Diversity, Equity, And Inclusion In The Occupational Therapy Profession Podcast

Editor's note: This text-based course is a transcript of the Diversity, Equity, And Inclusion In The Occupational Therapy Profession Podcast, presented by Cristina Reyes Smith, OTD, OTR/L; Dennis Cleary, MS, OTD, OTR/L, FAOTA.

**Please use the handout to complete the exam.

Learning Outcomes

• After this course, participants will be able to:
  • identify the occupational therapist skills most used when designing an inclusive play space.
  • list the different ways that inclusive play spaces can be funded.
  • describe the model used to design inclusive play spaces.

Podcast Discussion

Dennis: Dr. Cristina Smith, thank you so much for being with us today. We really appreciate your time. Could you just tell us a little bit about your background in occupational therapy?

Cristina: Sure, I am very excited to be here with you. I appreciate the invitation. I have been practicing since 2007, so almost 20 years. It has flown by and has been an incredible journey. I've learned so much from being an entry-level clinician to now being an associate professor at the Medical University of South Carolina, where I've been able to develop and teach leadership and management courses in our new occupational therapy doctorate program. I've also been very fortunate to have different leadership roles throughout our university, our state association, and AOTA over the past couple of years. The relationships have been incredible with colleagues such as yourself, as well as patients and students. I owned a private practice for about 8 1/2 years which sadly closed in 2020. We were committed to providing access to quality care, particularly for underserved communities with language barriers, rural families, and lower-income families. We saw everyone across the spectrum of society through that journey.

Dennis: I think, especially right now, our awareness of issues around diversity, equity, and inclusion is so important for everyone. We're going to talk today a lot about how that influences our profession. As you said, as a practitioner and leader, and in your work at MUSC, you've been very involved in diversity, equity, and inclusion. Could you just talk about how you became interested in the topic or why it's been such a passion for you within the profession?

Cristina: Absolutely. I grew up in Charleston, South Carolina, since the age of three years old. During my time here, most of my interactions were cross-cultural in some way. I grew up between different cultures and ethnicities. My mother is lighter skinned, and my father is darker skinned, so their social groups were very different. As a result of that, I'm very fortunate that I'm able to connect with people from different backgrounds professionally and personally as an adult in unique ways. It was a different skill set and mindset. The Puerto Rican cultural background is a mixed race with Dutch, Spaniards, and Africans coming through the island. There are also indigenous populations. It is a melting pot, for lack of a better word.

Growing up, my mother had a bit of a language barrier, so I would have to review the notes that she would send to school to my teachers because of grammar and spelling. There have been so many different circumstances throughout my lifetime along those lines. As an occupational therapy student, I remember looking for some organization around Hispanic Latino student needs. I found that there were no resources that were accessible at my university. So I helped start one, the MUSC Alliance for Hispanic Health. This group continues to be strong today, almost 20 years later. I'm very proud of that.

This is a little bit about some of my early interests in diversity, equity, and inclusion. As I entered into the profession, I continued to see a need for transformational changes for our profession, the workforce, available resources, educational processes, structures within our professional associations and leadership roles, and what and who we recognize. There are various aspects of our society that have been marginalized historically, and I want to bring this to the forefront to help us move forward.

Dennis: I'm happy that you've been doing this important work. Culture is such an important part of all that we do as occupational therapists. Could you define some terms and tell us what diversity, equity, and inclusion mean to you? 

Cristina: Diversity at its core is differences. These are differences in preferences, choices, context, and appearances. I tell students when we're having an interview day that people may talk differently, walk differently, or act a little differently. I also want them to ensure that everyone feels that they belong and they have a place. This is where the inclusion piece comes in. When individuals, groups, or populations are left on the outside or in the margins, that is that exclusion piece, which is the opposite of inclusion. We need inclusion to move forward in our profession and in healthcare at large. Occupational therapy is one of the many health professions that have been sounding the alarm in this area. We need to do better to serve our workforce, students, future workforce, and consumers of our services as well. Our society is growing more diverse racially and ethnically. We also look at religious minorities, sexual and gender minorities, and individuals with disabilities, just to name a few. Inclusion is about incorporating everyone and creating a space for that. Non-discrimination is another term that is used to help describe that we're not excluding or discriminating against people in some way. Equity is where everyone has access to the same opportunities and outcomes at the end of the day. These are terms that are utilized by the World Health Organization and other national healthcare and international healthcare organizations.

