Meaningful occupation in older age
Section 1: Executive summary
Meaningful occupation contributes significantly to health and well-being across the life span (Hamell, 2004; Wright and Sugarman, 2009; Reed, Hocking and Smythe, 2013). With 1.4 million people aged 65 or older in the UK, focus on continued engagement in meaningful occupation during retirement is considered essential in supporting positive ageing (Hewitt, Howie and Feldman, 2009). The current socio-political climate offers the opportunity for occupational therapy to be recognised as an effective therapeutic medium through and by which to maintain wellbeing in retirement.
This paper positions occupational therapy literature, theory and practice as central to the healthy ageing process during the transition to retirement. In support of this assertion the following key points are highlighted:
- Meaningful occupation is central to the wellbeing of (older) adults.
- Retirement presents an opportunity for positive occupational engagement.
- Retirement also presents significant occupational disruption and deprivation, shaped by the temporal and social context in which the older adult lives.
- There is no recognised retirement transition support package.
- The social-political climate draws focus onto holistic, client centred working.
- There is extensive scope for occupational therapy to apply its theory base to supportive retirement transition through the design and delivery of retirement transition programmes
Section 2: Occupational therapy theory and literature: Retirement transition
Currently 14.1 million people in the UK are aged 65 or older, comprising 22.6 per cent of the overall UK population (AgeUK, 2013a). These figures are likely to continue to rise as a result of the ‘baby boom’ (Bender, 2012) and increasing longevity resulting from better health care (Schultz and Wang, 2011). Whilst recognised as a positive shift (World Health Organisation: WHO, 2012) this has inevitably resulted in a larger proportion of the population being retired. Occupational therapy is required to respond to the needs of the broad spectrum of society (COT, 2010), making this shift a contemporary research and practice concern.
Active ageing is considered central in effectively supporting the increasingly ageing population and is defined by WHO (2002) as optimised health, participation and security, resulting in wellbeing. Occupational therapy has long viewed participation in meaningful occupation as central to personal well-being (Hammell, 2004; Reed, Hocking and Smythe, 2013) through its theoretical position and, recently, through a growing body of occupational science literature (Hocking and Wright-St.Clair,2011). Reed, Hocking and Smythe (2013) establish the current view (though evolving over time) that meaningful occupation is central to the individual’s sense of identity, shaping the choices an individual makes and how they spend their time. Additionally, meaningful occupation is thought to be shaped by the cultural and social environment in which the occupation takes place.
This relationship between occupational engagement and well-being is captured theoretically within a number of contemporary models of occupational therapy. For example, the Canadian Model of Occupational Performance and Engagement (CMOP-E; Polatajko, Townsend and Craik, 2007) demonstrates the interplay between individuals and their environment, and presents health, wellbeing and occupational justice as being achievable through effective occupational engagement (Polatajko, Townsend and Craik, 2007). This model of occupation demonstrates the link between the person and the environment in which they exist, with occupational engagement occurring across a function-dysfunction continuum. Optimal engagement is impacted on by a lack of occupational opportunity, restrictive environment or personal limitations. A wealth of literature exists to demonstrate the value of this model in representing the person-environment-occupation relationship (Bonikowsky, 2012), relevant in this case for its applicability across the ages (Dorestein and Hocking, 2010).
The Model of Human Occupation (MOHO: Kielhofner, 2008), presents the link between the individual, their occupational identity, volition and habituation, and the environment. A balance of these factors is seen as being necessary for effective occupational engagement and ultimately, increased well-being. There is a body of evidence showing the model to be effective in presenting the occupational experience of older people (Dorestein and Hocking, 2010; Lee et al., 2008).
Both theoretical models discussed (amongst others), consider the individual from a holistic perspective; one who is continually interacting with the contextual environment. Whilst these models do not directly address the inter-relationship of any specific group of individuals or life event, they offer a framework for presenting the dynamics of the person-environment-occupation relationship, its impact on occupational engagement, and dysfunction. Indeed, Reed, Hocking and Smythe, 2013 carried out a hermeneutic review of the theory and literature of occupational therapy. While this was considered to be a valuable research approach due to its focus on personal meanings (Thomson, Dykes and Downe, 2011) Reed, Hocking and Smythe (2013) found the approaches that did not consider the relationship between the individual, their context and occupation were limited in their ability to achieve wellbeing through occupation
The contribution of meaningful occupation to wellbeing is no less relevant for the community-dwelling older adult. Stav et al. (2010) completed a systematic review exploring the benefits of occupational engagement to older adults. They established that participation in occupation, physical activity, work, leisure and sleep, promotes health and wellbeing in the older adult. Similar views were echoed by the World Health Organisation (2012) who emphasised the importance of active participation for healthy ageing. The College of Occupational Therapists (COT: 2011) reinforce this perspective within their own professional guidance publications.
