Preliminary Professional Competency Standards for Occupational Therapists in India: A Global Review and Adaptation

Abstract

Background

Competency is the ability to apply knowledge and skills efficiently to achieve required outcomes, typically measured through performance. Professional competency standards in healthcare describe the specific knowledge, skills, and attributes required for practice. In India, the occupational therapy (OT) profession is gaining recognition, highlighting a need for national competency standards to improve quality of care and professional visibility.

Objective

The overall aim of this study is to create a draft set of professional competency standards for occupational therapists in India by reviewing, synthesizing, and adapting existing competencies published in other parts of the world.

Study Design

Formative research design involving document analysis of global competency standards and an adaptive process in collaboration with the Indian Occupational Therapists Think Tank (IOTTT) to develop a draft set of professional competency standards for Indian OTs.

Methods

An iterative Delphi process was used. An Expert Working Group (EWG) was formed with three IOTTT executive members. A document analysis was conducted to gather and critically analyze existing OT competency standards. Competency documents were identified from professional associations and regulatory bodies worldwide. The analysis followed the framework method, involving a series of steps to extract and analyze data to create a draft set of competency standards for Indian OTs. The coadaptation process included individual reviews, scoring, and review meetings with the EWG.

Results

Document analysis revealed 31 OT competency standards, with 12 meeting the inclusion criteria, including documents from Australia, Bangladesh, Canada, Hong Kong, Ireland, Mauritius, the Netherlands, the Philippines, Singapore, Sweden, the UK, and the USA. After the iterative decision-making process, a draft set identified 15 competency domains, 97 competency standards, and 2 61 competency indicators, including essential competencies across various aspects of OT practice.

Conclusions

We prepared the draft set of Indian OT competency standards that reflected global practices and adapted to the Indian context. The next steps are further refinement of the document with iterative feedback from other IOTTT members and contributing OTs, followed by a collaboration with the All-India Occupational Therapy Association for endorsement and implementation, ensuring relevance to the Indian context.

Introduction

Competency is the ability to apply knowledge and skills efficiently to produce required outcomes, typically measured through performance.^[1] In healthcare, professional competency standards outline the specific knowledge, skills, and judgment required for practice, ensuring high standards and professional excellence.^[2] Competency standards have versatile applications and are commonly used by regulatory or national bodies to recognize an individual’s skills and behaviors, professional integrity, accountability, and competence.^[3] Profession-specific competencies exist for many professions in healthcare, including nursing, physiotherapy, speech-language pathology, and medicine, in many high-income countries such as Australia, Canada, and Ireland.^[4–8] Certain core competencies apply across healthcare professions, such as providing patient-centered care, working in interdisciplinary teams, and employing evidence-based and quality improvement practices.^[9]

Competency standards are accepted as important in OT practice across the globe.^[10] The World Federation of Occupational Therapists (WFOT) encourages its member organizations to develop context-specific competency standards in collaboration with practitioners, educators, member associations, and society.^[11] India, however, despite being a founding member of the WFOT, has not yet developed standards exclusively for Indian OT practitioners, academicians, and researchers.

In India, OT has been in existence for 75 years with a growing number of institutions offering degree programs and producing more OT professionals every year.^[12] Furthermore, the Indian government is recognizing the importance of regulating allied healthcare professionals by enacting the National Commission for Allied and Healthcare Professions (NCAHP) Act, 2021.^[13] There are currently no competency standards for any allied healthcare profession in India. Experts have discussed the implication of the NCAHP for the OT profession and recommended the need to formulate policies and a competency standard framework for education and professional practice.^[12]

Competencies form a fundamental basis of regulation. Hence, it is imperative to develop a set of Indian-specific OT competency standards to assist with emerging professional regulatory efforts, enhance quality, ensure consistency in OT practice, and promote the visibility of the OT profession in India. Therefore, the systematic development of competency standards for OT in India is required.

