Chapter 17: Occupational Therapy
Libby Callaway; Gabrielle Brand; and James Bonnamy
Uncertainty in Occupational Therapy
Occupational therapy is a person-centred health profession with the primary focus of enabling people to participate in the activities or occupations of everyday life. This is achieved by ‘working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement’ (World Federation of Occupational Therapists, 2012, para. 1). Occupational therapy theory recognises the dynamic interaction of the person, their environment, and the activities or occupations they undertake, and how these factors may impact human activity and performance (Baum et al., 2015).
Occupational therapists work with people of all ages and abilities. They work across various settings, including institutional environments (e.g., healthcare, disability, or aged care services) and community contexts (e.g., homes, educational settings, or workplaces) within which people engage in their everyday occupations. With services being delivered across this range of diverse environments, contemporary occupational therapy practice must have a strong focus on person-centred choice and control and on human rights (World Federation of Occupational Therapists, 2019), and it must work to address systemic injustices (Hammell, 2013). This foundational focus on rights-based practice enables occupational therapists to move beyond the binary of clinician and client or patient and to shift power to a collaborative partnership approach (Layton et al., 2022).
Globally, occupational therapy as a profession holds central the premise that ‘humans are occupational beings, that human occupations occur in social and environmental contexts, and that an occupational lens can be used to work toward an occupationally just society’ (Malfitano et al., 2019, p. 300). However, evidence-based clinical guidelines for some interventions provided by, or practice contexts of, occupational therapists are lacking. For example, assistive products and services are common interventions recommended by occupational therapists (Layton et al., 2023). However, a recent review of clinical practice guidelines specific to adults with progressive or complex conditions demonstrated that only 7% of these guidelines referenced assistive technology interventions and, where such references did exist, recommendations were most often general in nature (Callaway et al., 2025). Following, specific to occupational therapy practice context, in non-urban services researchers have discovered that practice guidelines that exist may favour ‘individualist rehabilitative strategies provided by [occupational] therapists remote from the client’s context’ (Hayes et al., 2023, p. 119). The profession’s scope of practice is both broad and individualistic, and in some practice areas, occupational therapists have the broadest scope of any healthcare practice, and it can challenge even the most experienced practitioners (Layton et al., 2023; Wimpenny & Lewis, 2015). While the World Federation of Occupational Therapists (2022) offers guiding principles for professional competency which span behaviours, knowledge, values, and attitudes that occupational therapists bring to their practice, various sources of uncertainty exist within occupational therapy practice.
For some time, it has been recognised that occupational therapy raises uncertainty for practising clinicians because of the ‘very nature of working with inexact health sciences in human contexts and because of the rapid changes constantly occurring in the health sciences’ knowledge, practice and technology’ (Higgs & Titchen, 2001, p. 526). Occupational therapists work at both community and individual levels, and they undertake assessments and interventions specific to the person, their environment, and/or their specific occupations; uncertainty can arise across all these domains (Dunn, 2017). At a systemic level, over recent decades there have been significant reforms across healthcare, disability care, and aged care, which are all practice areas for occupational therapists (Burkhauser et al., 2014; World Health Organization, 2015). In the Australian occupational therapy practice context, these reforms have been coupled with important government inquiries which have made a number of recommendations for changes to the ways services – including health professions like occupational therapy – are designed and delivered (Royal Commission into Aged Care Quality and Safety, 2021; Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability, 2023). Broadening to a global practice context, occupational therapists contribute to the realm of social action beyond healthcare, including, for example, working to help people mitigate and adapt to the changing climate (Du et al., 2024; Hess & Rihtman, 2023; Malfitano et al., 2019).
The systemic reforms mentioned above have led to further uncertainty for both service users engaging with healthcare, disability care, or aged care services and occupational therapists and other healthcare professionals working within these systems. In occupational therapy, uncertainty has been driven by the need for rapid learning of new policies and processes in new-graduate practice; changes to the ways occupational therapy is funded and delivered; and both curriculum and professional development needs that can be time-intensive and complex (Barclay et al., 2020; Calderone et al., 2022).
The COVID-19 pandemic further heightened uncertainty and stress for occupational therapists (Müllenmeister et al., 2025). Uncertainty spanned issues relating to personal health and safety, implementation and enforcement of public health protocols, and ways to achieve continuity of quality occupational therapy care across the broad spectrum of practice (VanPuymbrouck & Friedman, 2024). Furthermore, occupational therapists’ increasing role in the treatment of emerging conditions, when coupled with a lack of evidence-based information and consistent guidelines, has been found to create clinical uncertainty for therapists (Müllenmeister et al., 2025). More broadly, while ‘uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education’ (Strout et al., 2018, p. 1518), the highly individualised nature of occupational therapy practice means uncertainty can occur across all stages of the therapist’s engagement (Layton et al., 2023).
