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2007 ELEANOR CLARKE SLAGLE LECTURE Becoming Innovators in an Era of Hyperchange

We live in a time of hyperchange—rapid, dramatic, complex, and unpredictable change occurring in today’s society, which creates unprecedented challenges. High-speed advances in technology and knowledge and changes in society require that we shift our paradigms. We must become innovators of change. This lecture examines how occupational therapy is reacting to hyperchange as a profession. How is hyperchange influ- encing the roles and responsibilities of practitioners? How is hyperchange affecting education? And, in accepting hyperchange, what can we do as occupational therapy practitioners, educators, and scholars to shape our own future?

Hinojosa, J. (2007). Becoming innovators in an era of hyperchange [Eleanor Clarke Slagle Lecture]. American Journal of Occupational Therapy, 61, 629–637.

We are living in a time of rapid and unpredictable change. Advances in knowl-edge and technology have made our lives more interconnected and complex. New expectations are changing the dynamics of our personal and professional lives. We’re speeding up and struggling to hold onto control of all our responsi- bilities, both personally and professionally. We are living in a time of hyperchange.

I’ve become extremely aware of how it is affecting my life and the people around me. My personal to-do list seems endless, and deadlines are getting shorter and shorter. Everyone around me seems too busy. I’m not sure exactly what they’re doing, but they’re busy doing it. I have to make professional decisions quicker than ever before. The very pace of my work world seems faster. Sometimes I feel overwhelmed with the amount of new knowledge and emerging technologies I’m expected to master.

How is hyperchange altering our personal and professional roles and responsi- bilities? How is it affecting occupational therapy education, practice, and research? In preparing this lecture, I came across a tale from India about three fish.1 I think the fable’s moral is particularly fitting with this topic:

Three fish lived in a pond. One was named “Plan Ahead,” another was “Think Fast,” and the third was called “Wait and See.” One day, they heard a fisherman say that he was going to cast his net in their pond the next day.

“Plan Ahead” said, “I’m swimming down the river tonight!” “Think Fast” said, “I’m sure I’ll come up with a plan!” “Wait and See” said, “I just can’t think about it now!” When the fisherman cast his nets, “Plan Ahead” was long gone. But “Think Fast”

and “Wait and See” were caught! “Think Fast” quickly rolled his belly up and pre- tended to be dead.

“Oh, this fish is no good!” said the fisherman, and threw him safely back into the water. But “Wait and See” ended up in the fish market.

And so the saying goes: “In times of danger, when the net is cast, plan ahead or think fast!” (Forest, 2006)

Jim Hinojosa, PhD, OT, FAOTA, is Professor, New York University, 35 West Fourth Street, 11th Floor, New York, NY 10012; [email protected]

KEY WORDS • health professions • hyperchange • leadership • occupational therapy • professional education

1Note: From “Stories in a Nutshell,” by H. Frost, 2000, Story Arts Online, retrieved October 18, 2007, from www.storyarts.org/library/nutshell/index.html. Copyright © 2000 by Heather Frost. Reprinted with permission.

Jim Hinojosa

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As occupational therapists, we cannot afford to “wait and see.” I propose that we must both plan ahead and think fast. We must plan with an understanding of hyperchange and its influences on our lives. We must plan to ensure that we maintain our professional competence. We must plan for an unsure future with a vision of the world we want to live and work in.

In these rapidly and unpredictably changing times, uncer- tainty about the future is natural. Hyperchange is abrupt, erratic, and random. It makes long-term forecasting and planning increasingly difficult and risky. Decisions must be made faster, particularly at the professional level. If we do not participate timely and effectively in the decision-making pro- cess, we risk being swept aside.

In 2001, for instance, the U.S. Surgeon General chal- lenged health professionals to assess their roles and take action in preventing and decreasing obesity (U.S. Depart- ment of Health and Human Services, 2001). The report notes that people are spending too much time in inactive behaviors and watching television. But the report does not mention occupational therapy. There is no reference to occu- pation or changes in family routines or activities.