I also want to address people who have concerns about reverse discrimination. These concepts do not promote excluding anyone or discriminating against anyone, so it is important that we consider that as we provide initiatives, strategies, and resources.

Dennis: Could you describe the difference between inclusion and tolerance? 

Cristina: I'm going to talk a little bit about educational theory for a second. Bloom's taxonomy is discussed frequently when we talk about knowledge, skills, attitudes, and values. This includes attitudes towards others. Tolerance is maybe acceptance, but there is that concept of potential hostility or abrasiveness with it. In contrast, inclusion has value and positive connotations. There's also respect that underlies this concept of inclusion that is not always present when we talk about tolerance. In 2005, as a student, I was invited to provide some remarks at a Martin Luther King Jr. event. One of the key speakers talked about tolerance. When I spoke, I added that we should also bring appreciation, wonder, and value to individuals who are not like ourselves. We could get into a philosophical discussion, but we won't do that here.

Dennis: There is something to be said about curiosity and valuing cultures that are not your own. Learning from each other is so important in this journey that we're all on. I often hear the term JEDI. What is this?

Cristina: JEDI stands for justice, equity, diversity, and inclusion. Interestingly enough, some people from underrepresented groups reject the acronym JEDI for whatever reason. I'll also add that multiple other terms have been included in the lexicon. There is A for accessibility and B for belonging, so you may see things like DEIJB, DEIJA, or other variations.

It's interesting because the pandemic seemed to catalyze this era of hyper-change for us with regard to technology, but also with racial and ethnic circumstances in our society. There was a huge explosion of literature being published, resources being generated, development of theoretical frameworks, and context being disseminated. We'll talk about some of the current sociopolitical aspects here shortly, but it is an area that is rapidly changing. It's important to continue to educate ourselves and learn all the time.

Dennis: Absolutely. Why don't we talk about some of those things? COVID was stressful for everyone, but I think especially for people from the African-American community in the US after George Floyd. It was a summer of discontent. You were on the AOTA board of directors at that time, and while you're certainly not speaking for them now, could you tell us what it was like during this time? 

Cristina: I was elected in January 2020 to the AOTA Board of Directors, and I certainly did not know that it was going to be as exciting a time as it was going to be. That June was my first board meeting. The pain that people were experiencing at my immediate, local, and national levels was unbelievable. The pandemic brought to light health disparities that people had been trying to call attention to for several decades. Back in 2002, the Institute of Medicine published its groundbreaking report on racial and ethnic disparities in the healthcare system. During this time, it was unprecedented how many lives were lost, disproportionately from racial and ethnic minority groups. I heard many lived experiences of those who lost so many. For example, I had a student that lost four people in one year in 2020. Remember, often, there are multiple generations living under one roof in some cultures within the United States. On top of the pain and suffering, there were also economic repercussions that disproportionately affected people in minority groups, like in the hospitality and tourism industries. The trifecta for people was the killing of George Floyd. This was not an isolated incident, as there were concerns about police brutality for years. As a child, I heard about Rodney King in Los Angeles, so it wasn't just one incident. Many challenges that had been ongoing for decades bubbled to the surface.

I was the first person of color, racial, and ethnic minority to be on the board of directors in several decades. Additionally, everything was on Zoom unexpectedly. Typically, we have face-to-face meetings in Bethesda, Maryland, at the headquarters, but not during this difficult time. The board members, whom I have been able to get to know very well since that time, were committed to helping us to move forward in these areas. However, there were not a lot of strategies that were evident. It has been a process of evolution. In fact, we had a national conference called Occupational Therapy Evolving Diversity, Equity, and Justice back in 2021.

