The impact of COVID-19 restrictions on the delivery of occupational therapy: How technology use affected practice during COVID-19 among occupational therapists in British Columbia
Funding information: This study was not funded directly by any source. This research was undertaken with in kind efforts provided through in person hours by the Canadian Association of Occupational Therapists British Columbia.
Abstract
Introduction
COVID-19 activity restrictions altered clinical practice around the world. Anecdotal evidence observed by the Canadian Association of Occupational Therapists – British Columbia (CAOT-BC) suggested a rapid adjustment to virtual care technologies occurred among occupational therapists in the initial restrictions. The purpose of the study was to determine the scope of how COVID-19 restrictions impacted the use of technology to provide client care in British Columbia. It will inform the future provision of occupational therapy in the developing technological landscape related to heath care provision.
Methods
This descriptive cross-sectional survey was completed using Qualtrics, an online survey tool. Registered occupational therapists received the survey via email invitations. The data were analysed using descriptive statistics in IBM SPSS Software.
Results
Of 342 participants, 98.4% reported increased technology use to support practice with the advent of COVID-19 restrictions. Those with some technology experience prior to COVID-19 reported higher intent to continue using technology following COVID-19 restrictions. Overall, occupational therapists were confident in their perceived abilities to use technology in their practice. Occupational therapist-related, client-related, and practice area considerations occurred with the rapid uptake of technology. Some components of practice were perceived to be improved and others impaired with the use of technology.
Conclusion
Occupational therapists substantially increased their use of technology to enable ongoing client care during the Covid-19 restrictions. Implications for improvements and reduction of limitations in care delivery are substantial, given the intent to continue using technology going forward. These implications can be further explored to understand how the advances in occupational therapists' ability to use technology may impact rural or remote care, which practice areas may be most amenable technology use, and how policies and funding can facilitate effective and appropriate use of technology to support clinical care in public and private settings.
Key Points for Occupational Therapy
- Technology to support telerehabilitation can be widely used to deliver occupational therapy.
- Some components of occupational therapy practice are more amenable to telerehabilitation delivery than others.
- Education and access are important considerations to support clients and occupational therapists' use of technology for care.
1 INTRODUCTION
On 11 March 2020, the World Health Organization (WHO) declared a COVID-19 pandemic. Countries around the world implemented various public and social measures to limit the spread of COVID-19. In British Columbia, these restrictions included limitations to in-person health-care service provision. On 23 March 2020, the Provincial Health Officer provided a statement that defined the expectations of health professionals in the province (Henry, 2020). The expectation was that all ‘non-essential and elective services involving direct physical contact with patients and clients should be reduced to a minimum’ (Henry, 2020, p. 1) and that health professionals provide care to clients via telephone or video technology. The College of Occupational Therapists of British Columbia (COTBC) followed with a guidance document specific to the impact of the Provincial Health Order document on occupational therapy practice. In this document, it was outlined that ‘in-person community occupational therapy services should be suspended unless they are deemed to be urgent services’ (College of Occupational Therapists of British Columbia, 2020, p. 1). Primary funding sources for community-based private occupational therapy quickly released policy statements that would allow funding for virtual therapy, primarily including phone and video-based sessions. This pattern of health service provision mirrored trends in other jurisdictions around the world. In the United States, telemedicine visits were seen to increase as in person visits declined; the peak use of telemedicine during this initial wave was in April 2020 and started declining the week of 10 June 2020 (Patel et al., 2021). Physiotherapists in Ontario also were seen to transition quickly through a substantial change to their practice to providing all or at least a portion of their services through telerehabilitation versus in person (OPA Survey Report, 2020). Studies of how this transition affected other allied health providers and their clients have not been completed to date in British Columbia. This study aims to understand how this rapid change occurred in the occupational therapy community in British Columbia and what the potential implications for future provision of health-care delivery in British Columbia.
Occupational therapists have often used common technologies in their practice to support particular components of care provision or occupational support for the clients they work with. This type of general technology use includes mobile phones, digital photography, computer games, the Internet, e-mail, work-based programs, online education, online shopping, and banking (Hills et al., 2016). Feasibility studies looking at the potential utility for specific assessments in occupational therapy have shown that the use of technology can be useful for primarily for assessment (Stillerova et al., 2016). Aside from research studying specific aspects of the occupational therapy process, there is a gap in literature focussing on the use of technology to provide access to clinical practice in general. There is minimal literature on the type and magnitude of clinically focussed technology uptake by occupational therapists as was required during the initial stages of the pandemic and how technological adaptation during this period may shape occupational therapy in the future.
