“Justice Becomes Our Agency.” Occupational Therapists in Germany Reflect on Their Practice Processes in and with Communities

Abstract

Community development and population-oriented approaches are emphasized to advance the occupational therapy profession’s scope of practice to meet the increasing demands created by socio-cultural-political and economic changes. This study explored the practice processes of occupational therapists in community settings outside existing health care structures in Germany. Data was gathered through five individual qualitative interviews and one focus group and analyzed using thematic analysis. Three main themes were identified: navigating parallel processes within the larger context or system; building community connections through occupation; growing professional identity. The utilization of occupational science concepts was essential to work successfully on a community level.

Keywords:

• Community development
• community practice
• occupational justice
• occupational therapy
• processes of transformation
• professional identity
• transformative practice

Introduction

Today, more than ever, societies are affected by enormous changes. Growing populations, increasing poverty, climate change, pandemics, and migration are examples of current major challenges presenting in societies around the world. The United Nations 2030 Agenda for Sustainable Development (UN, 2015), adopted by all UN Member States, calls for action to implement strategies to improve health and education and to reduce inequalities on a global level. The World Federation of Occupational Therapists (WFOT) emphasizes the opportunities that the UN Sustainable Development Goals hold for the occupational therapy profession and reinforces working with communities from a societal perspective on the principles of inclusion and social enterprise (Pattison, 2018).

The WFOT identifies eight international research priorities for occupational therapy to build capacity among the profession for meeting the future challenges of health care provision, including “sustainable community development and population-based occupational therapy interventions” (Mackenzie et al., 2017). The “Strategic Plan 2017–2020” of the Council of Occupational Therapists for European Countries (COTEC, 2017–2020, under revision) emphasizes occupational therapy’s engagement in communities and the WFOT (2019) identifies communities as clients of occupational therapists and thus supports community practice. In response, there is a need for the occupational therapy profession to advance its practice into population and community service. In international occupational therapy literature, there is growing attention to occupational therapy development in community practice (Barros et al., 2005; de Almeida et al., 2011; Lauckner et al., 2019; Pollard et al., 2008). Examples of community practice exist across continents and demonstrate the breadth of occupational therapy community practice (Booth & Nelson, 2013; Carra et al., 2019; Fransen-Jäbi, 2016; Fukuma et al., 2017; Gerlach, 2015; Hyett et al., 2017; Lauckner & Stadnyk, 2014; Zur & Rudman, 2013). Various international researchers have explored occupational therapists’ work in community-based programs, community-centered practice, community development, and marginal settings (Creek & Cook, 2017; Galvaan & Peters, 2014; Hyett et al., 2016; Lauckner et al., 2011; Melville et al., 2023; Scaffa & Reitz, 2014). Some of the authors have developed community-centered/community-development conceptual models and practice frameworks (Booth & Nelson, 2013; Galvaan & Peters, 2014; Hyett et al., 2019; Lauckner et al., 2011; Scaffa & Reitz, 2014; Zinkstok et al., 2017) to guide occupational therapy practice on the community level.

Occupational therapy conceptual and practice models reflect a holistic perspective in advancing engagement in meaningful occupations, participation, and social inclusion (Baum et al., 2015; Cutchin & Dickie, 2013; Fisher & Marterella, 2019; Law et al., 1996; Polatajko, 2007). Occupational justice, a concept central to occupational science, provides a paradigmatic and theoretical base for occupational therapists to work with individuals, groups, and communities to achieve participation and social inclusion (Townsend & Wilcock, 2004; Wilcock & Hocking, 2015). Theories in occupational therapy and the profession’s philosophical underpinnings place occupational therapists at the forefront in collaboratively designing and implementing approaches that target environments and systems on a community level (Hammel, 2020; Scaffa & Reitz, 2014; Townsend & Polatajko, 2007; WFOT, 2019; Wilcock & Hocking, 2015; Wilding & Whiteford, 2009).