During this era of hyper-change, people are trying to do their best. They're hosting listening sessions, creating resources, and advocating. Sometimes, we mess up and don't always get it right as individuals, as groups, or as organizations, but it's important that we learn from that and do better in the future. We need to continue to listen, especially before we speak. This is something I've been focusing on more these last couple of years. Through dialogue, we can calm down. There's a great book called "Crucial Conversations," which I have utilized throughout this journey with diversity and culture. It talks about important topics that are potentially emotionally charged. We can use calming down as a strategy to progress to where we want to be. If we're not talking, we're not going to get anywhere. And if we're yelling, there's defensiveness and a threatening aspect that's not constructive. These are some of the lessons that I've learned along the way.

Dennis: I appreciated many of the listening sessions. As a white male, often my first reaction is to solve problems. However, I need to listen first. This is what we're supposed to be doing as occupational therapists. It's not our goals; it's the goals of the individuals that we're trying to support. It was great listening to fellow occupational therapy practitioners, especially now that I'm older. When I was in school, we talked about "cultural competency." It was about supporting clients that we were working with without any thought about fellow students, practitioners, or underrepresented groups. One impactful part of the discussion was hearing from students and practitioners who had negative experiences with other occupational therapy practitioners. I don't know what the listening experiences were like for you and for the board, but did these influence some of the decisions that you made following the summer of 2020?

Cristina: The listening sessions were crucial for providing space for people to share and, in some situations, things that had happened a long time before. For some, they shared about daily occurrences. These listening sessions were essentially a needs assessment for our profession. We had an ad hoc DEI committee that had started in February 2020, before the pandemic and before George Floyd. The initiative was started under President Wendy Hildenbrand and was moving forward. This group was tasked with assessing the needs at that time. There were surveys that went out and interviews with different stakeholders. The listening sessions became a part of that to help develop a strategic framework around diversity, equity, and inclusion at that time. The group recommended a permanent DEI committee for the AOTA which became part of the bylaws. 

Currently, the DEI Committee has been working incredibly hard these last couple of years, including the chair of the DEI Committee, who has been serving with the board of directors with a voice but no vote. Hopefully, this will be changing at some point. The listening sessions, especially having board members there, were helpful for increasing understanding, assessing the needs, and being able to conceptualize some initiatives that have real concrete solutions and strategies for our profession.

The needs are multifaceted, including educational, clinical practitioner, language access, advocacy, and sociopolitical needs. From this strategic framework, we've had incredible momentum. However, I think communication of all these initiatives can be a challenge. For example, emails will go out or are posted somewhere on a website, but due to the huge influx of information, members may not get all of it. This is especially true for non-members. There are also YouTube videos, podcasts, articles through AJOT, OT practice articles, and societal statements that have been updated. We also have ethics advisory opinions that are available and are being revised right now for the next iteration of the code of ethics.

As you mentioned, for a long time, the focus was on patient-provider interaction, and we weren't really talking about the workforce. That's an area that we were able to bring to the Ethics Commission through the representative assembly via a motion to expand cultural competence and sensitivity to the workforce. Now, we have three different ethics advisories that are going to be related to culture and diversity in some way.

Dennis: Which is so important and makes the profession better. It is the mentality that we should all be in this together to support others within the profession. There are some specific DEI initiatives that you mentioned that the board helped to fund. Do you want to talk about the toolkit and how that came into being? I believe the toolkit is free and open to members and non-members alike.

Cristina: The modules are great resources that are available for students, practitioners, and educators, and it's growing. There's information being added from time to time. There are resources around case studies, videos, and links to official documents related to diversity, equity, and inclusion. There is also a glossary of terms available. Many articles have been linked through the DEI toolkit as well. There may be some that are available behind the firewall to members only, but for the most part, the resources are available to the general public.

Dennis: The board was intentional about having many resources available. Our state associations are member-driven organizations.  I had a friend who was the president of the Ohio OT Association at one point and testified for the Ohio House or Senate. She stated that she represented the 10,000 occupational therapy practitioners in the state of Ohio. The member replied, "Well, how many members are in your organization?" She replied about 2,500. The response was then, "You're representing 2,500, not 10,000." So again, is it important to have the resources available to everybody?