During the initial stages of the COVID-19 pandemic, the general population pivoted to the use of a variety of technologies to further support day to day activities, especially during the widespread social health measures and activity restrictions that resulted in home-based lockdowns. Occupational therapists, and all health-care providers, were required to find ways to continue providing care for clients outside of in-person contact with exceptions only for the most severe cases. Adoption of additional forms of technology, and adaptation to new types of technology to support telerehabilitation, was required of practitioners in a short time frame. Telerehabilitation, also known as virtual care, is described in the Ontario Physiotherapy Associations Survey Report (2020) as the delivery of professional rehabilitation services at a distance using telecommunications technology as the service medium delivery method. This definition is used for the purpose of this study where we describe occupational therapists' adaptation to the use of telerehabilitation during the pandemic. The purposes for the use of technology for practice both before and after the onset of COVID-19 is also explored. Practice areas are defined by funding sources, groups of clients served, and regions that clients live in. Given the relatively short period of time that this change has occurred, there is minimal literature on the type and magnitude of technology uptake by occupational therapists, for which components of their practice, barriers, and facilitators of use and how technological adaptation during this period will shape occupational therapy in the future. The objective of this study is to support a better understanding of occupational therapists' technology use prior to the onset of COVID-19 and to describe the uptake and changes in technology use by occupational therapists to provide care. Further implications for the potential changes to practise in the future are also discussed.
2 METHODS
To address the study objective, a survey using Qualtrics© was implemented. The survey was piloted with five individuals who provided feedback on the content (questions and responses), flow of the questions, and formatting. Inclusion criteria for participation were registered occupational therapists with the College of Occupational Therapists of British Columbia (COTBC), practising in British Columbia. An email list of registered occupational therapists who had consented to being contacted for research purposes was provided through the COTBC (N = 1,995 of 2,965 practising registrants). Three emails were sent to the participants list, 2 weeks apart, starting 14 September 2021 and ending 15 October 2021. The study was approved by the University of British Columbia Behavioural Research Ethics Board: Ethics ID: H21-01282.
The survey program Qualtrics was used to collect data from participants in an online questionnaire format. The survey was divided into four sections: demographic details, pre-COVID technology use and comfort, present day COVID technology implementation and impact, and post-COVID predictions of technology maintenance or improvements for the clinician were collected along with barriers and facilitators of technology use. Multiple choice, select all, 5-point Likert scale, and short answer question types were utilised as appropriate to the question stem. To investigate occupational therapists use of technology in the timeframes specified in our questionnaire, a value of 1 was assigned to all yes answers in dichotomous questions, with 0 representing participants who selected no. Likert scales were assigned numbers starting at 0 for other or not applicable, whereas lowest numerical values were assigned to detractors and higher numerical values assigned to attractors. Multiple choice and select all questions were also assigned numeric values start at 0 for other or not applicable answers and then ascended in value based on the order defined in the question stem. IBM SPSS statistics software was used to conduct descriptive statistics on the quantified data responses. Relationships between technology use pre, during, and post-COVID were interpreted by organising similar question stems together and comparing measures of central tendency.
3 RESULTS
Occupational therapists that replied to this survey are representative of the overall registrants in British Columbia based on comparison of the basic demographic information (age, sex, and gender) provided in the Profile of Occupational Therapists section of the COTBC 2021 Annual Report (COTBC, 2020). Rural and remote occupational therapists made up 18.5% of the sample and 81.5% identified working in urban or sub-urban regions. The majority of the respondents identified themselves as having the primary role of being a direct service provider (88.2%) and working more than 0.7 FTE (75.2%). Private practice occupational therapists were 37.9% of the respondents, 57.3% from public settings, and 9.1% from non-profit settings. Paediatric occupational therapists were 22.3% of the sample, and those that work primarily with adults made up 76.2% (Table 1).