Background

In Germany, the population growth has reached an unprecedented high in 2022. Refugee migration is a main factor, peaking in 2015s refugee crisis and the current war in Ukraine. The number of those aged 80+ has doubled in the past ten years leading to more need for care. Injustices in educational opportunities have increased during the Covid-19 pandemic and every fifth person is at risk of poverty or social exclusion (European Union, 2022; Statistisches Bundesamt, 2022). These developments present many challenges in society, for example increasing the gap of opportunities in education, health, or welfare services between different populations groups, displaced people being the most salient at present. They are facing disparities, such as in housing and employment, access to health care due to legal status, language barriers, and/or lack of migrant-inclusive policies. This affects the well-being of both individuals and the (hosting) community (UN, 2023). Communities are identified to be a critical factor in improving health. Therefore community/population-oriented services, addressing the conditions and context in which people live, work, play, and learn, can foster health-related outcomes, such as quality-of-life and social belonging (National Academies of Sciences, Engineering, and Medicine et al., 2017).

Within Europe, the German government has taken on a leading role in promoting global health (Kickbusch et al., 2017). German rehabilitation and health associations, including the German Occupational Therapy Association (Deutscher Verband Ergotherapie e.V., DVE) are responding to the calls of expanding their scope of practice to meet the ever-changing needs of societies (DVE, 2019, 2022).

Within the DVE, different working groups address areas of practice outside the health care system, and the development of community practice is still new. Community practice is defined in this study as working in a setting outside mainstream healthcare structures, with individuals, groups of people, and populations, in and specifically with whole communities, focusing on socio-cultural-political and economic issues (Hyett et al., 2016, 2019; Lauckner et al., 2019).

There is an increasing focus on community development approaches in the German occupational therapy literature (Arens et al., 2018; Coqui, 2012; Helmbrecht, 2012; Schiller, 2012b; Schiller et al., 2012, 2015). Furthermore, community practice has gained more attention in the occupational therapy profession through the European refugee crisis. Displaced people with very limited or no access to health or social services have become a focus of occupational therapy (Loer, 2015; OT Europe Interest Group Displaced Persons, 2016; Schiller, 2012a, 2012b). However, the developments of occupational therapy in Germany in these areas are not described with the overarching notion of community practice. This could be due to differences and/or uncertainties in the understanding and conceptualization of community practice (Lauckner et al., 2011, 2019).

For the profession’s transformation from individual to community-oriented practices, it is important to understand the processes it requires. No literature exists exploring the practice processes of occupational therapists across different community practice settings in Germany to provide a better understanding of how community practice is conceptualized within the German context. An explicit understanding of practice processes in community practice will assist occupational therapists to reflect on their current scope of practice and its expansion to communities. It can further inform and guide occupational therapy practice in unfamiliar settings outside health care structures and build capacity among the profession to address the many aspects of life impacted by socio-cultural-political transitions. Learning across the different contexts will allow for a more general comparison and serve to strengthen occupational therapy’s role and recognition in partnerships with communities. This study explored the understanding of community practice processes of occupational therapists in Germany. The aim was to gain a better perception and conceptualization of community practice in Germany. The specific research question was: how do occupational therapists working in community practice in Germany describe and understand their practice processes?

Methods

Design

Interpretive Description (Thorne et al., 2004) was chosen for this study as a methodological framework as it is suited to explore questions about understanding “the nature of knowledge as it works within the applied discipline” (Thorne, 2016). Interpretive Description is a qualitative research approach that aims at understanding the perceptions and experiences of a group and identifying aggregated knowledge that can further inform practice (Burdine et al., 2021). It is grounded within the interpretive paradigm with the underpinnings that the nature of phenomena is socially constructed within a particular context. Interpretative Description is an applicable approach used across health sciences to answer specific questions within a discipline.

Ethical review or approval of this study was not required by the State Medical Association (Landesärztekammer), the overseeing entity for ethical review in Germany. Adherence to the legal provisions under the German and European General Data Regulation (BDSG, 2018; DSGVO, 2018) was ensured; this includes the right to privacy and confidentiality, securing all personal data of participants and documented information, and written informed consent with the right to withdraw from the study at any time without specified reasons.