Why? Because occupational therapy is not recognized as a viable profession to prevent disability. Occupational ther- apy is not understood as a profession that has the potential for increasing people’s participation in life activities. And, thus, by extension we’ve not been seen as a profession that can assist in the fight against obesity. Yet, every day we help people change their routines and actions so they can willingly engage in meaningful, healthy activities. Occupational ther- apy was not part of the national plan to address obesity because we did not respond immediately to the U.S. Surgeon General’s call.

In occupational therapy, we are acutely experiencing the effects of hyperchange. Consider the expansion of knowl- edge and related skills needed to provide competent therapy services today. Think of all the information that practition- ers need today to be effective and ensure qualification com- pared to only 5 years ago. Today, beyond reading scholarly articles and attending continuing education workshops, practitioners need to be aware of what is on the Internet and what colleagues are writing on practice-related e-mail groups as well as what evidence is available supporting their inter- ventions. We also have to be aware of changing policies and advancing technologies.

Society’s knowledge as a whole is expanding rapidly. It’s obvious in our development of new information. As knowl- edge expands, some becomes outdated. Pat Lynch (“ERC 2000 Spring Conference Review,” 2000), president of the consulting firm Potential, believes that 90% of what we know today will be irrelevant in 5 years. Professional competence

is not easy to maintain within this context. The amount of new information we need to process each day can be over- whelming. With so much new input and so many changes, it is very easy to begin to feel that we cannot keep up with all the demands of proficiency and packed schedules.

Four conditions that characterize hyperchange are increas- ing uncertainty, rapid pace of change, growing ambiguity, and increased complexity in the workplace. We experience growing ambiguity in the workplace when everyday prob- lems seem to become resistant to routine solutions. We have more complex responsibilities and live with ever-increasing performance expectations. For many of us (personal life stresses aside), these work expectations are the most stressful. The systems and institutions we work in are changing and evolving every day. Many are changing their missions, poli- cies, and goals, even their basic organizational structures. For those of us in private practice, competition is greater than ever, and outside payers are engaging in aggressive cost con- tainment practices.

In these years of instant information and high value cost- effectiveness, clients and employers expect affordable, high- quality interventions. For therapists, a clear focus on practice is absolutely necessary today to provide interventions that result in immediate outcomes. Therapists are under incredi- ble pressure to increase productivity with fewer resources.

When expectations of employers and clients can’t be met, it is easy to feel ambiguous about our work and professional lives. We struggle to merge our fantasized view of occupa- tional therapy with the reality of practice in today’s world. Our values often come in conflict with workplace demands and employer and business models. These issues are just a few we deal with as a profession.

I began preparing for this lecture by reading literature on times of change, planned change, and effective management both past and present. I was amazed at how this issue seems to be on so many people’s minds today. But these concerns really aren’t new. Charles Darwin captured the notion best when he said, “It is not the strongest of the species that sur- vives, nor the most intelligent, but the one most responsive to change.” As for resistance to change, Earle (n.d.) summa- rizes it with “the only person who truly welcomes lots of changes is a baby with a full diaper.”

As occupational therapy practitioners, are we aware of the implications of hyperchange? Or are we just living within it, coping each day without any awareness of what is happening? I think we all realize the world is changing rapidly, and I think many of us recognize the negative con- sequences. But for the sake of our profession and for the benefit of our professional lives, we must alter our views and behaviors to meet the challenges of life in hyperchange. We cannot wait and see.

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In 1962, Thomas Kuhn described the concept of a paradigm shift in science. He saw change coming from break- ing old ways of thinking and proposed that thought is strongly determined by a person’s assumptions and theories about the world. Paradigms are our individual worldviews that influence our thinking and, therefore, our actions. Some scholars have objected to the term paradigm because they feel it’s overused. I’ve chosen to use it because it captures the importance of examining beliefs, perceptions, and actions in the context of our worldviews. To adapt to this rapidly chang- ing world, we must alter our ways of thinking. We must cre- ate paradigm shifts.

In 2006, Weiner and Brown echoed Kuhn. Instead of talk- ing about a paradigm shift, they emphasized thinking clearly. They asserted that our assumptions, prejudices, prejudgments, and even yearnings influence our thinking and that to deal effectively with change, we must become innovators.

So then, how do we do this? How do we shift our para- digms? We must determine where to focus our energies and how to acknowledge our potentials and learn when to use rea- soning skills to advance practices and interactions. We must recognize and draw on personal and professional relationships for the advancement of the profession and ourselves.