An occupational perspective of the later stage of adulthood has been important in recognising the impact of a change in roles that can occur during the ageing process. This might include loss of a role as partner and friend through bereavement (Kielhofner, 2008), or the addition of that of grandparent (AgeUk, 2013a). For example, Kielhofner (2008) focussed on the individual and the shift in their occupational roles, habits and volition during older age resulting from the complex interplay between physical, social and environmental challenges of ageing. Recent occupationally focussed research has considered the quality of life achieved through the personal importance given to ongoing engagement in occupations and the sense of enjoyment experienced across the three domains of doing, being and becoming in older age (Hibbert, Heathcote and Chia, 2011).
Focus on the ageing population must consider the process of retirement (AgeUk, 2012). Retirement has been deﬁned as ‘the period following an individual’s complete withdrawal from participation in the paid workforce’ (Hewitt, Howie and Feldman, 2009 p. 9). Covering the cessation of full-time, life long careers and part-time work (Pettigrew and Prior, 2011) retirement is considered a key phase in older adulthood from an occupational life-course perspective (Wright and Sugarman, 2009). From more general health- and social-care perspectives (National Health Service: NHS, 2001) retiring from employment (full- or part-time) as a result of age is seen as the first phase of older adulthood, preceding those where the adult might experience less independence and require more direct support.
Much research has been published of the practical implications of retirement, such as financial provision and pension planning (Scott, 2011; Graham, 2011; Harman, 2012). Often this research is conducted from a fiscal perspective, largely due to the need to manage workforces effectively (Voelpel and Steb, 2010) and reduce ongoing social welfare reliance (Royal College Nursing, 2010). This literature base provides some insight into the contextual aspects of retirement, such as limited resources. However, there is little consideration of the impact of retirement on the occupational functioning and therefore the wellbeing of the older adult as, presumably, was obtained from engagement in meaningful occupation during the working life.
Occupational therapy offers a small, but growing body of literature exploring retirement from an occupational perspective. When the older person is considered to be an occupational being (Odewara, 2010), there is the recognition that retirement offers positive opportunities for increased leisure time and the uptake of new roles (Kielhofner, 2008; REF). For many, this increased freedom of time and choice is welcomed (Pettigrew and Prior, 2011).
The negative impact on wellbeing through the occupational disruption caused by retirement is also explained within the occupational therapy literature. Employment is recognised as a substantial, meaningful occupation for many, taking up a considerable proportion of life from schooling years onwards (AgeUk, 2013). It is proposed that employment is representative of an innate desire to be meaningfully occupied as well as providing the opportunity to fulfil personal and contextually shaped roles associated with being carer, parent and partner (COT, 2007). It impacts positively on health, wellbeing, and wider cost to society through reduced access to health services (Black and Frost, 2011).
Retirement results in a void of meaningful paid occupation. In their study, Peppin and Deutscher (2011) found the retirement process results in the reduction of occupational roles and occupational identity. These need to be restored in order to achieve the wellbeing afforded by occupational engagement experienced at any other life stage (Kielhofner, 2008). The work of Peppin and Deutscher (2011), although based on an Australian sample, is similar to that of Odawara (2010) who noted that occupational continuity through periods of change, such as retirement, was essential for providing a sense of safety and security.
Pettigrew and Prior (2011) further developed the occupational view of retirement as a significant life course transition, consisting of three phases: planning for retirement, enjoyment of new freedom and finally, a desire for routine. This approach would appear to echo the doing, being and becoming of occupational engagement established as the key-stone to well-being (Hamell, 2004; Doble and Santha, 2008). Applying this model to the retirement transition, Wright-St. Clair (2012) reiterated the importance of ongoing engagement in meaningful occupations that help to maintain a positive self-identity from the past, in the present and into the future. The rewards associated with being able to act as an occupational being are impacted on significantly by a lack of connection to the future. This work also established occupational engagement as being essential to the health and wellbeing of the retired older adult. Whilst there are limitations to both of these studies due to their small sample size and limited wider application of the ethnographic data, they clearly demonstrate the relationship between occupation and the person.