| Practitioner demographics | Total sample (n = 342) | |
|---|---|---|
| Total (n = 330) | ||
| Age | Respondents (n) | Percentage (%) |
| 18–24 | 1 | 0.3% |
| 25–44 | 198 | 57.9% |
| 45–64 | 124 | 36.3% |
| 65+ | 7 | 2.0% |
| Total (n = 330) | ||
|---|---|---|
| Sex | Respondents (n) | Percentage (%) |
| Female | 301 | 91.2% |
| Male | 29 | 8.8% |
| Total (n = 330) | ||
|---|---|---|
| Gender | Respondents (n) | Percentage (%) |
| Woman | 297 | 90.0% |
| Man | 28 | 8.5% |
| Non-binary | 3 | 0.9% |
| Other | 2 | 0.6% |
| Total (n = 330) | ||
|---|---|---|
| Location of practice | Respondents (n) | Percentage (%) |
| Remote | 12 | 3.4% |
| Rural | 53 | 15.1% |
| Urban/suburban | 286 | 81.5% |
| Total (n = 323) | ||
|---|---|---|
| Primary role | Respondents (n) | Percentage (%) |
| Direct service provider | 285 | 88.2% |
| Professional leader/coordinator | 13 | 4.0% |
| Manager | 8 | 2.5% |
| Educator | 6 | 1.9% |
| Researcher | 1 | 0.3% |
| Other | 10 | 3.1% |
| Total (n = 323) | ||
|---|---|---|
| FTE | Respondents (n) | Percentage (%) |
| ≤0.6 FTE | 54 | 16.7% |
| 0.7 FTE | 26 | 8.0% |
| 0.8 FTE | 45 | 13.9% |
| 0.9 FTE | 31 | 9.6% |
| 1.0 FTE | 145 | 44.9% |
| >1.0 FTE | 22 | 6.8% |
| Total (n = 323) | ||
|---|---|---|
| Primary sector | Respondents (n) | Percentage (%) |
| Private | 125 | 37.9% |
| Public | 189 | 57.3% |
| Not for protfit | 30 | 9.1% |
| Total (n = 323) | ||
|---|---|---|
| Primary client age category | Respondents (n) | Percentage (%) |
| Preschool age (0–4) | 20 | 6.2% |
| School age (5–17) | 25 | 7.7% |
| Mixed paediatrics (0–17) | 27 | 8.4% |
| Adults (18–64) | 101 | 31.3% |
| Seniors (65+) | 39 | 12.1% |
| Mixed adults (18–65+) | 106 | 32.8% |
| Not applicable | 5 | 1.5% |
Occupational therapists representing various practice areas and regions in British Columbia indicate that they increased their use of technology during the initial wave of restrictions associated with the onset of the COVID-19 pandemic. Participants reported the use of technology prior to COVID was 67.9% overall, and it increased to 91% of the participants adopting technology during COVID. Ninety-one per cent also plan to use technology after COVID restrictions no longer necessarily require it (Table 2). As the activity restrictions increased, so did the use of technology with 98.4% of the 254 respondents for that question (Table 3) saying they increased their technology use with stricter restrictions. Activities that were identified as increasing in use of technology were client monitoring, client treatment, collaboration, individual, and group communication. Nearly 40% (39.9%) of the sample endorsed that technology helped them to provide quality assessment, and 77.4% reported that it helped occupational therapists provide quality monitoring and management during the pandemic restrictions. Technology increased the number of clients occupational therapists could see during the Covid restriction phases for 42% of the respondents. Ninety-one per cent of occupational therapists said they would be using technology in their practice into the future.
| Technology use before, during, after COVID-19 | Yes | No | ||
|---|---|---|---|---|
| Respondents (n) | Percentage (%) | Respondents (n) | Percentage (%) | |
| Before | ||||
| Did you use technology prior to COVID-19 in your clinical practice? | 218 | 67.9% | 103 | 32.1% |
| During | ||||
| Have you adopted technology for your clinical practice during the COVID-19 pandemic? | 282 | 91.0% | 28 | 9.0% |
| Did your use of technology change to adapt to COVID-19 restrictions? | 260 | 93.9% | 17 | 6.1% |
| After | ||||
| Will you continue to use adopted technology once COVID-19 restrictions lift? | 258 | 91.2% | 25 | 8.8% |
| Technology adaptations during COVID-19 | Respondents (n) | Percentage (%) |
|---|---|---|
| How did your use of technology adapt during stricter COVID-19 restrictions? | ||
| More | 250 | 98.4% |
| Same | 3 | 1.2% |
| Less | 1 | 0.4% |
Technology use was described according to the activities or purpose it was used for. The categories included clinical assessment, clinical management, client prescription/treatment, collaboration, document creations and editing, individual and group communications, web access, and other. As seen in Table 4, all uses of technology saw an increase in use with collaboration (+41.2%), prescription/treatment (+37.1%), and individual/group communication (+42.0%) seeing the largest increases.