In the past, occupational therapy leaders have challenged us to shift or change our paradigms. But usually the challenge was to get us to accept a single one. This will not work today. Our responsibilities and roles are too varied to fit within one way of thinking. This won’t lead to innovation but rather to stagnation in our abilities to think “outside of the box.”

Take, for instance, the American Occupational Therapy Association’s (AOTA; 2002) mandate for absolute profes- sional acceptance of the Occupational Therapy Practice Framework: Domain and Practice. This document restrains practitioners. It limits how we look at occupational therapy, and it blinds us to new conceptualizations about our domain of practice. No one document, single theory, or intervention paradigm should be considered more important than any other.

In the December 2006 issue of Popular Science, I was star- tled that the Grand Award for Best Innovation of 2006 was given to the Bostitch Harriquake nail. A redesign of the sim- ple nail was selected because of its far-reaching effect on many people’s lives (Clynes, 2006). The judges selected it in a year when innovations included the growth of new body organs, the cloning of a lamb, and a 253-mph car. Why a nail? It had existed for more than two centuries without any major mod- ifications. But researchers found that during the recent hur- ricanes more damage was done to homes and buildings when they were ripped apart because of a limitation in the nail’s design. The function and purpose of the nail determined its redesign (Clynes, 2006).

This innovation and change in thinking closely parallels an important aspect of occupational therapy. Like therapists’ interventions, the nail redesign emerged from a functional need and its relevance to people’s daily lives. And like many interventions, the development was not particularly exciting. The nail designers observed its function and design. They noted its positive aspects and also where there were problems. They adapted and modified its overall structure to meet newly identified realities. It blended into people’s lives and was not considered important enough to make the nightly news. Most people who benefit from the intervention will never even be aware of the amount of work and reasoning that led to the innovation.

If we are to become innovators, we must accept our indi- vidualities and operate from three basic principles. First, we must anticipate hyperchange and accept that the world is erratic but still full of opportunities. Second, we must look for what changes are really taking place. We must observe, reflect, and confirm our conclusions with others. Third (and most difficult), we must stop ignoring ideas or events because they do not fit in our current thinking.

Today, occupational therapy practitioners may share core values, knowledge, and skills, but there can be no one right theoretical approach or perspective on practice. Innovation requires that we not accept just one set of rules. Innovators are willing to challenge past attitudes and ways of thinking. Innovators recognize that some limits to what we can do are within ourselves. Innovators reflect and create new realities, dream, and are not afraid to take chances (Rumball, 1998).

But even though we may share values, knowledge, and skills, what we do and how we do it varies in many ways. We must consider what influences our thinking and reasoning. Barnitt and Partridge (1997) studied occupational and phys- ical therapists’ reasonings. They determined that physical therapists adopted a diagnostic or procedural style, whereas occupational therapists used a narrative style. When trying to understand a client, occupational therapists are more likely to consider the social context and the client’s point of view. But while these are important, we must not let our reliance on narrative reasoning blind us from considering other options.

In fact, in some practice situations, diagnostic or proce- dural reasoning may be the most appropriate style to use. If a young client, for example, has a wrist fracture, the goal is to return functional use to the hand. The occupational ther- apist would be most effective by focusing on the diagnostic aspects and realizing that resolving those issues will lead to the client’s return to function and participation in daily life activities.

In this situation, an occupational profile is of little use in treatment planning. The critical factors are the client’s

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specific deficits and limitations. Of course, as treatment pro- gresses, ongoing evaluation of the client by the therapist will provide information to develop a profile of the person as an occupational being in his or her life context. But initially, the therapist should use procedural reasoning to obtain the information needed to develop realistic, functional, and achievable goals based on clear, baseline data.

If we see the world as static, believing that occupational therapy is limited by what we currently can do, then we will act and respond consistently with those beliefs and views. But if we stretch our viewpoints and welcome change, realizing interventions must be based on a client’s problems or needs, we will act accordingly. We can shift our paradigms.