Priorities to Prepare Learners for Uncertainty in Occupational Therapy
The changing role of contemporary occupational therapy practice is often coupled with varied goals and needs of service users engaging with occupational therapy services. The dynamic influence of both the environment and the multiple systems in which people with health, disability, and age-related conditions interact means that developing skills to manage uncertainty should be prioritised in progress towards graduate occupational therapy practice (Dancza et al., 2019). Adding to this, the growing role of and demand for occupational therapists are well recognised in the care and support sector internationally (Australian Health Practitioner Regulation Agency & National Boards, 2020; Burkhauser et al., 2014; World Health Organization, 2015). This has been further stimulated by government and civil society investment in health and community services for people with disability, an enhanced focus on human rights across the lifespan, and an ageing population also experiencing increasing disability (United Nations Convention on the Rights of Persons with Disabilities, 2006).
While systemic and practice reforms, including role-emerging opportunities, can lead to uncertainty for occupational therapists, these changes also offer opportunity for the profession (Dancza et al., 2019). Occupational therapy’s core concepts, which focus on human occupation, may offer new treatment options and strategies for managing emerging conditions (Malfitano et al., 2019; Müllenmeister et al., 2025). Given the contemporary practice environment, occupational therapy near and new graduates require developing capability to problem-solve (Dancza et al., 2019); to embrace appropriate levels of risk while enabling individual choice (Royal College of Occupational Therapists, 2018); and to manage uncertainty while working with people whose needs intersect with the healthcare, aged care, or disability support systems (Wimpenny & Lewis, 2015).
Fostering Uncertainty Tolerance in Occupational Therapy Learners
The longstanding concept of ‘nothing about us without us’ stems from the disability rights movement and highlights the need for service user co-design (Charlton, 1998). ‘Co-design brings together lived experience, lived expertise and professional experience to learn from each other’ and leads to co-production with people of all abilities to align with the needs, values, and expectations of health and social care (McKercher, 2020). Co-design methodologies are increasingly recognised as important in the field of occupational therapy to shift power imbalances that may otherwise exist (Layton et al., 2022) and engage end users in decision making about service design and improvement in health or social care (McKercher, 2020; O’Brien et al., 2021). Uncertainty can arise for occupational therapy learners with this necessary power shift, and thus foundational occupational therapy skills are required that focus on person-centred approaches and management of uncertainty (Hammell, 2013). Implementation of the activity described in this chapter requires both educators and learners to proceed without the judgement or power dynamic that may traditionally shape occupational therapists’ clinical reasoning and approaches to practice.
The use of co-designed photographic portraits and personal narratives to explore and challenge concepts of the person, their context, and the activities they value can be one way of strengthening current and future healthcare professionals’ reflective capacity (Brand et al., 2016). This includes creating an immersive approach to aid the power shift required in a contemporary collaborative partnership approach (Layton et al., 2022). The exemplar activity in this chapter draws on innovative visual narrative portraits co-designed by service users with health professional researchers. These portraits can offer alternative, and at times more inclusive, ways of representing diverse perspectives, informing person-centred approaches and shifting power relationships (Brand, Sheers, et al., 2021). The aims of the exemplar activity are to assist learners to sit with and accept uncertainty when engaging with a person’s portrait; to challenge learners’ assumptions of lived experience; to reframe healthcare professionals’ perspectives for working with people within a range of contexts; and to inform the co-design of interventions linked to each person’s goals rather than to assumptions that rapidly drive the direction of occupational therapy practice.
Co-created visual narrative portraits infused with personal artefacts can be utilised to convey deep meanings that transcend traditional teaching and research methods, challenge assumptions and/or unconscious biases, and stimulate reflective discussions (Brand, Wise, et al., 2021). The exemplar activity provides the opportunity to link critical learner reflection (moderator: reflective learning) to the domains of the individual person, their physical and social environments, and their meaningful occupations while informing approaches to person-centred occupational therapy and interdisciplinary allied health practice.
As mentioned above, the visual portraits depict people with lived and living experience of rehabilitation, ageing, disability, and/or independent living. Drawing on the five core principles of co-design (inclusive, respectful, participative, iterative, and outcomes-focussed), the powerful images have been co-produced to represent diverse lived experience perspectives. The portraits aim to focus learners on using visual thinking strategies to sit with uncertainty, challenge their personal – and also broader societal and professional – assumptions, and explore concepts of health and rehabilitation, age and healthy ageing, and disability and independent living from the perspective of people with lived and living experience.
