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OCCUPATIONAL THERAPY PRACTICE
FRAMEWORK:
Domain & Process
3rd Edition
Contents PREFACE
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S1 The Occupational Therapy Practice Framework: Domain and Process, 3rd edi-
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S1
Evolution of This Document . . . . . . . . . . . . . . . . . . . . .S2 tion (hereinafter referred to as “the Framework”), is an official document of
Vision for This Work . . . . . . . . . . . . . . . . . . . . . . . . . .S3 the American Occupational Therapy Association (AOTA). Intended for oc-
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S3
Domain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S4 cupational therapy practitioners and students, other health care professionals,
Occupations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S5 educators, researchers, payers, and consumers, the Framework presents a sum-
Client Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S7
Performance Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . .S7 mary of interrelated constructs that describe occupational therapy practice.
Performance Patterns . . . . . . . . . . . . . . . . . . . . . . . . . .S8
Context and Environment . . . . . . . . . . . . . . . . . . . . . . .S8 Definitions
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S9
Overview of the Occupational Therapy Process . . . . .S10 Within the Framework, occupational therapy is defined as
Evaluation Process . . . . . . . . . . . . . . . . . . . . . . . . . . .S13 the therapeutic use of everyday life activities (occupations) with individ-
Intervention Process . . . . . . . . . . . . . . . . . . . . . . . . .S14
Targeting of Outcomes . . . . . . . . . . . . . . . . . . . . . . . .S16 uals or groups for the purpose of enhancing or enabling participation
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S17 in roles, habits, and routines in home, school, workplace, community,
Tables and Figures and other settings. Occupational therapy practitioners use their knowl-
Table 1 . Occupations . . . . . . . . . . . . . . . . . . . . . . . . .S19
Table 2 . Client Factors . . . . . . . . . . . . . . . . . . . . . . . .S22 edge of the transactional relationship among the person, his or her en-
Table 3 . Performance Skills . . . . . . . . . . . . . . . . . . . .S25 gagement in valuable occupations, and the context to design occupa-
Table 4 . Performance Patterns . . . . . . . . . . . . . . . . . .S27 tion-based intervention plans that facilitate change or growth in client
Table 5 . Context and Environment . . . . . . . . . . . . . . .S28
Table 6 . Types of Occupational Therapy factors (body functions, body structures, values, beliefs, and spirituality)
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S29 and skills (motor, process, and social interaction) needed for successful
Table 7 . Activity and Occupational Demands . . . . . . .S32
Table 8 . Approaches to Intervention . . . . . . . . . . . . . .S33 participation. Occupational therapy practitioners are concerned with
Table 9 . Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . .S34 the end result of participation and thus enable engagement through ad-
Exhibit 1 . Aspects of the Domain of Occupational aptations and modifications to the environment or objects within the
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S4
Exhibit 2 . Process of Occupational Therapy environment when needed. Occupational therapy services are provided
Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . .S10 for habilitation, rehabilitation, and promotion of health and wellness for
Exhibit 3 . Operationalizing the Occupational clients with d isability- and non–disability-related needs. These services
Therapy Process . . . . . . . . . . . . . . . . . . . . . . . . . . . .S17
Figure 1 . Occupational Therapy’s Domain . . . . . . . . . .S5 include acquisition and preservation of occupational identity for those
Figure 2 . Occupational Therapy’s Process . . . . . . . . .S10 who have or are at risk for developing an illness, injury, disease, disorder,
Figure 3 . Occupational Therapy Domain condition, impairment, disability, activity limitation, or participation
and Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S18
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S36 restriction. (adapted from AOTA, 2011; see Appendix A for additional
Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S40 definitions in a glossary)
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S40
Appendix A . Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S41 When the term occupational therapy practitioner is used in this document,
Appendix B . Preparation and Qualifications of Occupational it refers to both occupational therapists and occupational therapy assistants
Therapists and Occupational Therapy Assistants . . .S47
(AOTA, 2006). Occupational therapists are responsible for all aspects of oc-
Copyright © 2014 by the American Occupational Therapy cupational therapy service delivery and are accountable for the safety and ef-
Association .