The older retiree’s context is a necessary consideration in the occupational therapy literature that explores the transition from employee to retiree. Occupational context is defined as ‘a variety of interrelated conditions within and surrounding the client that inﬂuence performance’ (American Occupational Therapy Association: AOTA, 2002, p. 623). It is considered central within theoretical models of occupational therapy (Kielhofner, 2008). Occupational context takes into consideration the temporal, personal and virtual contexts in which the retiree exists, mindful of the changing dynamics of these. Occupational therapy theory offers clear opportunity for consideration of these aspects of the retiree’s context, though to date there has been limited exploration of the impact of the context on the individual’s wellbeing during retirement.
Adjustment is a necessary aspect of life changes (Wrosch, Amir and Gregory, 2011; Frazier et al., 2011). Kielhofner (2008) noted that effective retirement requires occupational adjustment; taking on new roles and engaging in activities that provide personal reward. Retirement adjustment literature, though predominately offering a psychological perspective may be relevant when considering the occupational process of retirement in the context of the older adult. Donaldson, Earl and Muratore (2010), for example, recognised that effective adjustment to retirement is influenced by context as well as psycho-social factors.
Occupational adjustment resulting from the response to an internal or external change (such as voluntary termination of employment) is likely to happen over three phases: exploration, competency and achievement (Kielhofner, 2008). Ability to achieve, maintain and express self and social identity is essential to positive adaptation through life’s events (Lahberte-Rudman, 2011).
The importance of planning for retirement is widely recognised within the occupational therapy literature. Pettican and Prior (2011), Peppin and Deutscher (2011), and Hewitt, Howie and Feldman (2009) all recognise the importance of planning for this major transition, taking into consideration role loss and the importance of occupations remaining personally meaningful. In these studies participants maintained that they had not valued planning opportunities prior to retirement, only recognising their value afterwards. Others noted the need for stronger emphasis on the psycho-social aspects of retirement planning to complement the wealth of fiscal advice. This reflects the holistic occupational perspective of the individual (Kielhofner, 2008; Polatajko, Townsend and Craik, 2007).
Section 3: Occupational therapy practice: retirement transition
The value placed on engagement in meaningful occupation for health and wellbeing outcomes is clearly evident in the occupational therapy theory and literature. The fundamental ethos of occupational therapy practice is client driven and occupationally centred (COT 2008). Whilst this approach to practice may be occurring more readily within interprofessional health and social care settings, it seems that it is being driven largely by recent Government policy, including the Health and Social Care Act (Great Britain, 2012) and most recently the draft Care and Support Bill (Great Britain, Department of Health, 2013).
The benefits of occupational engagement for the older adult are implied in a number of key public health strands. For example, well-being for the older adult’s mental health (National Institute for Clinical Excellence: NICE, 2008) and management of long term absence of illness (NICE, 2009). Until recently, however, the role of the occupational therapist, along with other allied health professionals, has been clearly defined in only a small proportion of health and social care publications (NHS Scotland, 2010). Conversely, in practice, occupational therapists are increasingly taking leading roles in the management of care, applying profession-specific theoretical models in the design and delivery of holistic care packages, documented across a range of international peer reviewed sources (Metzler, Hartman and Lowenthal, 2012). The author questions, however, whether the true power of occupation theory and literature in driving the wellbeing of the older adult is fully realised.
In practice, the work of the occupational therapist related to employment occupations has been focussed on maintaining clients in employment. The College of Occupational Therapists (COT) (2007) recognises that whilst not all individuals desire to be in paid employment, most people would chose to be occupied with an activity that has personal meaning to them, providing an occupational role and identity (Kielhofner, 2008). In support of this assertion, and with the Government’s drive to increase employment and reduce the social and economic burden of unemployment, COT produced the working document, Work Matters (COT, 2007). This provides guidance for the role of the occupational therapist in client-centred employment planning across three key areas of focus: person, environment and function (COT 2007).
Progression to retirement, however, was determined as the first point at which an individual enters the ageing adult health and social care arena (NHS, 2001). Whilst acknowledging the value of employment, in practice there appears to be limited focus on the value of meaningful occupation beyond working age for the healthy older adult, and particularly the void left by involuntary loss of the employed-worker role and identity. Focus is still on applying occupational therapy intervention to entry and maintenance of employment, with exit and subsequent occupational transition being devalued. Recognition of the fluidity of the life course (Wright and Sugarman, 2009) and the necessary stages of occupational adjustment (Kielhofner, 2008) would ensure a client-centred, holistic approach more reflective of both COT’s (2010) core ethos and the health, care and support reforms.