Becoming innovators in adapting practices to meet the new realities of the world is essential to our profession’s con- tinuing development. Innovation begins by examining a sit- uation and reflecting on it from different perspectives. This reflection is critically important. We have to examine our own beliefs, values, and biases. We must look for patterns and common themes. We should confer with others more and try to understand their perceptions.

Occupational therapists tend to engage in narrative rea- soning in attempting to understand a client’s story. We can be more innovative, though, if we also try to learn what oth- ers around us think and see. Understanding a physical ther- apist’s diagnostic concerns can add to our options as we reflect on a client’s case. Repeated reflections of our own ideas will not lead to new treatment options. But reflecting on our thoughts while also taking into consideration the ideas of others will facilitate new alternatives. And talking with oth- ers who may not share our philosophical views and percep- tions of the world will expand our ideas and thus lead to even more potential alternatives.

In 1998, Barrett proposed a paradox process that he called the “recipe for life in an era of hyperchange” (p. 1). He sug- gested thinking opposite to what is conventional. In fact, he encouraged trying to think of two opposites simultaneously. These combined opposites will result in the synthesis of new and creative ideas. Let’s consider how we usually think about discharging a client. Our usual options are discharge or con- tinue therapy. In other words, one or the other.

If, however, we try to consider both at the same time—dis- charge and continuing therapy—it opens a whole new range of options. The possibilities for discharge and continuing ther- apy may become transitioning to a new setting, providing short-term outpatient therapy or home-based intervention, or continuing therapy with new priorities. Innovative thinkers consider opposites in order to synthesize new ideas.

Today, I’m going to discuss the need for innovative inter- ventions in three important areas of our profession: organi- zation, education, and practice.

Professional Organization Three organizational structures support our profession. Most notably, AOTA has wide-ranging activities at the national level. State associations (which often are less structured) have state- specific goals. And local groups offer membership support and continuing education opportunities. But are these organiza- tional structures effective? Do they really support the needs of our profession and colleagues?

Looking for innovative change here begs two simple ques- tions: If we were to create our professional association today, what would its purpose and function be? How would it be structured?

In this time of hyperchange, professional organizations must evolve and change. Activities that may have been effec- tive and important 10 years ago may not be so today. I served for 12 years on AOTA’s Commission on Practice. I chaired the commission from 1989 to 1995. It was an incredible learning experience, and I value the personal and professional relationships I made during those years. I strongly believed in the importance of our activities.

But today I question the need for some of AOTA’s com- missions. Does a professional association need governance commissions to develop papers and perform administrative functions? Do these papers and activities meet the needs of the profession and practitioners? I think our national associ- ation needs to focus its limited resources on other areas. We must recognize the difference between the profession and the professional association.

Occupational therapy, as a profession, has established a sound philosophical and theoretical base for its existence. The professional associations exist to support this profession. In a young profession, the association devotes resources to defining language, articulating a philosophical base, and educating society about the profession. As a profession matures, as occupational therapy has, the professional asso- ciation’s purpose changes to address more external issues affecting the profession.

Our associations must develop mechanisms for dealing with rapid change and shifting priorities. I believe that the professional associations need to reorganize their structures to directly support their purposes. The associations should explore smaller administrative structures that can make timely decisions. They also must support activities that pro- mote the long-term viability of the profession. They must monitor legislative and reimbursement policies. They must advocate with other organizations to support the profession’s present and future goals.

Unlike in the past, our associations do not need to direct the philosophical or theoretical development of the profes- sion. This is happening among our scholars and will continue

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to do so. The professional association’s responsibility today is to provide outlets for dialogue and the sharing of ideas from multiple perspectives.

Education To survive into the future, occupational therapy educational programs must develop clearly defined research agendas and develop timely and relevant curricula. Colleges and uni- versities across the country are increasing expectations for faculty to engage in research and scholarship. Faculty must conduct research, publish, and provide university service. Programs are expected to be integrated consistently into the institution as a whole. If a program is isolated, then it would be better doing training outside of the expensive environment of a university.

In 2002, our department at New York University (NYU) was examined as part of a systematic review of all programs in the Steinhardt School of Education. The university president clearly stated that programs can continue to exist in the research university only if they had clear research agendas and faculty who were actively contributing to the development of knowledge. He made it very clear that it was not enough for professional programs to graduate competent professionals.