Participants

Within Interpretive Description, the participants are acknowledged as key informants to provide the interpretive account based on their specialist knowledge and experience about the phenomenon of interest. Purposive sampling was used as it presented an important form of strategic identification of key informants (Thorne, 2016). Different working groups within the DVE and authors who had written about their practice in community settings in German occupational therapy journals were contacted. Additionally, snowball sampling served to identify more eligible participants (Morgan, 2008). Recruiting practitioners from different practice areas served the variation needed to explore practice processes across settings and allow for the applicability of the findings to diverse contexts (Lauckner et al., 2019). Inclusion criteria were defined as (a) being a licensed occupational therapist in Germany; (b) being engaged in community practice in a position outside the health care system in Germany; the job title or description did not necessarily need to be that of an occupational therapist; and (c) experience in community work for a minimum of 1 year.

This study included five occupational therapists from four different states in Germany and five different practice fields (Table 1). All participants worked in unfamiliar settings outside health care structures. Their job description and employment were not that of an occupational therapist, except one, and all of them were the sole occupational therapists in their work setting. Four of the five therapists had previous experience in clinical settings. All five had sought deliberate positions in new areas outside health care structures because of dissatisfaction with their limited possibilities of how to serve their clients due to the existing structures.

Table 1. Sample description.

P	Current work setting	Client group	Education	Years of experience
				As OT	In community practice
1	Service for outpatient assisted living, state organization	People with enduring mental difficulties	OT Diploma BSc OT MA Social Work	16	3
2	Empowerment project, private organization	Occupational therapists and other professionals	OT Diploma BSc OT	13	3
3	Office for equality, institution of higher education	Students, employees, academic staff	OT Diploma Bsc OT Interprofessional Msc OT/PT/SLP	18	9
4	Office for peer counseling, private foundation	People with disabilities and their families	BSc OT MA in psychosocial counseling and law	3	3
5	City counseling center, community center for prevention and health promotion	Senior citizens	Diploma OT BA OT BA Gerontology	20	16

Note. All participants agreed to the publication of their background information.

Data collection

Individual, semi-structured interviews, follow-up interviews, and one focus group with the same participants were conducted based on the foundational underpinnings and the elements of design in Interpretive Description (Burdine et al., 2021; Thorne, 2016). A semi-structured interview guide was developed, and peer reviewed by experienced occupational therapy practitioners and researchers (Table 2). Participant feedback on the initial analysis served as a quality check and presented additional data for further analysis (King & Brooks, 2017). The focus group engaged participants in a critical dialogue around preliminary findings and added to the richness of the data (Thorne et al., 1997). One participant did not wish to participate in the focus group. The data analysis is based on the five individual interviews, the individual follow-up interviews for all, and the focus group.

Table 2. Interview guide, sample questions.

Research questions	Questions asked
What was your motivation/were your reasons to consider working in a setting outside the traditional health context?	Can you tell me how you came to work in the current setting? How did you decide/choose to work in a nontraditional setting outside existing health-care structures?
What do you do? What are your tasks?	Can you describe your workplace? What is the setting? Structures, who else works there, who is your client, your target group? What are your tasks? Can you describe a typical day? What exactly does that look like? Can you give an example?
Why do you think an occupational therapist (OT) can fill this position? Why do you think an OT is important in this area? What does an OT bring into such a field? What aspects of your job are OT specific? What aspects of OT do you consider important for this area? Why?	Can you talk about aspects in your work that you consider as OT specific, or specifically important? Which other aspects do you view as important in your work? Can you explain this in more detail? How do you decide on your focus? Can you explain this using an example?
How do you assess needs?	Can you describe how you assess your clients’/target group’s needs? Which elements do you consider are especially important?
How do you consider context in your work? How important is it? Does it influence your daily work? How?	How do you consider context in your work setting? For whom?
What are the goals in your work? Your goals, clients’ goals, …? How do they relate?	What do you see as goal of your work/interventions? And the client’s goals? Which goals are pre-dominant? How do you think are the goals of your work connected to those of your clients?
What is your role in the process? How do you describe your role?	How to you view your role in this particular setting? Are there any more aspects you consider as important? Can you explain more specifically?
How important do you consider OT in such roles? (local, regional, national, global)	What makes your role so specific? How is your role characterized? How important do you view your role in this area or practice? Why?