To develop a draft set of competency standards for OT practice in India, by reviewing and adapting competencies from other countries. Adapting existing competencies was a strategic decision, as we anticipated that basic competencies would be similar because core OT skills and standards are largely universal. Furthermore, using existing competencies as a starting point facilitates not only the description of India OT practice but also allows for comparison with OT practice internationally. This approach provided a strong foundation for quality practice and allowed us to efficiently adapt and contextualize competencies to fit the Indian context.

Methods

Study Design

A formative research design: involving review, document analysis, and Delphi process with stakeholder engagement.

Identifying Methods for Developing or Adapting Professional Competencies

Methods for developing competency standards for healthcare professionals vary^[14] and methods to analyze literature and data used to guide the development of competency standards, and reasons for selecting those methods, are often unspecified.^[2] We does not want to make those same mistakes, so we are clearly describing the methods we used and providing a clear rationale for those methods. The method we used was document analysis, which is a methodical approach to collecting and examining documents representing a variety of perspectives, and has been shown to efficiently produce new and trustworthy knowledge.^[15,16] We used document analysis to ensure a thorough and transparent approach to adapt competency standards for OTs in India.

Structure of the Methods Used to Adapt Competencies

Figure 1 illustrates the methods used to adapt the draft set of OT competency standards. First, we formed the Expert Working Group (EWG) with three executive members trained in India with expertise in OT, from among members of the Indian Occupational Therapists Think Tank (IOTTT). We then conducted a document analysis that involved gathering and critically analyzing available competencies followed by the coadaptation of the draft set of the competencies with the engagement of the EWG. Appendix A contains the completed Mixed Methods Reporting in Rehabilitation and Health Sciences Checklist.

Figure 1. Study Methods.

Document Analysis of the Existing Documents

We conducted document analysis using a four-step process that included searching for and identifying documents based on inclusion and exclusion criteria, reviewing and selecting documents for data extraction, and then data extraction and analysis. These steps and eligibility criteria are described in detail below.

Search and Identification

The search for OT professional competency standards began by identifying the websites of professional associations, organizations, and regulatory bodies on the WFOT website. In addition, we used the Google search engine to search for OT professional competency standards for other countries that were not members of the WFOT. The following search terms were used: “country names,” “occupational therapy,” “occupational therapy services” “occupational therapy programs,” “competency standards” “professional standards,” “standards,” “practice standards,” “competence,” and “professional requirements.” The search was conducted between August 2023 and January 2024. The initial search was conducted by DD and reviewed by KM individually based on the predefined eligibility criteria.

Eligibility Criteria

Inclusion Criteria

To be included, a document was required to meet the following criteria:

1. Listed a set of competency standards pertaining to OT practice that are applicable at a national or international level

2. Developed by or in collaboration with national or international professional OT organizations or regulatory bodies

3. Available in English.

Exclusion Criteria

1. Documents that listed a set of generic competency standards

2. Documents focusing solely on education or OT specializations.

Review and Selection

The search yielded 34 competency documents worldwide. DD and KM individually reviewed the documents for inclusion. Figure 2 illustrates the outcomes of the review and selection process. Twelve documents met the inclusion criteria, and Table 1 outlines the rationale for the inclusion and exclusion of the existing competency standards.

Figure 2. Results of Review and Selection.

Table 1. Inclusion and Exclusion Criteria.