Exemplar Activity: Visual Thinking Strategies
Activity Origin
The portraits reproduced here form part of a larger open access education package which represents diversity of culture, ability, age, gender, and sexuality and can be used entirely online, in face-to-face teaching, or in a hybrid manner. The larger package was developed as part of preliminary work in use of co-design processes to develop the mission and vision of the Rehabilitation, Ageing and Independent Living Research Centre at Monash University, Melbourne. It is available to educators on request to the first author.
It is important to note that the subset included here does not represent cultural diversity. This should be closely considered by educators, who may wish to draw on other chapters in this handbook or other resources to expand their teaching activities to represent culturally safe and respectful occupational therapy practice. For learners or educators who are blind or have low vision, alternative text has been provided for each portrait.
Sources of Uncertainty
Visual thinking strategies can be used to generate uncertainty for discussion. Task 1 in the activity introduces the concepts of visual thinking strategies in class or via online facilitation and encourages learners to practise the strategies with a narrative portrait featuring an older adult leading a group exercise program. The task has been deliberately designed to challenge learners to consider their own personal backgrounds, experiences, values, and attributes; to surface and own their personal biases; to explore concepts of uncertainty; and to foster uncertainty tolerance using visual thinking strategies in various ways. Task 2 involves learners applying visual thinking strategies in class or via online facilitation to explore concepts of rehabilitation, ageing, and independent living from the perspective of four people who have lived experience of these circumstances.
The activity deliberately does not provide context or information about the photographs before the learners see them. Labelling leads thinking, and even the year or name of the picture can influence reading of the photograph (and the person in it). Without these details, learners are free of any constraints and must rely on the evidence in the image. Learners are also encouraged to consider that there is no right or wrong answer and that thoughts will be guided by learners’ own personal and/or professional experiences and readings of the portraits. When others are describing their thoughts, learners are supported to listen and reflect, rather than speak, even if they disagree or have different opinions (moderator: psychological safety). The aim is for learners to pay attention to details they may otherwise have overlooked.
Facilitator Guide
In this activity the following learning objectives are addressed:
- Apply visual thinking strategies to challenge assumptions and manage uncertainty in healthcare, aged care, and disability care.
- Learn to question assumptions held about people who engage in rehabilitation, ageing, disability, and independent living support through visual thinking strategies.
- Explore what service users think enables them to live a life that they choose.
- Identify why service users want to be liberated from deficit framing which disempowers them.
Visual literacy includes the ability to critically create, analyse, use, and share visual information; however, despite seeing hundreds, even thousands, of images and photographs every day on traditional and social media, we can encounter barriers to visual literacy (Thompson et al., 2022). As so much information in practice is delivered visually, it is vital to support health professions learners to develop the skills to be discerning, questioning, curious, and sceptical. Therefore, rather than viewing images as ‘certain’, this activity supports learners to understand where ‘uncertainty’ may arise and need to be considered.
The goal of the activity is to cultivate reflective discussions and challenge assumptions or potential for unconscious biases in occupational therapy learners. Facilitators should aim to enable learners to experience both uncertainty in their own knowledge and new ways of seeing and hearing individual perspectives that can be used to inform their practice in more person-centred ways.
The activity comprises two standalone tasks built in the Moodle learning management system and includes interactive HTML5 Package plug-ins. This approach makes it easy to create, share, and reuse interactive teaching and learning resources. The learning resource required is either a data projector for the facilitator to share the digital content on screen with the whole group or a laptop or desktop computer, mobile tablet, or phone for each individual or pair of learners.
A model of paired learning is used in the activity, and the tasks as described here are undertaken by learners in pairs and in large groups. However, they could also be undertaken individually and in small groups, with a suggested minimum of eight learners for the latter (to aid group reflection). The activity is targeted at learners in their first year(s) of study, but it could also be useful for near-graduate reflection in preparation for practice. Learners don’t need to be homogenous, and the activity could be undertaken with learners from different health professions (moderator: diverse teamwork).
Reflection prompts for both tasks are provided below.
Prompts to Aid Reflection on Portraits
Spend some time studying the portrait, then consider the following questions.
Description
- What is going on in this portrait?
- Who is this person?
- What are they doing?
- Is there an emotion in the portrait?
- Why was the photograph taken?
- What do you see of the physical, social, and attitudinal environments?
Interpretation
- What objects (human or inanimate) can you see in the portrait? What might they mean to the person? Might they link to occupations that have meaning to the person? Give reasons for your responses.
- What is the mood or feeling?
- What is the person’s story?