| Technology use in practice | Before COVID-19 | During COVID-19 | ||||
|---|---|---|---|---|---|---|
| Total (n = 213) | Total (n = 278) | |||||
| Respondents (n) | Percentage (%) | Respondents (n) | Percentage (%) | Difference (n) | Difference (Δ%) | |
| Components of practice | ||||||
| Clinical assessment | 43 | 20.2% | 111 | 39.9% | 68 | 19.7% |
| Clinical management | 162 | 76.1% | 193 | 62.3% | 31 | −13.8% |
| Client monitoring | 20 | 9.4% | 42 | 15.1% | 22 | 5.7% |
| Client prescription/treatment | 19 | 8.9% | 128 | 46.0% | 109 | 37.1% |
| Collaboration | 60 | 28.2% | 193 | 69.4% | 133 | 41.2% |
| Document creation and editing | 197 | 92.5% | 217 | 78.1% | 20 | −14.4% |
| Individual and group communication | 109 | 51.2% | 259 | 93.2% | 150 | 42.0% |
| Web access | 166 | 77.9% | 199 | 71.6% | 33 | −6.3% |
| Other | 15 | 7.0% | 25 | 9.0% | 10 | 2.0% |
Clinically, occupational therapists endorsed using technology for all aspects of their practice including assessment, monitoring, clinical sessions, treatment, and collaboration. Technology was primarily perceived as being useful and compatible with their daily work. The data suggested less congruency among occupational therapists regarding of the technology in helping provide quality care and assessments versus enhancing productivity at work. It is also not clear if occupational therapists were consistently able to increase the number of clients they could see nor the amount of time spent serving clients compared to their pre-Covid provision of care. A clear benefit was that occupational therapists felt they were able to reach clients they typically could not provide care for (68.1%). The environment (physical and social) or workplaces that occupational therapists worked in influenced their adoption of technology into their practice. Many occupational therapists learned to use technology from informal sources such as colleagues or friends (60.8%), online resources (45.3%), or self-taught (74.3%). The majority also felt they had the resources (80.5%) and knowledge (81.7%) to use technology at work. Support at work was also common with 76.3% endorsing that the technology used at work is compatible with other technologies already implemented. Many felt that they could get help with the technology they have adopted at work (80.1%).
Following the initial uptake and learning that occurred, occupational therapists were able to identify that the most significant barrier to adopting technology to support practice was the client's ability or access to technology (58.8%). Difficulty applying the technology to their practice area (48.2%) and funding (34.6%) were also ranked higher as barriers compared to other options presented in the questionnaire. Only 9.3% stated that they had no perceived barriers to using technology.
4 DISCUSSION
The onset of the COVID-19 pandemic and the associated activity restrictions forced a rapid shift to virtual health-care provision or telerehabilitation. Occupational therapists adapted to the change, and there was a significant increase in the use of technology to support practice. Studying the changes as they happened allowed us to explore the differences in uptake of technology in relation to the geographical areas that occupational therapists practice in, the specific areas of practice, funding models that support practice, and specific components of practice that were amenable to the use of technology. Occupational therapists were nearly evenly split on the ease in which technology could be adopted and that it was easy to become skilful at technology use. The largest barrier to technology use for telerehabilitation was the occupational therapists' perceptions of clients' technology ability to use or understanding of their access to technology. These barriers represent gaps in knowledge and skills that can be supported by the employers, educational institutions, and professional associations through development of policies, education, and funding for the necessary support for clinicians and clients. Ensuring adequate skills and access for the areas of practice where we have seen the most effective and appropriate use of technology should be considered a primary goal for occupational therapists and their employers.