For decades, our faculty have prided themselves in grad- uating outstanding, competent, and ethical occupational therapists. As the university review process began, though, we realized we needed to realign our priorities. We needed to revise immediately our research agenda and shift to focus- ing on hiring highly qualified, tenure-track faculty. And we needed to develop working relationships with faculty in other departments across the university.

In less than a year, the department faculty responded to the challenges, and we reorganized to become a better, more integrated department within NYU. While we continue to graduate competent therapists, our priorities now are con- sistent with the goals and guidelines of the university. In the future, I believe the survival of occupational therapy pro- grams in research universities will depend on our willingness today to move beyond education and include the continued development of our profession’s body of knowledge and increased collaboration with others in the institution.

I know we’re not alone in having to respond to such chal- lenges. Dr. Paula Kramer (personal communication, Febru- ary 9, 2007) from the University of the Sciences in Philadel- phia reports that faculty in her institution are expected to engage in research or activities that inform teaching. Faculty have responded by developing and implementing commu- nity-based, grant-funded service learning projects and explor- ing the scholarship of teaching. This response has been viewed positively by the university.

In the future, I believe all occupational therapy programs will have to have clearly defined research or community agen- das consistent with their college or university’s mission and goals. In all institutions, faculty will have to become inte- grated members of the larger institutional communities.

Another concern for all occupational therapy educators is to make sure that the curriculum remains relevant. Many curricula will need to be revised consistent with the educa- tional goals of the university or college. They also will need to be revised to meet students’ learning needs and styles. Ninety percent of what students learn today will be irrelevant in 5 years. Educators need to adjust curriculums to teach stu- dents how to learn rather than focusing only on skills, pro- cedures, and techniques. There also will be increased pres- sures for interdisciplinary, interactive curriculums.

Prensky (2006) observed that most educators have not prepared themselves for the 21st century. Kids entering col- lege today are the first generation to have spent their entire lives using computers, videogames, digital music players, video cams, and cell phones. A college student today has spent 10,000 hours playing video games, answered 200,000 e-mails, watched 20,000 hours of television, seen 500,000 commercials, and spent nearly 5,000 hours reading books (Prensky, 2001a).

Innovators in occupational therapy education must develop effective teaching styles compatible with the students that enter our programs. The next generation of occupational therapy students may think and reason differently because of their life experiences and because they live in a highly tech- nological world (Prensky, 2001b). They may have different learning styles that require different or new instructional methods. Occupational therapy educators need to build new, innovative curriculums based on sound teaching and learn- ing theories. Some occupational therapy educators have begun to explore new instructional methods, such as prob- lem-based learning (McNulty, Crowe, & VanLeit, 2004). But revised curriculums will need to go beyond philosophical beliefs and content concerns to include new teaching and learning theories.

In revising and developing curriculums, occupational therapy educators need to realize that there is no one correct teaching or learning theory appropriate for all students. To respond to today’s practice demands, occupational therapy graduates need to be able to reason and solve problems in a timely, efficient, and cost-effective manner. Educators should explore alternative teaching and learning theories beyond the domain of occupational therapy to develop new curriculums that give students the knowledge and skills to succeed in a rapidly changing world. Curriculums need to focus more on reasoning and problem solving and less on specific knowl- edge and intervention techniques. For example, a curriculum

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does not need to focus on learning conditions; instead, stu- dents need to learn to use resources to find relevant infor- mation in an efficient manner.

Practice Graduates of occupational therapy programs are entering an exciting but very demanding work world. Reimbursers, pay- ers, and consumers all are demanding increased accountabil- ity and documentation. Payers expect services that are cost effective and result in immediate functional outcomes. Ther- apists are under incredible pressure to increase productivity with fewer resources.

In response, occupational therapy practice has become less individualized and more routine, based on accepted treat- ment protocols. Therapists spend less time with clients and focus more on specific treatment techniques. From my per- spective, innovation in practice requires a new focus on the- ory-based intervention and attention paid to our personal and professional relationships.

It’s only natural that when a practitioner is expected to treat more patients, he or she will focus on productivity and efficiency. Some therapists will develop treatment protocols that standardize interventions based on clients’ diagnoses or conditions. Others will select a preferred treatment approach for all clients.