fectiveness of the occupational therapy service delivery process. Occupational
When citing this document the preferred reference is: Ameri- therapy assistants deliver occupational therapy services under the supervision
can Occupational Therapy Association . (2014) . Occupational
therapy practice framework: Domain and process (3rd ed .) . of and in partnership with an occupational therapist (AOTA, 2009). Addi-
American Journal of Occupational Therapy, 68(Suppl . 1), S1– tional information about the preparation and qualifications of occupational
S48 . http://dx .doi .org/10 .5014/ajot .2014 .682006
therapists and occupational therapy assistants can be found in Appendix B.
The American Journal of Occupational Therapy S1
Copyright © 2014 by the American Occupational Therapy Association.
Evolution of This Document refinement of the writing and the addition of emerging
The Framework was originally developed to articulate concepts and changes in occupational therapy. The ra-
occupational therapy’s distinct perspective and contri- tionale for specific changes can be found in Table 11 of
bution to promoting the health and participation of per- the second edition of the Framework (AOTA, 2008, pp.
sons, groups, and populations through engagement in 665–667).
occupation. The first edition of the Framework emerged In 2012, the process of review and revision of the
from an examination of documents related to the Occu- Framework was initiated again. Following member re-
pational Therapy Product Output Reporting System and view and feedback, several modifications were made
Uniform Terminology for Reporting Occupational Therapy to improve flow, usability, and parallelism of concepts
Services (AOTA, 1979). Originally a document that re- within the document. The following major revisions
sponded to a federal requirement to develop a uniform were made and approved by the RA in the Fall 2013
reporting system, the text gradually shifted to describing meeting:
and outlining the domains of concern of occupational • The overarching statement describing occupa-
therapy. tional therapy’s domain is now stated as “achiev-
The second edition of Uniform Terminology for Oc- ing health, well-being, and participation in life
cupational Therapy (AOTA, 1989) was adopted by the through engagement in occupation” to encom-
AOTA Representative Assembly (RA) and published in pass both domain and process.
1989. The document focused on delineating and defining • Clients are now defined as persons, groups, and
only the occupational performance areas and occupational populations.
performance components that are addressed in occupa- • The relationship of occupational therapy to orga-
tional therapy direct services. The third and final revision nizations has been further defined.
of Uniform Terminology for Occupational Therapy (AOTA, • Activity demands has been removed from the do-
1994) was adopted by the RA in 1994 and was “expanded main and placed in the overview of the process to
to reflect current practice and to incorporate contextual as- augment the discussion of the occupational ther-
pects of performance” (p. 1047). Each revision reflected apy practitioner’s basic skill of activity analysis.
changes in practice and provided consistent terminology • Areas of occupation are now called occupations.
for use by the profession. • Performance skills have been redefined, and Table
In Fall 1998, the AOTA Commission on Practice 3 has been revised accordingly.
(COP) embarked on the journey that culminated in • The following changes have been made to the in-
the Occupational Therapy Practice Framework: Domain terventions table (Table 6):
and Process (AOTA, 2002b). At that time, AOTA also o Consultation has been removed and has been in-
published The Guide to Occupational Therapy Practice fused throughout the document as a method of
(Moyers, 1999), which outlined contemporary practice service delivery.
for the profession. Using this document and the feedback o Additional intervention methods used in prac-
received during the review process for the third edition of tice have been added, and a clearer distinction
Uniform Terminology for Occupational Therapy, the COP is made among the interventions of occupations,
proceeded to develop a document that more fully articu- activities, and preparatory methods and tasks.
lated occupational therapy. o Self-advocacy and group interventions have been
The Framework is an ever-evolving document. As added.
an official AOTA document, it is reviewed on a 5-year o Therapeutic use of self has been moved to the
cycle for usefulness and the potential need for further process overview to ensure the understanding
refinements or changes. During the review period, the that use of the self as a therapeutic agent is inte-
COP collects feedback from members, scholars, authors, gral to the practice of occupational therapy and
practitioners, and other stakeholders. The revision pro- is used in all interactions with all clients.
cess ensures that the Framework maintains its integrity • Several additional, yet minor, changes have been
while responding to internal and external influences that made, including the creation of a preface, reorga-
should be reflected in emerging concepts and advances in nization for flow of content, and modifications to
occupational therapy. several definitions. These changes reflect feedback
The Framework was first revised and approved by received from AOTA members, educators, and
the RA in 2008. Changes to the document included other stakeholders.