Cristina: Absolutely. We can go back to the centennial vision of having a profession that is powerful, widely recognized, and evidence-based with a diverse and globally connected workforce, meeting society's occupational needs. Society's occupational needs will need to be addressed by our entire profession, including our students, clinicians, faculty, researchers, inventors, and entrepreneurs. All of all of us are a part of meeting society's occupational needs.

Vision 2025 helped to focus us even more, so it is important that resources be accessible and available to our profession at large to make transformational change. Often, we don't think about those who are entering into the profession. I'm an admissions director currently, and so this is something I think about frequently. Those prospective students don't have access to membership resources, but they do have access to our website, so this is a part of the perception that we're building for them.

Dennis: I'm going to read Vision 2025 verbatim. Vision 2025 states, "As an inclusive profession, occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living." The inclusive piece is important because we're an inclusive profession. As such, there's more of an emphasis on the profession, not just on the people that we're working with. How do you see us doing currently with being inclusive as a profession, and how can we maybe get better at that? That's a loaded question, isn't it?

Cristina: No, that's a great question. For those of us who have been in the profession for a little while, we may remember that "as an inclusive profession" was added later after the first iteration of the vision statement back in 2017. That piece of it is so critical. It's something that, as a society, we've been learning more and more over the years in order to meet the needs of our diverse society. We must have a diverse profession and workforce that is helping to meet those needs in terms of having representation of individuals. We've learned from the research that diverse teams can outperform teams that do not have that diversity because of the homogeneity of ideas, values, and beliefs that do not allow "thinking outside of the box."

Diversity, equity, and inclusion are evidence-based. Research shows that health outcomes, access, trust, rapport, safety, and different factors are better when there is diversity present within the workforce. When it comes to things like holistic admissions and mandatory training, they can be a double-edged sword. People reject it, but often, the people who reject mandatory training are the ones who need it the most. It is a process.

Not any one of us is an "expert" in all things DEI. We are all on a journey of learning and growing, referred to as cultural humility. I tend to try to think in opposites whenever I'm trying to understand a construct. For example, the opposite of humility is supremacy. Cultural humility is seeking to understand and appreciate in a positive way where others are coming from. What are their needs? What are their desires? What are the barriers and challenges? What are the supports and strategies they have in place? And when we speak about one person, we're speaking about one person. Each person may have many different identities that contribute to how they see themselves or their culture. It's important to ask. Ask how people want to be identified, like preferred pronouns for sexual and gender minorities. And when we talk about disability status, it's important to ask if they prefer person-first or condition-first terminology. Sometimes, it's generational. An example would be the diversity found in Hispanic Latino communities or the newer term LatinX. Some of the older generations do not endorse this term. Some are even saying "Latine," so there is no gender associated with it, as in Latino or Latina. Again, these terms are evolving and vary from region to region. Thus, there has been pushback that you can't be competent about all things culture.

There has been an exploration of terminology. Culturally relevant or appropriate care are now terms that are being used. The US Department of Health and Human Services published the National Class Standards back in the early 2000s and then revised them in 2013 with CLAS, standing for Culturally and Linguistically Appropriate Standards. There is a lot of terminology. Another one is transcultural competence. We are becoming more educated, but we also need to refer back to our code of ethics and core values, looking at justice, autonomy, fidelity, and veracity. 

Dennis: It's useful to go back to Ted Lasso. He tries to be curious, not judgmental. I think this is the same with cultural humility and competence. We're all on a journey and earning. And one of the best ways to learn is to listen, and that should be our job as an occupational therapy practitioner. What is important to the person that we're treating? It is such an important aspect of our profession. 

Cristina: Our OT Practice Framework talks about culture about 45 times. Culture impacts our contexts, roles, habits, routines, preferences, values, beliefs, the way we dress, the people with whom we interact, the work we do, our education, our access to education, our health literacy, et cetera. There are so many different aspects of us as occupational beings. We should be leading the health professions in these areas of culture and diversity. Social determinants of health are where you live, what activities you're engaged with, access to healthy food, transportation, and language. All these different aspects impact our occupation, performance, participation, and the skills that we have. However, if you look at the literature on social determinants of health and occupational therapy, there is very little out there right now. We need more researchers to help establish the evidence within our profession. There are a myriad of resources available across other health professions that we can utilize to ultimately better serve our communities and clients.