Take “Jane”: Jane works at a large metropolitan hospital in a rehabilitation unit. She is expected to treat six or more patients with a wide range of diagnoses each day. Patients spend an average of 2 weeks on the unit. She doesn’t have time to develop individualized treatments for each client because she feels overwhelmed with evaluations and dis- charge summaries. She has to document everything she does.

Or “Sally”: Sally is an itinerant therapist working at three different schools. She is frustrated at not having opportuni- ties to talk and work with her colleagues. She feels that the administrations do not support collaboration because it could take away from treatment times. She believes their only concern is the child’s IEP (individualized education program) completion. She feels like her treatment services are being defined by curricula and are resulting in her hav- ing to treat too many children who need help with hand- writing. She thinks principals are not concerned about the quality of interventions.

In these examples, therapists reported spending less actual therapy time with clients. Their concerns were centered on efficiency over effectiveness. They have mixed feelings about this because they value client-centered priorities but feel forced to focus primarily on productivity. To cope, they focus on establishing routine treatment protocols specific to their client’s problems. They deliver what they consider to be the

most efficient treatments. But this shift is away from attend- ing to the individual to focusing only on efficiency. Therapy becomes about protocols, techniques, and procedures rather than driven by the theory of practice.

Like medicine, occupational therapy is a science-based profession. Guidelines for interventions or frames of refer- ence are based on theories that have been developed by the scientific disciplines. As professionals, we have an ethical responsibility to provide interventions based on these estab- lished theories. A theoretical base for a frame of reference is an integrated whole. It’s not the whole theory, and it’s usu- ally developed using several theories. That theoretical base is the foundation for the guidelines for intervention.

Occupational therapy scholars and researchers must engage in applied research to establish the efficacy of occu- pational therapy frames of reference. Researchers should focus on applied research designs concerned with the prac- tical question of whether a frame of reference does what it is designed to do. Does the frame of reference lead to success- ful remediation of the problem? Applied research focuses on the validity, reliability, and efficacy of a theoretically-based guideline for intervention (Mosey, 1996). The challenge for occupational therapy scholars and researchers will be to develop research protocols acceptable to the scientific com- munity. We must look beyond the criteria set by basic research to obtain evidence supporting the efficacy of our interventions.

Theory-based interventions are critical. Society grants occupational therapy practitioners the right to practice because of our expertise and unique skills. We must, then, be able to provide society with evidence supporting our exper- tise. We must be able to provide theory-based interventions built on valid theories. Would you go to a doctor who gave you medication but could not tell you what to expect? Of course not. Likewise, occupational therapy practitioners should be able to inform clients about possible outcomes of an intervention. We can do this only when our interventions are based on solid theories, which give us the knowledge we need to make educated predictions.

Theory-based frames of reference direct how we then use our therapeutic modalities and techniques. For innovation, practitioners must apply treatment techniques or modali- ties as they are directed through theory-based frame of ref- erence. A theoretically based frame of reference describes how a specific modality will be applied and under what conditions based on a client’s needs. Practitioners should look beyond modalities to ensure that they are consistent with valid theories.

A therapist’s conscious use of self, a basic modality in almost all treatments, varies depending on how the theory guides the therapist to interact with a client and the envi-

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ronment. A therapist applying a frame of reference based on Bandura’s (1977) social learning theory, for instance, would apply the conscious use of self by modeling and reinforce- ment. But a therapist applying the neurodevelopmental frame of reference would use physical handling and social interactions.

Providing competent and effective interventions is a chal- lenge for any occupational therapy practitioners given today’s rapidly changing service delivery models and treatment envi- ronments. Society, payers, and consumers are demanding that practitioners describe the specific outcomes of interven- tions. Innovation in treatment means that all practitioners must now be able to explain a theory that underlies a frame of reference. Just as we expect doctors to tell us what the effects of a medication may be, consumers and payers expect occupational therapists to be able to explain rationales for intervention and what outcomes might result. Innovation also demands that therapists look for new theories and develop new frames of reference or guidelines for interven- tion. Some may need to be modified based on revised theo- ries and still others with questionable validity may no longer be appropriate to use. New or revised frames of reference or guidelines for interventions must address the needs of clients in today’s world.