Analysis

Template Analysis (Brooks et al., 2015) was used to perform a thematic analysis. Template Analysis is a structured, yet flexible and highly iterative approach recommended in Interpretive Description as it allows to revise and refine subsequent data for the development of comprehensive themes in a straightforward documentation of the analysis (Burdine et al., 2021). Based on “the intention to focus on particular aspects of the phenomena under investigation” (King & Brooks, 2017), the five following a priori themes were identified from relevant international literature to serve as a foundational structure: context, occupation, enablement, participation, and justice.

All individual interviews and the focus group were audio recorded and transcribed verbatim. The manuscripts were coded by the first author to identify data that fit into the a priori themes yet being aware of staying open to modify themes and/or identify additional themes. An initial template was developed for clustering (Brooks et al., 2015; Burdine et al., 2021). The individual follow-up conversations served as member-checking, refinement, and enrichment of the analytic process. First preliminary findings were derived and presented during the focus group as a base for discussion and critical reflection. The focus group served to deepen and as an enrichment of the data. In an iterative process, all relevant data was fed into the existing templates, revising the templates, and constructing new versions. The last step included synthesizing, theorizing, and re-contextualizing (Thorne et al., 1997) to adequately capture the richness of the data across diverse contexts and experiences (Lauckner et al., 2019). A final template was created presenting three main themes.

Trustworthiness

An iterative process provided for a coherent account of data and findings. A thick description of the research process and findings including direct quotes is presented in this article. Different aspects of triangulation were used: data triangulation, researcher triangulation, and methodological triangulation (Curtin & Fossey, 2007). The sampling methods used added to the range of data and the transferability of the findings to other contexts (Letts, 2007; Nowell et al., 2017). Peer debriefing and supervision were sought at several intervals throughout the research process. Participants feedback on the first analysis was used as a check for the accuracy and resonance of their experiences. Involvement in the data analysis process by providing comments and critical reflections on the preliminary findings during the focus group adds to the credibility of the findings (Candela, 2019; Creswell & Miller, 2000; Fossey et al., 2002; King & Brooks, 2017; Thorne et al., 1997). The researcher kept a reflexive journal with records of and reflections on the research process, written case reports after interviews, notes on methodological and analytical choices and debriefing sessions as well as diary notes for regular self-inquiry (Thorne, 2016).

Findings

Three main themes were identified: Navigating parallel processes within the larger context or system; building community connections through occupation; and growing professional identity.

Navigating parallel processes within the larger context or system

The participants described the expansion of context into multiple levels. They used the word “level” to express the shifting of their practice focus from the individual to more complex structures. They explained how they needed to navigate these different levels to successfully collaborate with their clients in achieving their goals.

Context, systems, and structures

The participants emphasized the importance of a holistic understanding of the context, systems, and structures around a single issue. This included the client’s social environment and the interactions with people or groups of people, the neighborhood, community, and the society as a whole. As one participant stated:

“I can never see this client without this context. … And [there are] intercultural aspects that play a role … there are a lot of different societal issues that manifest themselves within a community.” (P5)

The participants considered knowledge about institutional structures, in the client’s context and in the context of their own work setting, as essential to be able to engage in the processes needed to support their clients. They further explained that the structures at the institutional level not only influence their practice but also represent an extension of it as those structures must be approached in the intervention process, as expressed in the following:

“So, in my case I would see the level of the institutions; for my client this is really the youth welfare services, because it strongly affects the family… . Then there’s the client, who is under legal care with a probation officer, so there is the law court, …. Then I really see the community and the neighborhood, … . And also, the society, and here again we have the levels with the changes. And I have to respond to it.” (P1)

Interconnectivity and complexity of different context levels

The participants talked about “the interconnections in which the person moves” (P3), their influence on each other, and their unique relation to the clients’ issues. They expressed how the connections and the individuality of the larger context display complexity in the practice processes. Participants regarded the understanding of this complexity as a key element in their work as described in the following quote:

“What I mean with levels and how they influence, for example, the level of the relationship. Then there is in fact … the professional level, and the organization or structural level, and it all plays together… . I think they all are connected with each other really tightly. They reach into one another, like cogwheels” (P2)

The professionals elaborated that the different issues and needs present another complexity and they constantly needed to shift between the multiple levels, balancing the individual, community, and structural issues to get a complete and bigger picture of what is involved. The two following quotes show how and why this needs to happen:

“And sometimes it can be a solution to have a different perspective … Sometimes the solution can be to find and offer other possibilities. And that’s why I am acting on the different levels.” (P2)

“I ask a lot of questions … And yes, in the end, it is like a puzzle, and I have to find the focus.” (P3)

Building community connections through occupation

Occupation focus

The participants described how their work is centered around occupation. They had a clear perception of themselves as “experts in occupation.” They talked about how their occupational perspective made their work differ from that of other professionals and made them do their job well. One participant commented:

“I have a different perspective on occupation than others in the team. I look at occupations differently, in relation to the client, I consider them within the existing conditions and the context.” (P1)

The participants viewed focusing on occupation as core when working in community contexts.

Occupational needs

It was seen in the interviews that the processes often begin at an individual level. The participants described that through the understanding of the meaning of occupations and “knowing that we come to being through doing” (P2) they were able to identify the occupational needs and conflicts that arise when different occupational needs collide, for example, a mother wanting to be with her child and at the same time being able to attend classes at university. They said that through these conflicts, the processes touch on another level, such as institutional structures. The participants explained, that when carefully attending to the needs of the client, they were able to identify additional issues. One participant provided an example:

“Yes, it is about working on occupational needs with the client. They don’t know it, but I do. That it is ALWAYS about occupation. If her son wants to go bowling and the mother cannot drive him, and that is a meaningful occupation for him, even if in that moment we call it providing services for participating or something else, for me it is occupation.” (P4)

Shared needs and interests

In the process with their clients, the participants realized that some of the clients’ problems were also experienced by others. They said that the identification of shared needs and interests presented an important step.

“Sometimes it is a personal, very individual conflict, but at the same time it meets the broader needs. … But when you find people who have similar interests, and that becomes a push.” (P5)

The participants explained how this led them to initiate community-oriented processes working with the different groups not only in but increasingly with their environments. They explained that advocacy plays an important role at this level:

“I only provide something, a frame or structure. Not like a midwife, but a bit like that.” (P2)

“I realize, as an occupational therapist I always stand for this client.” (P1)

The process is characterized by an equal partnership that one participant called “true client-centeredness” (P4). The participants reflected that change starts to happen on a societal and political level with the goal of participation and social inclusion for disadvantaged, at risk, stigmatized, or excluded groups or members of the community:

“I believe that if we link to participation, it is very important to act beyond the individual.” (P4)

“It is about belonging. It is about having a connection. About being connected and staying connected. Yes, and there we get to doing, being, becoming, belonging.” (P2)

“And it is about the general mastery of life, and it always should be about that in occupational therapy.” (P3)

Growing professional identity

The participants talked in detail about the importance of enhancing their own professional identity to be able to overcome experienced uncertainties and gain professional ground in an unfamiliar work setting.

Uncertainties

Uncertainties arose from the unfamiliarity of the new work context as there was no outlined approach. There was some lack of clarity about the required tasks and their roles. One participant said she was “quickly hit by reality” (P1). And another participant said: “You are the stage director, because nothing is given.” (P5). The occupational therapists had to find their way through to create a profile for themselves, seeing about a way of doing it that felt like occupational therapy. One participant explained this:

“And I do find that difficult, to see, what is there that is occupational therapy? Or do I sometimes just frame it to myself that it fits? Then I go look at literature and … it is actually written there, okay, this can be occupational therapy.” (P4)

The perception of their work by others also added to the feeling of uncertainty. They were confronted with statements telling them they did not work as an occupational therapist anymore or had left the profession, causing doubts about their identity, and losing their professional ground.