Additionally, further research to build understanding of the characteristics of the clinicians and factors related to rapid and/or easy technology adoption versus slower transitions can help inform occupational therapy education and policy development. The need for occupational therapy skill development to support practice was initially suggested by Hills et al. (2016). The rapid uptake of widespread use of technology for telerehabilitation since that time increases the relevance of these early recommendations. Hills et al. (2016) were discussing primarily the education of occupational therapy students. However, this study suggests that this type of education would be useful for practising occupational therapists as well. Further research to understand the gaps in knowledge is needed to inform targeted skills development to support consistent and competent care across occupational therapists. Considering the significance of the barriers introduced with the clients' inability to access or use technology, it would also be important to further explore how to improve access and support for clients that would benefit from increased access to care through technology. Further research that specifically identifies the barriers and facilitators for the provision of telerehabilitation, particularly for those who live in rural and remote locations, would be beneficial in developing effective and accessible care options.
Occupational therapists increased their use of technology for the various components of practice including assessments, interventions, client monitoring, and individual and group communications. Whereas some literature has explored the use of technology for specific components or assessments related to clinical care (Stillerova et al., 2016), it would be beneficial to further understand the effectiveness of provision of these broad categories of clinical care considering the potential for future application and sustainability of technology use in practice. It is suggested that further research supports a better understanding of the effects of technology use on the specific therapeutic components, such as rapport and consistency in intervention efficacy. Information around the characteristics of the occupational therapists and the client's served within this sample can be explored in further studies to build understanding of how technology can be used effectively in the future to support clinical practice in different practice areas and geographical regions. Understanding which components of practice can be well supported with technology use can help develop future funding, access, and use policies to make the most effective and efficient use of technology to support the provision of quality occupational therapy care using telerehabilitation.
This study is limited primarily in relation to the sample size and potential lack of participation from the rural and remote providers specifically. It is a reasonable assumption that virtual care could be of particular importance in providing care to those that live in rural and remote areas. As such, further research should include increased effort to reach therapists that work in those areas.
The response rate was 17% of the list who consented to research and 12% of overall number of registered occupational therapists in British Columbia. It is reasonable to assume that occupational therapists across Canada experienced the need to drastically increase their technology usage to support practice. It would be beneficial to support quality practice nationally to research the ongoing use of technology along with the areas of practice it is most effective in. COVID-19 continues to evolve at the time of this study. As such, it is the ideal time to continue research in the moment as changes occur to inform future practice. At the same time, it is recognised that health providers and their clients are currently in the midst of constant adaptation to their clinical relationships, and it will be challenging to make clear statements on the impacts of current trends on future practice. Collaboration with other health professions facing similar challenges is recommended considering the likely similarities experienced across health disciplines in this forced rapid change to practise provision. Building a collective understanding of how the use of technology is actively impacting practice will undoubtedly support clear decisions when it comes to the practical and policy perspectives both in publicly and privately funded settings and across practice areas.
5 CONCLUSION
Coronavirus has been one of the top health related issues in the world, being deemed a global pandemic and affecting occupational participation in all aspects of daily life. This study investigated the impact COVID-19 had on widespread technology usage in occupational therapy practice. The results indicate that occupational therapists in British Columbia increased their use of technology across practice areas, primarily in relation to clinical activities. Preliminary analysis outlines occupational therapists in British Columbia adapted to practise changes to continue client care throughout initial COVID-19 restrictions. These changes continue to evolve as the associated pandemic restrictions change. A significant majority of these therapists state that they will continue using technology to support their practice into the future. Further research is needed to better understand the use of technology in geographical areas underrepresented in this study: specific research investigating the facilitators and barriers to practise using technology and the specifics on perceived effectiveness in the components of clinical care provided by occupational therapists. This understanding can help build consistent education, funding, and provision of occupational therapy using technology for those areas of practice that may benefit from this mode of service provision in the future.
AUTHOR CONTRIBUTIONS
Tanya Fawkes contributed to the conception and design of the study and led the distribution of the survey, data interpretation, and manuscript writing. Olivia Yung led the survey design and analysis and was involved in the interpretation and manuscript writing. William C. Miller contributed to the conception and design of the study, analysis and interpretation, and manuscript writing. Emma Smith supported the conception and design of the study and editing of the manuscript. Parmeet Matharu and Natalie Yu supported survey development, analysis and interpretation, and manuscript writing.
ACKNOWLEDGEMENTS
The research team wish to thank all the participants that shared their experiences with us for the purpose of this study.
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest to declare.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