Athena Tsai, an NYU occupational therapy student, developed a frame of reference in 1996 called “Patient’s Acceptability of Using Humor for Pain Relief.” In exploring the literature, she discovered McCaffery’s (1979) theory of reducing pain with humor. After developing this frame of reference, she studied its viability in a nursing home with clients who were experiencing upper-limb pain. All five of her participants found that humor—in this case, telling a Reader’s Digest joke—created a joyful atmosphere and reduced their pains. This new frame of reference has great potential for older clients with chronic pains. It innovatively addresses both the physical and psychological needs of its target population.

Being innovative in occupational therapy does not mean always turning to the latest techniques or strategies. It means addressing the basic concerns that underlie practice. We must provide interventions that will address the wide range of activities people participate to give their lives meaning. Take self-care and personal hygiene, for example. Yes, they are rou- tine and not very glamorous, but they are important for human dignity. Innovators will realize the value of these important human activities and ensure that they remain a treatment priority. Innovators will ensure that these inter- ventions are treated as relevant and meaningful to clients. A person’s ability to complete self-care determines his or her ability to participate in society. We should rethink how we address self-care. Occupational therapists often spend time

working with a client on his or her ability to complete spe- cific self-care tasks out of context. Shifting goals from a client’s ability to do self-care to a focus on a client’s partici- pation in society may change interventions. The innovation is in addressing a client’s needs in the context of society today.

The need for innovation in our professional organizations, educational models, and practice strategies is obvious. But what about our basic interactions, like sitting with a client, meeting a coworker in the hall? Anne Cronin Mosey (1981, 1986) argued that therapists can only create environments for change; they can’t change a client directly. A skilled occu- pational therapy practitioner uses himself or herself with other tools to create situations that encourage positive change. Fundamentally, this therapeutic use of self is core to occupational therapy practice. Occupational therapy occurs in our interactions with clients and colleagues. It’s the nature and scope of our modern relationships that makes becoming innovators so difficult. Today, practice innovations have to be constructed to take place within our rushed workplace inter- actions. As a profession that values the person and personal choice, our innovations must address our relationships with others.

Transformational thinking in innovation highlights the importance of human behaviors and interactions with others. To be effective, relationships should be fostered on under- standing and respect as professionals. A relationship-oriented approach to living allows us to come up with new and dif- ferent solutions in our rapidly changing world.

To become person-centered, reflect on the following ques- tions: What would your colleagues, patients, and people you care about say about you? What characteristics would you like to have? What contributions do you make to your fam- ily, friends, clients, people you work with, and all those you cherish in your life? What difference would you like to make in the lives of others? We cannot truly separate our work lives from our personal lives. And we can’t let our work dominate our free time.

In this time of hyperchange, it is so important that we rec- ognize the value of personal and professional relationships. In our daily efforts to get everything done, we may not be giving enough attention to developing and maintaining rela- tionships. It is too easy to lose contact with others or to com- municate in impersonal methods such as e-mail, text mes- sages, or voice mail. And yet, relationships are essential to being innovative and to having a satisfying personal and pro- fessional life. Without such connections, we will not have the support systems we need to respond to the stresses of hyper- change. No innovation can be realized if others don’t recog- nize and accept it as well.

Occupational therapists need to re-examine practice. Interventions are changing. Service delivery models are

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changing. Expectations for outcomes are changing. And, at the very heart of it all, the relationships we have with others are changing and often at the expense of productive collab- oration. We must find efficient ways of establishing rapport with other therapists and work for the benefit of clients. Our goal should be to have interactions that enhance interven- tions and effectiveness. “We” are the only part of the rela- tionship that we can be responsible for. We need a paradigm shift in how we view our modern interactions.

We can redefine collaboration in this time of hyperchange. We must make a personal commitment to work in partner- ship with others. We also must welcome change as a chal- lenge, not a burden. We should embrace innovations, prac- tice flexibility, and take time to reflect on practice.

Recognizing change as a challenge means we need to rec- ognize that we often feel overwhelmed with new knowledge, technologies, and busy schedules. Think about and remem- ber the strategies and skills that you have. Acknowledge your strengths. Learn to enjoy the challenges of change. And finally, manage change; don’t let it manage you.