Professional role

The participants reflected on the content of occupational therapy practice, their own professional values and possible new roles. They described this process of critical reflection as another complexity in their practice and considered self-reflection crucial for practicing in an unfamiliar field. They emphasized how it helped them shape their own understanding of the profession:

“And for example, how about the professional roles of occupational therapy: what is the professional role today and what should it be in the future? How about transitions? What transitions are there? What are the times we live in today? And how about paradigm change?” (P2)

Self-identifying

The participants explained how they became aware of their specific expertise and how it added to the setting and the processes with the clients. They also explained that they developed a new way of thinking about occupational therapy within the given conditions and contexts. They were able to identify new roles and grow professional identity, as emphasized by the following statement:

“I identify myself as occupational therapist …, I am and I will always be an occupational therapist.” (P3)

Occupational science

The participants were required to self-identify as working in community practice. When asked about how they reasoned and what they considered made their work community practice, they drew strongly on concepts of occupational science. The professionals talked about existing power structures and their influence on the possibilities and limitations for both their clients and their occupational therapy practice. They continued how they were addressing the injustices these existing structures create within a society or community in their practice processes. They expressed the importance of their professional role in advocacy and empowering their clients to be able to fulfill their everyday needs. The participants elaborated that all the processes and interventions ultimately aim at participation, and they consider participation and social justice their professional call and responsibility, as an overarching focus and goal, “to contribute to quality of life and sustainability” (P1, P3, P5). One participant said:

“Participation and justice are why I am an occupational therapist. It is unjust if people cannot participate because of the system and context, and I see the occupational therapy role in accompanying them through it and empowering them” (P4).

And another therapist explained:

“I am a change agent, occupational therapy has to take on the aspect of justice, it is our focus, … with our knowledge of occupation it is impossible to think without the aspect of justice” (P1).

Discussion

This study explored the perception and conceptualization of community practice in Germany. The occupational therapists described how they view their doing within the community context and relate it to a socio-political agenda in health care.

Apparent among the participants in this study is the high degree of complexity of community practice. Complexity as an integral part of community practice has been described in previous studies (Lauckner et al., 2011, 2019; Leclair et al., 2019). In this study, the application of a strong contextual focus is emphasized to answer the complexity, specifically including the socio-political shaping of the client’s possibilities of doing. Consequently, a re-interpretation of how practice processes can be navigated is needed. The occupational therapy processes in community practice are described as parallel rather than linear to navigate more complex structures. This requires the critical position of occupational therapy regarding social issues and the right to be a full member of society (Fransen et al., 2015; Hammell & Iwama, 2012). Occupational therapists need to take their understanding of the connection of person, environment, and occupation and place it in the context of institutional, socio-political, and ecocultural structures and their interrelations (Hyett et al., 2016; Scarpa & Trickett, 2022).

In this study, the participants talked about their understanding of the interplay of the different context levels and the complex ways in which they influence each other. They explained how they constantly must react, adapt, and interact with and within the different dimensions at the micro, meso, and macro level to bring it all together, with consequences for their practice focus and the approaches applied. This highlights the need to integrate a social lens and inter-sectorial practices to link socio-political factors and inequalities to participation, health, and social inclusion (Barros et al., 2005; Farias & Rudman, 2019; Hammell, 2013; Malfitano & Lopes, 2018). A developed holistic understanding of the interrelated complexity of the living world of the client and the systems involved is essential to transform the occupational therapy profession’s perspective and conceptualize their doings within the context of socio-political and community structures (Kantartzis, 2019; Pollard, 2014; Scarpa & Trickett, 2022). Successful interaction with the different parties can support transformation processes and create the conditions that allow for the clients’ enablement in the occupations of daily life and foster full citizenship (Lopes & Malfitano, 2017). Creek and Cook (2017) describe this responsiveness as one of the enabling characteristics to practice effectively in marginal settings.