Dennis: Yes. Looking at inclusion in our own profession, if we look at the last salary survey that was done by AOTA, it shows the work that we have to do. For instance, about 91% of practitioners are female, and 84% are white. There's a huge underrepresentation of African Americans. They make up 13.6% of the general population but only 3% of OT practitioners. Hispanics make up 19% of the population, but they only make up 3.6% of OTPs. Additionally, only .3% of us are Native American or indigenous practitioners. About 6% of us are Asian practitioners, which is closer to where we're at as a society in the US. There has been an uptick in more diverse students. We need to have a workforce that looks like the people that we serve. How do we change that number, especially in light of the US Supreme Court's recent decision about not using race-based admission policies? 

Cristina: That's a great question. We know that the pandemic has increased some of the disparities in education as well, but we're hopeful that those are going to eventually settle out a little bit. There was an upward trajectory prior to the pandemic that has been a little slow, particularly for individuals from lower socioeconomic backgrounds and other disadvantaged groups. Holistic admissions have been endorsed by the American Association of Medical Colleges for almost 20 years now. They looked at some of the resources and the national class standards from the Institute of Medicine and the World Health Organization. For example, they recommend looking at social determinants of health, health equity, and some of those different aspects through a workforce that is representative of the communities. That is one of the standards from the national class standards as well. I highly encourage anyone who is not familiar with those standards to go take a look.

There are strategies that we can utilize, which are evidence-based, to help attract and retain students from disadvantaged and underrepresented backgrounds. We're still understanding the implications and repercussions of the Supreme Court ruling. It looks like, for now, race is not able to be considered a factor. Previously, it was able to be considered a factor when it was part of a variety of other factors. There are other factors like socioeconomic status, language, country of origin, geographic region, rural communities, etc. An example may be a first-generation college student who goes to a school where SAT scores are lower than the state or national averages.

The Occupational Therapy Centralized Application Service system (OTCAS), has access to what are called HRSA indicators through the Health Resources Service Administration, a federal entity. There are about 15 to 20 questions related to environmental and socioeconomic disadvantages. These are some criteria that the applicants are able to share. There are other factors that we can look at as well. We can ask questions about what diversity they would bring to the program, including other aspects of diversity. It allows the applicant to self-identify if they wish to as well. There may be some things that they wouldn't disclose because of fear of adverse repercussions, but providing those opportunities is important for us.

When we look at the applicant pool, we historically have allowed the applicants to come to us. I have a saying, "If they haven't heard about occupational therapy, they will not choose occupational therapy 100% of the time." This, we know. There are not a lot of things that we do know, but that is one that we can count on. We need to get the word out. We have social media at our disposal, can conduct events, and have an online presence that we can utilize through webinars and outreach. All of us who love this great profession have a responsibility to help spread the word about this profession.

Unfortunately, there is a lot of negativity out there that's being posted on social media right now. My students tell me about it, and I hear about it from other practitioners. I believe the majority of us have had positive experiences, even though we all have ups and downs from time to time. Sometimes we need to make shifts in our job positions, and the pandemic certainly has put some risks and wrinkles into our positions and careers. However, we need to share our love, passion, and the impact that we have with our clients and colleagues now more than ever before. The vitality of the profession depends on it. The AOTA and our professional associations also have a responsibility to be engaged in promoting the profession. At the end of the day, each of us, within our different spheres of influence, can help be a part of growing and sustaining this profession.

Dennis: It is so important that we have a diverse workforce, and all of us, as you know, are responsible for encouraging people in and out of our spheres to consider the profession. Then, once they are in the profession, how do we encourage people from underrepresented groups to move into faculty or board of director positions? Dr. Lela Llorens was the last Slagle lecturer who was African American, and she gave her Slagle lecture in 1969. How do we encourage more diversity within academia and leadership of our profession? 