- Who took the photograph? What is the relationship between the person and the photographer?
- Why was the photograph taken? Why was it taken of this person at this location?
Imagination
- What more can you find? What else do you wonder? What would you hope to find out?
- What would you ask the person?
- Why do you want to know these things?
Prompts to Aid Reflection on Narratives
Read the narrative, then consider the following questions.
Description
- What is going on in this portrait?
- Who is this person?
- What are they doing?
- Is there an emotion in the portrait?
- Why was the photograph taken?
- What do you now know about the physical, social, and attitudinal environments?
Interpretation
- What symbols can you see in the portrait? What might they mean to the person? Do they link to occupations that have meaning to the person? Give reasons for your responses.
- What is the mood or feeling?
- What is the person’s story?
- Who took the photograph? What is the relationship between the person and the photographer?
- Why was the photograph taken? Why was it taken of this person at this location?
- Can you identify how the ideas you had about the portrait relate to your own background, previous experiences, or knowledge (personal and professional) that you bring your interpretation?
Imagination
- What more can you find? What else do you wonder? What would you hope to find out?
- What would you ask the person?
- Why do you want to know these things?
Task 1: Joy
This task will require up to 60 minutes to complete.
The activity commences with all learners collectively viewing a two-minute video, Visual Thinking Strategies, which introduces the concept of the approach.
Learners are then invited to choose a peer to work with for completion of the task. The educator communicates to learners that the task may stimulate uncertainty and may therefore pose challenges (moderator: setting clear expectations).
Learners work in pairs to step through the online activity Practice Visual Thinking Strategies. The portrait of a person, Joy, leading a group exercise class for older adults is presented visually.
Learners spend some time looking at the portrait, exploring all of its elements. The accompanying text encourages learners to enlarge the picture to see more detail, including personal artefacts. Reflective prompts and inquiry are offered (see Prompts to Aid Reflection on Portraits), and the paired learners work together to discuss and note their responses (moderator: reflective learning).
After approximately 15 minutes of paired exploration, learners share their reflections with the whole group. All learner contributions are accepted and considered neutrally by the educator, so that the group can learn from the perspectives of others (moderator: pastoral care).
Joy’s Narrative
“Our gym is our Joy”, wrote one of Joy’s active ageing group members.
Legs pistoning, music playing, hearts pumping…faces change from neutral to awake!
Joy knows how strong bodies, minds and social connections are key to ageing well. Four times a week, Joy runs the Active Ageing class bringing older people together to collectively reach, twist, lift, balance, strengthen and dance. Sometimes to ‘Nutbush City Limits’ or ‘Time Warp’ moving to the old-time favourites of the 60’s and 70’s, music is a key motivator.
Joy, who is now in her 7th decade of life, has been Monash University’s active ageing fitness instructor for the last 13 years. For Joy, it’s all about balance, strength, fitness, friendship and having fun. Driven by her passion to reach out and find older invisible people in the community, she wants RAIL to provide the resources to improve older people’s lives.
Finally, Joy’s narrative is presented. Learners are invited to return to their pairs to read the narrative and, using the Prompts to Aid Reflection on Narratives, to reflect on how their answers differ from the answers they gave before they read the narrative. After approximately 15 minutes of paired activity, learners are invited to share their reflections with the whole group once again.
To close the task, the educator can encourage learners to consider how their ‘ways of seeing’ (Brand et al., 2016) changed after they were provided with Joy’s narrative. Additionally, educators can discuss how both observing and listening to lived experience – considering the person, their environment, and the activities that are important to them – enable more holistic occupational therapy practice and can challenge positionality or unconscious biases that can prevent delivery of person-centred – and family-centred – care.
Task 2: Peter and Bernadette, Caleb, and Emma
Figure 17.1 Narrative Portraits of (l–r) Peter and Bernadette, Caleb, and Emma. Contributed by Peter and Bernadette, Caleb, and Emma
This task will take up to 90 minutes to complete (30 minutes per portrait). Although this might sound like a lot of time for ‘looking’ at portraits, the aim is to stimulate, through skilful facilitation, in-depth discussion that links back to the learning objectives. The group discussions are where the learning takes place, as learners share and question their individual perspectives (moderator: reflective learning).
Peter and Bernadette, Emma, and Caleb are introduced via their portrait images (Figure 17.1). Various objects, or artefacts, can be seen in each portrait, but no information is provided beyond each contributor’s first name. To begin, for each portrait, paired learners are invited to describe, interpret, and imagine the person using only the portrait image and the Prompts to Aid Reflection on Portraits. Learners are then asked to share their thoughts about each portrait with fellow learners in a group-based activity (moderator: peer teamwork).