This study highlights the importance of applying an occupation focus on all different levels to respond to the complexity of community practice. The professionals had a clear understanding of themselves as experts of occupation and placed occupation at the center of their doings. Linking broader contextual factors to occupational opportunities (Farias & Rudman, 2019) or lack thereof, presented the possibility of answering the complexity community practice encompasses and moving into intervention processes addressing community needs and the socio-political structures for equity of occupational engagement and participation (Gerlach et al., 2018).

Experiencing uncertainties and feelings of losing ground also presented barriers for the occupational therapists to place their work in the context of community practice. These tensions are not a unique finding but rather present as an encountered professional issue when practicing outside health structures (Hyett et al., 2016; Irvine‐Brown et al., 2021). However, reflecting on their own person as an occupational being assisted the professionals to position themselves in the new practice settings. Critical self-reflection and awareness of their professional values and beliefs fostered a professional identity that enabled the occupational therapists to work in the larger context of community and systems. These findings link to literature that calls for reflexive praxis in generating knowledge and understanding of the occupational therapy profession, and improving practice directed toward social injustices with consequences on service delivery and the scope of occupational therapy practice (Irvine-Brown et al., 2022; Mackey, 2007).

Recent studies identified that occupational therapists drew on a range of frameworks and theories to guide their work in community practice (Lauckner et al., 2019; Leclair et al., 2019). The participants in this study drew strongly from occupational science concepts to enhance their professional understanding and identity and utilized these to guide their processes in community practice. These findings resonate with literature that suggests the application of an occupational justice perspective to address the factors that limit the clients’ opportunities to engage in occupations, restricting participation (Chichaya et al., 2018; Durocher et al., 2014; Malfitano et al., 2019; Pereira & Whiteford, 2013). They highlight the actual utilization of occupational science concepts as presented in Whiteford and Townsend’s Participatory Occupational Justice Framework (2017). The practitioners linked their professional knowledge to aspects of (in)justice, empowerment, and social change, and turned their professional attention “to the macro-socio-political dimensions of people’s lives as the resource for their work” (Malfitano et al., 2019). In the development of expert consensus on occupational science concepts essential to occupation-based practice (Backman et al., 2021), occupational justice was identified by a 95% expert agreement. This study strongly supports the utilization of an occupational justice perspective as imperative and a prerequisite in supporting participation in one’s community. Occupational therapists in Germany, and elsewhere, need to utilize this perspective to orient and present the value of their work to communities, institutions, policy makers and new stake holders. Utilizing occupational science concepts guides the profession’s transformation in advancing the social justice agenda of the profession (Farias & Rudman, 2019).

Ongoing development of occupational therapy in Germany

In Germany, occupational therapists working outside existing healthcare structures are limited by health insurance, policies, and laws in providing community-oriented services beyond individual prescriptions by a physician. In its strategic plan for the future development of occupational therapy, the DVE aims for change to sharpen its profile and role to meet the increasing demands of modern times, and to ensure that occupational therapists can practice in community settings under their professional title.

This study’s findings have implications for the future direction of occupational therapy development in education and practice in Germany. They provide evidence for the importance of adopting a community-oriented approach and how this multi-faceted process can be navigated successfully (Hyett et al., 2016). They support the profession in the transition to improve practice directed toward population/community-oriented care, based on social justice and human rights (Scheepers-Assmus et al., 2015; Schirmer, 2013); they add to the current intra-professional and political dispute of reforming the regulations for the occupational therapy profession with an academic training for all occupational therapists and other health care professionals to ensure the quality of health care. Reforms will need to reflect and encompass the changes as targeted in the official documents (DVE, 2022), such as occupation-focus, evidence-based practice, and new practice fields. The inclusion of occupational science as a paradigm, employment of critical praxis and community-oriented approaches into the standard occupational therapy education and ongoing professional development will enable occupational therapists in the analytical, critical, and comprehensive ways of thinking and acting to meet the complex needs of clients, including those of whole communities and populations (WFOT, 2020). New graduates will be better prepared to stand their ground in creating new public health roles when practicing in unfamiliar settings (Bailliard & Aldrich, 2009; Nilsson & Townsend, 2014).