OT competency standards/practice standards	Country	Inclusion criteria									Exclusion criteria
		Applicable on national scale or broader			Developed by national or international bodies			English language			Generic competency			Solely educational/ specific to any health condition			Eligible
		Yes	No/not specified		Yes	No/not specified		Yes	No		Yes	No		Yes	No		Yes	No
Standards of practice	America	Yes			Yes			Yes				No			No		Yes
Standards of conducts, performance, and ethics for all health care professionals	Seychelles	Yes			Yes			Yes			Yes				No			No
OT standards of practice	Philippines	Yes			Yes			Yes				No			No		Yes
Occupational therapists, registration board, standards of proficiency and practice, placement criteria	Ireland	Yes			Yes			Yes				No			No		Yes
OT standards of practice	Singapore	Yes			Yes			Yes				No			No		Yes
Competencies for registration and continuing practice for occupational therapists	New Zealand	Yes			Yes			Yes				No			No			No
Standards of proficiency for OT	UK	Yes			Yes			Yes				No			No		Yes
Competency standard for occupational therapists	Hongkong	Yes			Yes			Yes				No			No		Yes
Competence descriptions for occupational therapists	Sweden	Yes			Yes			Yes				No			No		Yes
AOTCS	Australia	Yes			Yes			Yes				No			No		Yes
Competencies for occupational therapists	Canada	Yes			Yes			Yes				No			No		Yes
Competenţe profesionale - APTOR	Romania*	Yes			Yes			Yes				No		Yes				No
Competency and area	Spain		No			No			No		Yes				No			No
Professional standards for the art of healing in OT	Thailand*								No		Yes							No
Компетенции	Bulgaria*		No						No									No
Kompetencije stručnih prvostupnika radne terapije sa važećim odobrenjem za rad	Croatia	Yes			Yes				No			No			No			No
Professionsgrundlag for ergoterapi	Denmark*								No									No
Règles professionnelles - ANFE	France*								No									No
Kompetenzprofil ergotherapie	Germany*								No									No
Alie skal kunne delta ergoterapeuters kjemekompetanse	Norway*								No									No
Standardy praxe - česká asociace ergoterapeutů	Czech Republic*								No									No
Occupational qualification standard occupational therapist, Level 6	Estonia*	Yes							No									No
http://ergoterapija.lv/ergoterapeitiem/juridiskie-resursi	Latvia*								No									No
Competency profile OT	Netherland*	Yes			Yes				Yes			No			No			Yes
Competéncias do terapeuta ocupacional em terapia aquática	Portugal*	Yes							No									No
Professional code of conduct	Switzerland*	Yes							No		Yes							No
Occupational therapist oath and code of ethics	Korea*								No		Yes							No
Perfil profesionaly competencias del terapeuta ocupacional	Columbia*	Yes							No									No
Core competencies	Taiwan*								No									No

^*Did not understand the details about inclusion and criteria because of languages other than English. OT: Occupational therapy, AOTCS: Australian OT Competency Standards, ANFE: Association nationale française des ergothérapeutes, APOTR: Asian pacific occupational therapy regional

Data Extraction and Analysis

Once identified, OT competency documents were analyzed using the Framework method.^[17] The Framework method involves a five-step process: familiarization, identifying a thematic framework, indexing, charting, mapping, and interpretation [Figure 3].^[17,18]

Figure 3. A Flow Chart for the Steps Involved in Data Extraction and Analysis Using Framework Method.

WFOT: World Federation of Occupational Therapists

Step 1: Familiarization

In the first round of familiarization, the competency documents were read thoroughly to gain an understanding of the overall structure and organization of the content and become familiar with its content. In the second round, we extracted components from all the documents, including domains, competency standards, and indicators, and entered them into designated sections of Excel spreadsheets. The Excel spreadsheets were examined by two individual reviewers (DD and KM) to cross-check data and verify its correctness. By having two reviewers individually examine the spreadsheets, missing data and discrepancies were identified and corrected, ensuring the accuracy of the data entered for later analysis.

Step 2: Identifying the Thematic Framework

In the second step, the focus was on identifying a thematic framework to serve as a structure by which to organize the components in each of the competency documents. We identified two competency frameworks: the WHO Rehabilitation Competency Framework (2021)^[19] and the WFOT Entry-level Competency Framework.^[20] The comparison of the WHO Rehabilitation Competency Framework and the WFOT Entry-level Competency Framework can be found in Appendix B. The EWG was asked to consider the most applicable framework for the Indian OT competencies. The WFOT Entry-level Competency Framework is a globally recognized and standardized set of entry-level OT competencies.^[20] The framework provided categories that could be used to aggregate data from the different OT competency documents. The EWG concluded that the WFOT entry-level framework was most appropriate.