Learners return to their pairs to hear from Peter and Bernadette, Caleb, and Emma through their written narratives. They will see how these people focus on their strengths and opportunities offered through personal experiences, staying connected, and living their lives. The paired learners are invited to use the Prompts to Aid Reflection on Narratives and then to discuss their thoughts with the larger group.
Impact
The activity was developed and implemented in the School of Primary and Allied Health Care at Monash University, Melbourne. The visual thinking strategies and narrative portrait tasks were evaluated informally through piloting and observing their impact on our health professions educator colleagues. While we are preparing to deliver the activity in the classroom as part of core curricula, initial feedback from allied health colleagues included the view that the activity achieved a ‘good balanced mix of messages and media’ and a suggestion to include Aboriginal and Torres Strait Islander voices.
We anticipate that learner responses to this activity will be varied, based on individual and occupational therapy–specific experiences, as well as moderators that shape learning (e.g., age, gender, cultural background and diversity, social context, and life experiences). The aim of the activity is to build in learners an individualised and inquiring approach to understanding each person’s lived experience. Given this is a new learning package, it is yet to be adjusted over time. Some potential approaches to adaptation are, however, provided below.
Adaptations and Summary
Given occupational therapy focuses on the person, their environment, and the occupations they undertake or that have meaning for them, the exemplar activity outlined in this chapter could be developed to move beyond visual exploration of narrative portraits and to use of other visual learning strategies, such as the Human Library (https://humanlibrary.org/) or online interactive learning game spaces like My Home Space (https://www.myhomespace.org/). The activity could also be expanded into paired interdisciplinary learning opportunities, meaning learners consider not only the occupational therapy and lived experience perspective but also the variations in other health professions’ perspectives that occupational therapists may encounter in team-based care models.
The most important consideration in the implementation of the activity is creating a safe and non-judgemental space that allows authentic exploration of what each learner views as occurring in the images versus the truth offered by the narratives describing the lived experience of the portrait contributors.
Conclusion
Occupational therapists are required to draw on strategies that enable them to problem-solve, think critically, and willingly and confidently manage uncertainty when working in complex systems (Wimpenny & Lewis, 2015) and in broad and individualised ways (Perkins et al., 2020). This chapter presents the use of narrative portraits and visual thinking strategies as methodologies in occupational therapy education to foster uncertainty tolerance. The aim is to allow learners time for exploration of, and reflection on, individual lived experience of rehabilitation, ageing, disability, and independent living as areas of occupational therapy practice. Strengths-based approaches also offer consideration of the person, the activities or occupations which have meaning to them, and the contexts or environments in which that person completes their daily occupations (Baum et al., 2015). The narrative portraits widen the view of rehabilitation, ageing, disability, and independent living, demonstrating how co-creative approaches can produce valuable experiential knowledge and new meanings that provoke reflection both within the field of occupational therapy and across health professions.
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About the authors
name: Libby Callaway
name: Prof Gabrielle Brand, RN, BN, MN (Research), PhD, SFHEA
institution: Monash University
website: https://research.monash.edu/en/persons/gabrielle-brand
Gabrielle is a Registered Nurse and Professor in the School of Nursing and Midwifery in the Faculty of Medicine, Nursing and Health Sciences at Monash University, Victoria, Australia. Her academic interests include narrative medicine, health humanities, planetary health, creative and critical
pedagogy with a focus on co-designing health professions education with healthcare consumers. Gabrielle is co-founder (with author Steve Wise in Chapters 9 & 11) of ‘Depth of Field’ ©, a growing body of health humanities research that draws on healthcare consumers voice (narrative) and art
(narrative portraiture, artefacts & visual methodologies) to co-design strengths-based, consumer driven resources for widespread use in health professions workforce education.
name: James Bonnamy, MNurs, GradCertHlthProfEd, BN(Hons), BNurs, RN, FHEA
institution: Monash University
website: https://www.monash.edu/medicine/nursing/about/staff/james-bonnamy
As a health professions education Research Fellow in the School of Nursing and Midwifery and a Teaching Associate in the Department of Paramedicine at Monash University, James often works with learners who want to know the ‘right answer’. But in healthcare, the right answer is often elusive, and due to human characteristics and interpersonal variations, the ‘right answer’ is not always the same. James’ education research focuses on developing learner uncertainty tolerance in clinical learning environments, where he sees first hand learner tolerance of uncertainty in his role as a Clinical Nurse Specialist. With a strong co-design health professions education research focus, James has won multiple awards including the Head of School (Nursing and Midwifery) Award for Excellence in Education in 2016.