Application outside Germany

This knowledge, derived from practice and research, can serve as a resource if incorporated into occupational therapy educational programmes and the delivery of service specifically on community level, as it holds a foundational understanding to improve care for whole groups and populations. This can be especially relevant in countries where occupational therapy training and services are developing. Approaching the complexity of context levels and their interrelations through the occupational justice lens can serve as a framework for the occupational therapy profession globally in providing help to populations in vulnerable positions (Scarpa & Trickett, 2022). It might be relevant when discussing best practices in addressing global challenges and improving population health. For example when implementing programmes in areas where individuals or groups are difficult to reach or underserved due to remote geographic location, existing inequalities, or minimal resources (Jiménez-Arberas et al., 2021). It can also be used as a guiding foundation in occupational therapy student training in role-emerging placements, unfamiliar fieldwork settings, or International Service Learning (Cipriani, 2017; Sim & Mackenzie, 2016). The findings can be translated into assisting decision-making and policy formulation according to the Sustainable Development Goals. They can facilitate the professional discourse about the future direction of the occupational therapy profession globally. Occupational therapists from different countries can collaborate and learn from each other, drawing from the presented ideas and directing them toward action in their own contexts.

Limitations

The sample size of five occupational therapists limits the generalization and transferability of this study. Including perspectives from more participants across diverse settings, dissimilar contexts, and countries would add to the findings. The combination of individual interviews, member checking, and focus groups provides confidence that the findings are trustworthy. The use of a priori themes is arguable. However, in Template Analysis the realm of what is known serves as a foundational structure for the new inquiry (Thorne et al., 1997). Processes of reflexivity ensured as much clarity as possible about limiting potential bias. Coding by multiple coders is discussed in the literature to increase rigor in qualitative research (O’Connor & Joffe, 2020; Raskind et al., 2019). Due to the requirements of the master’s program, this was not possible. As the study was conducted in German, it is possible that meaning can get lost in translation (van Nes et al., 2010).

Conclusion

This study adds to the understanding and conceptualization of community practice by portraying the occupational therapists’ perspective on community practice within occupational therapy in Germany. It demonstrates how occupational therapists learned to understand the evidence base relevant to their practice and translate this knowledge into their practice. Keeping in mind that this is a qualitative study, providing for an understanding of phenomena rather than generic truth, the findings of this study do have relevance for discussions of the future direction of occupational therapy development in Germany and globally. Applying evidence-based knowledge to practice assists in advancing occupational therapy’s practice and role, strengthening its relevance and contribution to society. “Gaining recognition from other discipline groups and funding bodies” is emphasized in the WFOT-identified international research priority of “international occupational therapy professional issues” (Mackenzie et al., 2017); this includes the needs of occupational therapists in particular areas of practice. Occupational justice provides an additional theory base in acquiring the skills, knowledge, and evidence needed for the successful transformation of the occupational therapy profession and positions occupational therapy community practice clearly within the political context of global health strategy plans and sustainable development agendas. Participation and social justice become the agency of all occupational therapy processes and interventions.

This study demonstrates evidence constructed within occupational therapy practice can guide the profession’s transition into partnerships with communities and different stakeholders. More international studies are needed to support evidence-based practice and knowledge translation that changes practice and practitioner behavior as stated in the WFOT international research priorities.

Acknowledgments

This research was carried out in partial fulfillment of the requirements of obtaining the first author’s degree of the European Master of Science in Occupational Therapy, supervised and co-supervised by the co-authors.

The first author would like to especially thank the occupational therapists who participated in this study for their time and thoughtful contributions.

This work is dedicated to the memory of Cornelia for her inspiration to further learning and research.

Declaration of interest

The authors report no conflicts of interest.

Additional information

Funding

The authors received no funding for this work.

Notes on contributors

Roswitha Hoerder

Roswitha Hoerder, Faculty Lecturer, ZHAW School of Health Sciences, Institute of Occupational Therapy, Zürich University of Applied Sciences, Winterthur, Switzerland.Debbie Kramer-Roy, PhD, Director Education, European Master of Science in Occupational Therapy, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.Staffan Josephsson, PhD, Professor of Occupational Therapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.