Cristina: Absolutely. Having programming that reflects that we value diversity, equity, and inclusion is key. This is something that can happen across all levels, including clinical settings, academic programs, research, workshops/training, scholarship funding, and sponsorships. In all these different areas, we can have programs that we offer that help to say and demonstrate, "We value diversity, equity, inclusion, justice, accessibility, belonging, etc."

Getting the word out and communicating it is really important too. Sometimes we're not great about communicating what we're doing and letting people know. We need to ensure that we have systems and structures in place and listen to any feedback, whether it's from our key stakeholders, partners, or constituents. This can be through surveys, focus groups, listening sessions, and interviews.

We can immerse ourselves in cultures within our communities to learn more about ourselves as cultural beings. For example, at our university for the last few decades, about 25% of the infants being born in our hospital were of Hispanic-Latino descent, with the vast majority being Spanish-speaking. It benefits practitioners to learn more about the families they are serving. I've had some students with capstone projects, and one was working with interpreters in the NICU. She created a mobile app, both in English and Spanish, to help facilitate the continuum of care. I have another student who's going to be helping to promote that within the community.

Through different initiatives, we can let people know what we're doing, whether it's through our website or other social media. We do not just want to talk the talk but to show that we are walking the walk. 

Dennis: Could you talk a little bit about your role in COTAD and how it came to be? 

Cristina: It started from some of the values and interests a group of people had at that time. As an aside, the MUSC Alliance for Hispanic Health ended up being students, faculty, and staff from a wide variety of backgrounds who were just very passionate about helping to meet the healthcare needs of the Hispanic Latino community. COTAD, the Coalition of Occupational Therapy Advocates for Diversity, was similar. We were at an event and had all come through the Emerging Leaders program of the AOTA. We were at a leadership event at the conference sitting around a table. We used a proverbial cocktail napkin and started jotting down some ideas with regard to the Centennial Vision in particular. Having a diverse workforce as part of the Centennial Vision was an area that we all felt very strongly and passionately about. We also felt that we were not seeing a lot of initiatives at that time. We were from different cultural, racial, ethnic, religious, geographic, and socioeconomic backgrounds. We thought that we could help to move our profession forward at that time through a presentation, so we were able to get sponsorship for a session on diversity in the workforce perspective from emerging leaders. We had an OT practice article as well. We discovered during that year that we loved working together in online mediums like this and face-to-face at conferences. The next year COTAD was born. I was very grateful that Dr. Catherine Hoyt took on the role of the founding chair at that time, as my daughter was born one month later.

Dennis: You had things to do.

Cristina: I did. I was a little busy at the time, but she was just an exceptional leader. She helped it to grow over her seven-year tenure as the founding chair, and the group became a national 501 organization. It offers a mentorship program and student chapters, which have grown like wildfire. I believe there are now over 100 academic programs across the country. There have been multiple articles, presentations, workshops, pre-conference workshops, panels, and annual events. There's an annual breakfast that just celebrated its 10-year anniversary this past April. COTAD-ED connects educators through the education summit, at the national conference, and through resources like Facebook pages. The social media presence has been very strong. There have also been some connections to advocacy initiatives. The AOTA has been supporting the Workforce Diversity Act, for example, and we've had different individuals provide input for that. It has been amazing to see how it has grown and evolved over these past 10 years.

Dennis:  If you want to take action, find out more about COTAD. Again, it's our responsibility to hand it on to the next generation, and culture is such an important context of all of the work that we do. Do you have any final words for us before we head out?

Cristina: I want to encourage everyone to continue to be involved and engaged with your membership at your state level with AOTA. Your membership and engagement matter for helping to impact our profession, societies, and workforce. There are a couple of other groups that are out there currently as well, like COTAD. it really shouldn't be an either-or. Each of these groups has different functions that are advocating on your behalf as a student, practitioner, and even as a constituent because one day, you may be receiving occupational therapy services as well. It's crucial that we are all engaged and involved in helping to move the profession forward together because that's the only way that we're going to continue to be able to grow and sustain this great profession that we love.

Dennis: Awesome. Well, Dr. Cristina Smith from the Medical University of South Carolina, thank you so much for your time. I hope you and everybody else have a great day.

Cristina: Thank you, you do the same. Thanks for having me.

References/Resources

Available in the handout.