S2 March/April 2014, Volume 68(Supplement 1)
Copyright © 2014 by the American Occupational Therapy Association.
Vision for This Work establishing a therapeutic relationship with each client
Although this revision of the Framework represents the and designing a treatment plan based on knowledge
latest in the profession’s efforts to clearly articulate the about the client’s environment, values, goals, and de-
occupational therapy domain and process, it builds on a sires (Meyer, 1922). They advocated for scientific prac-
set of values that the profession has held since its found- tice based on systematic observation and treatment
ing in 1917. This founding vision had at its center a (Dunton, 1934). Paraphrased using today’s lexicon, the
profound belief in the value of therapeutic occupations founders proposed a vision that was occupation based,
as a way to remediate illness and maintain health (Sla- client centered, contextual, and evidence based—the vi-
gle, 1924). The founders emphasized the importance of sion articulated in the Framework.
INTRODUCTION vided directly to clients using a collaborative approach
or indirectly on behalf of clients through advocacy or
The purpose of a framework is to provide a structure or consultation processes.
base on which to build a system or a concept (American Organization- or systems-level practice is a valid and
Heritage Dictionary of the English Language, 2003). The important part of occupational therapy for several reasons.
Occupational Therapy Practice Framework: Domain and First, organizations serve as a mechanism through which
Process describes the central concepts that ground occu- occupational therapy practitioners provide interventions
pational therapy practice and builds a common under- to support participation of those who are members of or
standing of the basic tenets and vision of the profession. served by the organization (e.g., falls prevention program-
The Framework does not serve as a taxonomy, theory, or ming in a skilled nursing facility, ergonomic changes to an
model of occupational therapy. assembly line to reduce cumulative trauma disorders). Sec-
By design, the Framework must be used to guide ond, organizations support occupational therapy practice
occupational therapy practice in conjunction with the and occupational therapy practitioners as stakeholders in
knowledge and evidence relevant to occupation and oc- carrying out the mission of the organization. It is the fidu-
cupational therapy within the identified areas of prac- ciary responsibility of practitioners to ensure that services
tice and with the appropriate clients. Embedded in this provided to organizational stakeholders (e.g., third-party
document is the profession’s core belief in the positive payers, employers) are of high quality and delivered in an
relationship between occupation and health and its view efficient and efficacious manner. Finally, organizations em-
of people as occupational beings. Occupational therapy ploy occupational therapy practitioners in roles in which
practice emphasizes the occupational nature of humans they use their knowledge of occupation and the profession
and the importance of occupational identity (Unruh, of occupational therapy indirectly. For example, practi-
2004) to healthful, productive, and satisfying living. As tioners can serve in positions such as dean, administrator,
Hooper and Wood (2014) stated, and corporate leader; in these positions, practitioners sup-
A core philosophical assumption of the profes- port and enhance the organization but do not provide cli-
sion, therefore, is that by virtue of our biological ent care in the traditional sense.
endowment, people of all ages and abilities require The Framework is divided into two major sections:
occupation to grow and thrive; in pursuing occu- (1) the domain, which outlines the profession’s purview
pation, humans express the totality of their being,
a mind–body–spirit union. Because human exis- and the areas in which its members have an established
tence could not otherwise be, humankind is, in body of knowledge and expertise, and (2) the process,
essence, occupational by nature. (p. 38) which describes the actions practitioners take when
The clients of occupational therapy are typically providing services that are client centered and focused
classified as persons (including those involved in care of on engagement in occupations. The profession’s under-
a client), groups (collectives of individuals, e.g., families, standing of the domain and process of occupational
workers, students, communities), and populations (col- therapy guides practitioners as they seek to support cli-
lectives of groups of individuals living in a similar lo- ents’ participation in daily living that results from the
cale—e.g., city, state, or country—or sharing the same dynamic intersection of clients, their desired engage-
or like characteristics or concerns). Services are pro- ments, and the context and environment (Christiansen
The American Journal of Occupational Therapy S3
Copyright © 2014 by the American Occupational Therapy Association.