Steps 3 and 4: Indexing and Charting

In this step, the competency standard indicators were coded by two individual reviewers based on the WFOT categories and subcategories. The reviewers noted any unique indicators that were not explicitly addressed in the WFOT entry-level framework. To enhance the clarity and organization of unique indicators, categories and codes were identified based on the commonalities and content of the unique indicators. Commonalities among unique indicators were identified based on the criterion that indicators measured the same skill domains or areas of competency. For example, all indicators that evaluated proficiency in using technology and its integration into therapeutic practices, such as “demonstrate competence in basic use of information technologies and other relevant applications,” “demonstrate competence in basic evaluation of assistive technology products for meeting clients’ needs, and to facilitate their proper and safe usage,” were categorized under the same codes.

After coding the indicators for all countries individually, the reviewers (DD and KM) engaged in the discussion to review and refine all categories. Any discrepancies were resolved by discussion. Following this, coded data from different spreadsheets for all countries was sorted, and indicators sharing the same codes across documents were entered into individual Excel worksheets for enhanced clarity and organization.

Step 5: Mapping and interpretation of extracted data

In the final step, DD and KM reviewed the sorted indicators with the same codes on each spreadsheet. DD and KM then entered all indicators with the same codes into ChatGPT 3.5 version developed by OpenAI, San Francisco, California, United States ^[21–24] to generate preliminary competency standards and indicators for each code. DD and KM reviewed the resulting competency standards and indicators for grammatical errors and any omissions to ensure accuracy. These two reviewers verified that competency standards and indicators adequately covered all essential points from the coded indicators, then edited, rephrased, and summarized where required, to ensure the quality and validity of competency standards and indicators. The competency standards and the indicators were then grouped into a broader category, referred to as “domains.” This hierarchical structure provided a comprehensive document containing domains, competency standards, and indicators.

Coadaptation with the Expert Working Group

After document analysis, meetings were held with the EWG to coadapt the preliminary competency standards for OT practice in India. The EWG has several years of experience in OT education, research, and practice in India as well as internationally. The coadaptation process was completed in two rounds, comprised (a) an introduction meeting and individual review and scoring of the competency indicators, followed by, (b) review meetings before the finalization of the draft set of Indian OT competencies.

Introductory Meeting and Individual Review and Scoring

All experts were invited to an introductory virtual meeting, which included a methodological introduction, a presentation of the findings of document analysis, a discussion of the next steps before the review meetings, and instructions to score the indicators. After the meeting, all experts were sent a scoring spreadsheet containing the indicators organized by domain and the instruction manual. In addition, experts were provided with a document containing the first draft set of competencies. The experts were asked to review and score the indicators individually, using a three-point Likert Scale where 1 indicated exclusion, 2 indicated uncertainty, and 3 indicated inclusion of the indicators for the Indian context. During the scoring process, experts considered the relevance of each indicator to the Indian context, provided the rationale for any rating of exclusion or uncertainty, and offered clarity on wording and accuracy as applicable to the Indian context. They also submitted comments related to specific indicators and overall feedback on domains. The experts had the opportunity to add additional components, including competency standards and indicators, for consideration by the group. The experts were given 4 weeks to review, score, and respond. Outputs from the experts were synthesized by DD and circulated to the experts before the review meetings, which were held online.

Review Meetings

The drafted set of indicators individually reviewed by the experts was divided into three categories based on the experts’ scoring of each indicator. Indicators that received scores of “3” by all experts were considered for inclusion and kept in the draft set of the Indian OT competency standards. Items that were marked with “uncertainty” or for which there was a discrepancy in scores among raters were considered to require further discussion and clarification before a decision could be made on their inclusion. Items rated as “1” by all the experts were excluded. The aim of review meetings was to discuss indicators marked with “uncertainty” and those with a discrepancy among experts. Experts carefully considered each indicator in these categories before final collaborative agreement and decision-making. The final version of the draft set of competencies was reviewed at the end of the meeting with the experts for agreement and modifications if required. Overall, meetings were a collaborative effort through open discussion and collective input, resulting in a draft set of competency standards to better reflect the Indian context.