The rapidly changing socio-political climate in which occupational therapy is practiced may be considered as a potential barrier to the application of evidence-based interventions to wider client groups (Crahm, White and Kruppa, 2013) including the older retiree. Indeed, WHO (2012) recognises there are a significant number of barriers to the effective knowledge transfer specifically around the topic of well ageing, and suggest the structured application of knowledge-transfer techniques to ensure effective service provision for this client group (WHO, 2012).
The draft Care and Support Bill (Great Britain. Department of Health, 2012) proposes modernisation of care and support systems through the provision of one law. This is likely to shape the context in which the retired older adult exists, and occupational therapy services operate. Whilst the focus remains to a degree on the latter stages of older adulthood, the lawful provision for the role of wellbeing in maintaining independence provides the opportunity for direct application of occupational therapy theory: understanding of the person, context, and occupational relationship (COT, 2012). Similarly, the Health and Social Care Act (Great Britain. 2012) also offers the opportunity for occupationally focussed practice through recognition of the needs of the individual (COT, 2012), whilst the Welfare Reform Act (Great Britain, 2012) may act to amplify the professions’ drive to value occupation to health and wellbeing. There is no direct mention of the retirement transition within these drivers, despite their application to the entire life course. However, they clearly open an avenue supportive of the occupational perspective (COT, 2012).
Section 4: The way forward: occupational therapy and retirement transition
The in-depth knowledge and understanding of the fit between person, context, and occupation places the occupational therapist in prime position to assist retirees in the transition process (Hewitt, Howie and Feldman, 2009; Kendig, 2010). Indeed, Pettigrew and Prior (2011) emphasise the importance of occupational therapy in responding to the increasing need for support during the retirement transition, given its inherent occupational focus. Culturally, the role of the occupational therapist practicing with older adults is not new, and the 2012 amendments to the Equality Act (2010) making ageism in the provision of services unlawful, further strengthens the position of the occupational therapist (and other allied health professionals) in providing services to meet the needs of the older client. Two key themes for future direction have emerged within this position paper: further research applied to practice and direct occupational therapy intervention.
The role of the occupational therapist as an evidence-based practitioner is clear (COT, 2010). Hewitt, Howie and Feldman (2009) state that additional research is needed to gain a fuller understanding of the processes involved in retirement transition to ensure interventions are timely and targeted.
WHO (2012) highlighted the importance of sharing theory and research in practice. Noting the challenges to information-sharing across professionals working with the ageing adult, WHO suggests a ‘knowledge transfer framework for healthy ageing adults’ (WHO, 2012). Though complex and designed to meet the directives of a wider range of professional bodies, its value to occupational therapy practice is clear. In particular, the opportunity it presents to reduce the ‘know-do’ gap (WHO, 2012) evidenced in this position paper. Consideration of new ways of working, such as application of this framework to enhance the theory and evidence base is encouraged within the profession. For example, Anderson and Nelson (2011) call for entrepreneurialism within the profession to ensure the needs of the wider client group are met.
The current health, social care and support reforms herald a period of opportunity for occupational therapists to apply their theoretical knowledge in practice. Stav et al. (2012) note the need for occupational therapy wellness programmes across all areas of the health- and social-care spectrum for maintaining the ongoing occupational engagement of community-dwelling adults. Localisation, with GP-led commissioning and Health Watch (Great Britain, Department of Health, 2012) may offer avenues through which to raise awareness of the value of occupational retirement transition planning and facilitate application across a broader range of settings.
When designing interventions to support the occupational retirement transition, Zecevic (2010) makes clear the importance of expanding the concept of occupation. In particular, focus is on the value of reflexivity in the doing of occupation and recognition of spirituality as a meaningful occupation. An occupational therapy retirement-planning programme might offer the opportunity to people to reflect on their working life and incorporate this personal learning into transition planning. In so doing, the client can be supported through the three stages of healthy retirement identified by Hewitt, Howie and Feldman (2009): preparation, transition from worker to retiree and final adjustment to retirement.
The reforms which facilitate the application of occupational therapy during retirement transition also call for stringent economic measures. Whilst this may present challenges when considering the professional requirement to provide services aligned with available resources (COT, 2010) it may also open up additional opportunities. For example, the increased use of information technology amongst both the older population (Wagner, 2010) and the health professions (Koti, 2010) may make an online retirement-transition support-package an appropriate, cost effective intervention method.
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