& Baum, 1997; Christiansen, Baum, & Bass-Haugen, occupational therapy intervention are multidimen-
2005; Law, Baum, & Dunn, 2005). sional and support the end result of participation.
Although the domain and process are described sepa- • Engagement in occupation—performance of oc-
rately, in actuality they are linked inextricably in a transac- cupations as the result of choice, motivation, and
tional relationship. The aspects that constitute the domain meaning within a supportive context and environ-
and those that constitute the process exist in constant inter- ment. Engagement includes objective and subjec-
action with one another during the delivery of occupational tive aspects of clients’ experiences and involves the
therapy services. In other words, it is through simultane- transactional interaction of the mind, body, and
ous attention to the client’s body functions and structures, spirit. Occupational therapy intervention focuses
skills, roles, habits, routines, and context—combined with on creating or facilitating opportunities to engage
a focus on the client as an occupational being and the in occupations that lead to participation in desired
practitioner’s knowledge of the health- and performance- life situations (AOTA, 2008).
enhancing effects of occupational engagements—that out-
comes such as occupational performance, role competence, Domain
and participation in daily life are produced.
Achieving health, well-being, and participation in Exhibit 1 identifies the aspects of the domain, and Fig-
life through engagement in occupation is the overarching ure 1 illustrates the dynamic interrelatedness among
statement that describes the domain and process of oc- them. All aspects of the domain, including occupations,
cupational therapy in its fullest sense. This statement client factors, performance skills, performance patterns,
acknowledges the profession’s belief that active engage- and context and environment, are of equal value, and
ment in occupation promotes, facilitates, supports, and together they interact to affect the client’s occupational
maintains health and participation. These interrelated identity, health, well-being, and participation in life.
concepts include Occupational therapists are skilled in evaluating all
• Health—“a state of complete physical, mental, aspects of the domain, their interrelationships, and the
and social well-being, and not merely the absence client within his or her contexts and environments. In ad-
of disease or infirmity” (World Health Organiza- dition, occupational therapy practitioners recognize the
tion [WHO], 2006, p. 1). importance and impact of the mind–body–spirit con-
• Well-being—“a general term encompassing the nection as the client participates in daily life. Knowledge
total universe of human life domains, including of the transactional relationship and the significance of
physical, mental, and social aspects” (WHO, meaningful and productive occupations form the basis
2006, p. 211). for the use of occupations as both the means and the ends
• Participation—“involvement in a life situation” of interventions ( Trombly, 1995). This knowledge sets
(WHO, 2001, p. 10). Participation naturally oc- occupational therapy apart as a distinct and valuable ser-
curs when clients are actively involved in carrying vice (Hildenbrand & Lamb, 2013) for which a focus on
out occupations or daily life activities they find pur- the whole is considered stronger than a focus on isolated
poseful and meaningful. More specific outcomes of aspects of human function.
CLIENT PERFORMANCE PERFORMANCE CONTEXTS AND
OCCUPATIONS FACTORS SKILLS PATTERNS ENVIRONMENTS
Activities of daily living Values, beliefs, and Motor skills Habits Cultural
(ADLs)* spirituality Process skills Routines Personal
Instrumental activi- Body functions Social interaction skills Rituals Physical
ties of daily living Body structures Roles Social
(IADLs) Temporal
Rest and sleep Virtual
Education
Work
Play
Leisure
Social participation
*Also referred to as basic activities of daily living (BADLs) or personal activities of daily living (PADLs).
Exhibit 1. Aspects of the domain of occupational therapy. All aspects of the domain transact to support engagement,
participation, and health. This exhibit does not imply a hierarchy.
S4 March/April 2014, Volume 68(Supplement 1)
Copyright © 2014 by the American Occupational Therapy Association.
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