Results

General Characteristics of Included Competency Standards

The document analysis revealed that 31 countries had established competency standards as summarized in Figure 2. Of these, 12 competency standards met inclusion criteria and were selected for detailed analysis. These included Standards of Practice for Occupational Therapy (OT), United States; Competencies for Occupational Therapists, Canada; Australian OT Competency Standards; OT Practice Guidelines, Bangladesh; Competency Standards for Occupational Therapists in Hong Kong; Standards of Proficiency for Occupational Therapists, Ireland; Professional Competence and Standards, Mauritius; Professional Competencies in OT, Netherlands; OT Standards of Practice, Philippines; Standards of Practice, Singapore; Competence Descriptions for Occupational Therapists, Sweden; and Standards of Proficiency-Occupational Therapists, United Kingdom. Only two low- and middle-income countries (Bangladesh and the Philippines) had established OT competency standards.

Nineteen competency standards were excluded based on the prespecified criteria and mutual agreement among reviewers. Documents from 15 countries (Bulgaria, Colombia, Croatia, Czech Republic, Denmark, Estonia, France, Korea, Latvia, Norway, Portugal, Romania, Spain, and Taiwan) were not available in English. The English version of New Zealand competencies was excluded from this document by mutual agreement, as some Mori terms could not be directly translated. We plan to include these competencies in a future version of the document, following the validating of translations by consulting the relevant authorities. In addition, documents from four countries were excluded due to their legislative or other specific focus and were unavailable or inaccessible.

Initial Draft of Preliminary Competency Standards

After reviewing and selecting the documents, the data were extracted and analyzed. The first draft set of competency standards included 16 domains and 97 competency standards with 277 indicators. A brief overview of each domain and competency standard is included in Appendix C.

Final Preliminary Competency Standards

Four indicators were identified for removal due to receiving two or more “exclusion” scores, signifying experts rated the indicator as irrelevant to the Indian context. Nineteen indicators were categorized as “uncertain” or showed discrepancies in “exclusion” and “inclusion” scores across raters, necessitating further discussion and clarification during the subsequent review meetings. The 19 indicators were discussed in three follow-up meetings with the EWG. The group removed four of the indicators and generated a final list of 15 indicators from the subset of indicators with discrepancies. Finally, out of a total of 277 indicators, 8 indicators were removed (4 after individual scoring and 4 after review meetings) and the final draft document included 269 indicators as illustrated in Figure 4. The number of domains, competency standards, and indicators included in the final draft set of the Indian OT competency standards are found in Table 2.

Figure 4. Results After Initial and Final Review.

*2 or more “exclude,” †Agreement by all reviewers for “inclusion,” ‡Discussed: “uncertain” or discrepancy with “remove” and “keep”

Table 2. Domains and Number of Competencies and Indicators in Each Domain.

Domains	Number of Competencies	Number of Indicators
A. Core principles for OT practice	6	18
B. Effective communication and documentation	7	15
C. Professional accountability and responsibility	8	14
D. Legislation requirements and obligations	4	10
E. Professional role and networking	8	23
F. Contextual responsiveness and adaptability	5	16
G. Decision-making and resource management	6	12
H. Quality assurance	5	20
I. Integration of theory into practice	3	19
J. Ongoing learning and continuous professional development	7	12
K. Data gathering, assessment, and intervention planning	10	30
L. Effective service delivery, monitoring, and intervention modifications	15	33
M. Transition planning and discharge management	2	10
N. Cultural safety and responsiveness	5	13
O. Skills in technology and its advancement	3	12
P. Engagement in evidence/research-informed practice	3	12
Total - domains 16	97	269

OT: Occupational therapy

Discussion

We set out to create a draft set of OT competencies for the Indian context. We made a strategic decision to adapt existing international standards to the Indian context, through a robust process of document analysis and discussion. The process involved several weeks of extensive engagement with the EWG and ensured that our preliminary adapted competency standards were comprehensive and reflective of expert agreement. By using international standards, we ensured that the Indian standards would align with globally recognized best practices in OT. The use of the WFOT entry-level framework provided the basis to categorize the common standards and offered a systematic approach by helping us identify overlaps and unique competencies among existing competency standards.

