demonstrates that individuals of equity-deserving groups are more likely to experience both interpersonal and systemic trauma and violence. This can affect the services they require and receive, and occupational therapists need to know how to properly manage client trauma experiences and responses. 


Occupational therapists have human rights too


It is important to remember that just as the College expects occupational therapists to provide culturally safe and justice-oriented services to the public they serve, registrants also have the human right to work in environments and with clients and colleagues that are not racist or discriminatory.

If an occupational therapist experiences unsafe or inappropriate behaviour from a client, they may choose to transition services to another provider. If the workplace or those in it are creating an unsafe situation, the employer should be informed, and solutions developed and implemented.

The College recognizes the practice challenges of delivering services in ways that are culturally safer and anti-oppressive. There is immense diversity within the population served by occupational therapists in Ontario, and all clinical situations are different. However, occupational therapists can employ several tools and strategies in their practice, including the following:


Critical reflexivity

 
  • Employ critical reflexivity to bring awareness to positionality and the perspectives brought into each therapeutic relationship.
  • Recognize and respect that clients enter the therapeutic relationship from their own social location and may have worldviews, values, beliefs, and traditions that differ from those of the occupational therapist.
  • Critically examine the traditions and knowledge they have, and the tools and approaches used. 

Relational accountability

 
  • Consider how their practice embodies (or could embody) the four Rs of relational accountability: respect, relevance, reciprocity, and responsibility (see the glossary for an example).
  • Recognize that they are accountable to the people they work with, including individuals, families, communities, groups, and populations.
  • Avoid making assumptions that a client will or will not benefit from a given tool or approach based on presumptions about the client’s social identities and contexts.
  • Strive to create ethical spaces and collaborative dialogue when determining which approaches and tools are appropriate for a given client.
  • Strive to foster a culture of belonging when working with clients, communities, and colleagues, as true inclusion can occur only when the people they are working with feel valued, seen, and heard.
  • Speak and write about clients as they wish to be described and referred to. When completing documentation, write notes with the assumption that clients will read them. Reflect on how notes might make them feel.

Consider what it means to be evidence-informed

 
  • Recognize that tools and approaches found in scholarly literature are not normalized or validated with a sample that represents the diverse clientele served.
  • Understand that scholarly evidence, while valuable in many contexts, is only one type of evidence, and it usually reflects Western knowledge and methodologies.
  • Respect and continue to learn about different ways of knowing, including Eastern, Global Southern, and Indigenous perspectives on health and occupation.
  • Be mindful of cultural appropriation when integrating knowledge and traditions from cultures that are not their own.

Strive for cultural humility and culturally safer practices

 
  • Recognize that cultural competency is unattainable as no one can fully be “competent” in the culture of another. Instead, strive to have cultural humility and culturally safer practices.
  • Commit to learning about the historical and ongoing social and political contexts that affect clients’ experiences with health, healthcare, well-being, and healthcare professionals.
  • Understand the ongoing legacies of colonialism and its impact on Indigenous peoples in Canada. This includes how colonialism, including the residential school system, has systematically disadvantaged Indigenous peoples and resulted in intergenerational trauma, creating ongoing barriers to health, well-being, and access to health services and occupational participation. Know that intergenerational trauma has been experienced by many other groups and cultures as well.
  • Recognize and honour the resiliency of equity-deserving groups, and commit to amplifying their voices and undertaking actions that promote reconciliation and self-determination.
  • Understand that while culturally safer experiences for clients are obtainable, it is the clients who ultimately determine whether a setting or experience is comfortable and safe for them. Be prepared to open this dialogue and respond sensitively to feedback. 
  • Expand awareness and understanding of trauma and violence, including historical and ongoing contexts, consequences of trauma across lifespans and generations, and the relationship of trauma with other physical and mental health concerns. This may require obtaining additional information on trauma- and violence-informed approaches in service delivery.

Commit to lifelong learning

 
  • Recognize that the information presented in this document is far from exhaustive and the process in learning about culture, equity, and justice will be different for everyone.
  • Identify learning and knowledge gaps and commit to addressing them as part of Professional Development Plans, workplace goals, and personal commitment to improving knowledge and understanding about anti-oppressive and culturally safer practices.


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