Innovation is, of course, essential for positive change. It includes advancing knowledge, modernizing techniques, and developing new technologies. A major responsibility for a professional is to translate these innovations to practice. Each of us must make sure that occupational therapy innovations are used to improve the lives of the clients we serve. Embrac- ing innovation will ensure competence and improve prac- tices. Embracing innovation ensures that we use innovation for good rather than becoming a victim of it.

There is a tendency today to increase regulations and develop policies to try to control our world. We create rules and rigid procedures. We start looking for efficiency over effectiveness. But when we become rigid and structured, we lose the ability to respond to an individual as a person. Devel- oping flexibility in thinking and action will help us respond to these tendencies.

When you take time to reflect on your practices and actions, you can learn from what you’ve done and improve on who you are. Thomas Paine wrote that “The real man smiles in trouble, gathers strength from distress, and grows brave by reflection.” Reflection is the one tool we have to improve our relationships with others. We are a part of a pro- fession that cares about people. We care about the individ- ual. We work to put people back in control of their lives. We must make the time to reflect on all of this.

The scope of occupational therapy practice has expanded over the years in response to changes in society and the needs of consumers. It also has changed in response to the demands and expectations of payers. Managed care, hospital-based programs, and home-based and education-based services each have their own cultures of interactions and communi-

cations. Systems delineate a person’s professional responsi- bilities and the kinds of relationships that are appropriate.

Nevertheless, we still can find effective ways to establish relationships with colleagues and ways to work together for the benefit of our clients and ourselves. Our goal must be to foster interactions that enhance interventions and treatment effectiveness. While working together, we must act consis- tently with our professional responsibilities, supporting our profession’s values and scope of practice. Use self-reflection to promote your competence. Become comfortable with inter- professional conflict. There is no single “right” way to resolve a conflict. Consider the disadvantages and advantages to each action. Remember the principles of a fair argument. Stick to the issues; don’t attack the person. And always remember that your position may not be the best or only option.

As occupational therapy practitioners today, we often pride ourselves in our ability to adapt. But, at this time in our history, we are uniquely challenged. Today many people still do not understand what occupational therapy is. As all pro- fessions, we are evolving and changing with society. We must clearly explain to society what we contribute, and we must provide evidence that supports that our interventions are effective.

But many occupational therapy scholars and researchers continue to focus primarily on the philosophical underpin- nings of the value of occupation rather than on establishing specific, effective interventions. When we have evidence that interventions are not effective—such as sensory integration (Mulligan, 2002; Pollock, 2006; Shaw, 2003; Vargas & Camilli, 1999)—we argue that the studies are invalid rather than working to change our interventions. I’m not saying that we should abandon sensory integration, for instance, but I think we may need to modify the frame of reference to assure its efficacy.

Conclusion We live in exciting and challenging times. Occupational ther- apy practitioners must respond to rapid and unpredictable change. We must become innovators to meet our responsi- bilities as therapists and as individuals. Our profession’s future depends not on what AOTA develops but on how each of us creates lives as modern professionals. The future of occu- pational therapy is in our control. I challenge you all to become innovative, reflective practitioners who embrace life in an era of hyperchange. It is time to plan ahead and think fast. ▲

Acknowledgment I thank Catherine Hensly for her editorial assistance.

636 November/December 2007, Volume 61, Number 6

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The American Journal of Occupational Therapy 637

Evaluation: Obtaining and Interpreting Data 2nd Edition

Edited by Jim Hinojosa, PhD, OT, FAOTA; Paula Kramer, PhD, OTR, FAOTA; and Patricia Crist, PhD, OTR/L, FAOTA

This 2nd Edition equips students and therapists with broad knowledge for evaluating clients, reflecting current knowledge and best practices in occupational therapy relative to evaluation and assessment. This much-needed single resource on the occupational therapy evaluation process offers a comprehensive view of the evaluative process, including screening, evaluation, reassessment, and reevaluation.

Order #1174B-J $55 AOTA Members $79 Nonmembers

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ISBN-13: 978-1-56900-209-4 ISBN-10: 1-56900-209-6

315 pages, 2005 B

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