A considerable number of OT competency documents exist globally. However, these documents have largely been developed in high-income countries and have had varied language and interpretation of key concepts. Unlike high-income countries, India currently lacks an extensive infrastructure of assisted living facilities and most of the patients are discharged to their living environment or home. Given the broad term “community agencies” and the lack of an established referral system to such agencies in India, the experts determined this indicator was not relevant to the Indian context. Another example was within the domain of legislative requirements. Unlike some countries, India lacks a unified regulatory system for OTs. Recognizing this, experts decided to include a rephrased version of the indicator, such as Indicator “specify a high standard of communication skills in the local language” rephrased to “specify a high standard of communication skills, preferably in the local language or when not possible, use strategies to optimize communication.” These critical considerations ensured the competency standards accurately reflect the current regulatory framework in India.

The All India Occupational Therapy Association (AIOTA) has been the voice of OT in India for 75 years and has effectively advocated for establishing professional autonomy and excellence in OT practice, research, and teaching in India.^[25] An important step to further establish the profession is to create a national registration system for the profession. In addition, while there is a framework for competency-based curricula, there is a need for national accreditation for programs that provide OT education in India. Furthermore, there is a lack of adequate high-quality research to strengthen professional development and practice.^[26] The drafted competency standards can be a core driver for the effective implementation of the NCAHP Act and provide guidance as the councils for professional regulation emerge.^[12] Furthermore, these competency standards provide the specifics required to implement the recently introduced competency-based OT curriculum created by the Ministry of Health and Welfare.^[27] The creation of this curriculum is a significant step toward standardizing OT education and training. There is an opportunity to incorporate the findings from this study with the curriculum to ensure a competency-based curriculum for OT in India. While the curriculum provides a broad framework, it could benefit a transparent, evidence-based approach toward the inclusion of specific professional competencies that relate to the context and the skills required for occupational therapists. Clear, detailed competencies are essential to ensure the curriculum prepares professionals to meet real-world demands effectively. To support this effort, the comprehensive set of professional competencies align with evidence-based practices and reflect the current needs of the OT profession in India and align with OT competencies internationally. These draft sets of OT competencies provide a clear roadmap for skill development, detailing how they can be evaluated to ensure their effectiveness, particularly in a country like India with a rigorous research approach. In addition, incorporating greater transparency in the competency development process and engaging an inclusive team of stakeholders further strengthens its relevance and applicability. We propose this draft as a collaborative contribution for the AIOTA and the Ministry of Health and Welfare to consider.

Limitations

This document analysis has several limitations. First, we included only competency standards that were available in English. Our search also yielded very few non-English standards. Hence, we believe that the impact of this omission would be negligible. Of note, all excluded competencies were from countries classified as high-income or upper-middle-income countries and may have limited applicability to the Indian context. A second limitation is that we included only three experts in the coadaptation process. We recognize that this limited the diversity of perspectives. We chose a smaller group so we could create a preliminary draft that could be used when going forward to involve a broader group of OT professionals, academics, and later, the regulatory bodies, to review the document and provide iterative feedback. That future step will ensure that competency standards incorporate diverse perspectives. Finally, we recognize that we have used document analysis in a novel context and started with a list of potential competencies, as opposed to a de novo process; by doing so, we may have limited more culturally specific content.

We minimized the effect of these factors by taking considerable time to discuss the application of each competency in the Indian context and developing the approach described in the method section and Appendix C.

Conclusions

The competency standards we developed form the foundation for moving the field of OT in India forward. Establishing and using competencies will strengthen the standards for OT professional development in India. There is a need to pilot these standards and understand the enablers and barriers to their implementation, recognizing the importance of knowledge mobilization to enhance uptake. The next steps will involve developing and executing a knowledge mobilization plan to ensure the effective dissemination and application of the standards. The AIOTA and the IOTTT can work synergistically to bring this plan to reality and support the effective implementation of standards of professional practice in OT in India.