Occupational Therapy Education and Entry-Level Practice: A Systematic Review

Abstract

Occupational therapists can currently enter clinical practice with either a master’s or clinical doctorate-level degree, as mandated by the American Occupational Therapy Association (AOTA); however, the single vs. dual points of entry remains a topic of debate among practitioners and stakeholders. This systematic review addresses the question of whether existing knowledge around this topic provides defensible policy decision making. As such, the overarching objective was to expound on this current issue in education by aggregating existing literature and synthesizing data related to entry mandates to practice occupational therapy (OT). From 20 May to 20 June 2021, a systematic search of three electronic scientific databases (Web of Science, PubMed, and Sports Medicine and Education Index) and the Google Scholar database was performed. Following the 2020 PRSIMA guidelines, a total of 15 articles met our established inclusion criteria, which included: (1) publication date from 1 January 2008 or later; (2) North American OT programs only; (3) articles that specifically focused on OT and entry-level degree requirements; and (4) articles published in English. Bias was assessed using risk level categorizations recommended by Cochran Collaboration. Participants across the articles included in this review (N = 1749) ranged from OT practitioners and assistants, program directors, and supervisors, to current students, graduates, and faculty. Results were categorized into two central themes related to each side of the debate, and findings indicated that a majority of the participants support maintaining two entry points into the profession, despite compelling arguments having been made for both sides. The authors acknowledge the presence of several limitations in the included studies and advocate that more evidence-based research focusing on objective measures, rather than commentaries and opinions, of clinical performance outcomes between the two OT degree groups is needed to ensure that patient needs continue to be effectively addressed and policy decision making is justifiable.

1. Introduction

Given the significance of the healthcare education sector in shaping the future of quality care, continued dialogue on issues in education and policy requirements for professional development is vital in ensuring delivery of the most effective practices going forward. While graduate-level training generally provides a robust foundation for aspiring healthcare professionals, addressing questions centered around appropriate levels of educational preparation and degree mandates for clinical practice remains critical. As it pertains to occupational therapy (OT) specifically, the Accreditation Council for Occupational Therapy Education (ACOTE) reports that there are 234 accredited graduate-level OT programs in the United States as of April 2022, 63 of which are offered at the doctoral level [1]. Nevertheless, degree-level requirements for entry-level OT practice remains a topic of debate among practitioners and stakeholders.

The American Occupational Therapy Association (AOTA) is a national member-based organization established in 1917 that supports and advances the profession of OT and its practitioners and students through advocacy, education, and research [2]. Since 2007, AOTA has only offered accreditation to post-baccalaureate programs, where either a master’s degree, generally credentialed as Master of Occupational Therapy (MOT) or Master of Science in Occupational Therapy (MSOT), or a clinical doctorate, generally credentialed as Doctor of Occupational Therapy or Occupational Therapy Doctorate (OTD), is required to practice OT in the U.S., e.g., [3,4]. However, this transition away from offering accredited programs at the bachelor’s level to a dual entry system still was not met with universal endorsement by practitioners and stakeholders, as debate continued regarding whether mandating two entry points into the profession was the most appropriate decision. In response, the ACOTE announced in August 2017 that occupational therapists would require a doctoral degree for entry-level practice by 2027 (i.e., a single point of entry) [5]. This decision did not stand long as it was reversed in April 2019, when AOTA’s Representative Assembly determined that occupational therapists may enter the profession with either a master’s or doctorate degree [6], thus vetoing the previous mandate and voting to maintain two entry-level degrees. To date, this still stands as AOTA’s official policy for entry into the OT profession [7].

In comparison, the Canadian Association of Occupational Therapists (CAOT) announced in 2001 that, starting in 2008, accreditation will only be granted to OT educational programs that lead to a professional master’s degree in OT as the entry-level credential [8]. This policy has not been amended since. As such, these recurrent modifications to degree-level requirements to practice OT (particularly in the U.S.) may lead to confusion among the public and particularly prospective OT students. This becomes particularly noteworthy given the aging North American population and large demand for new allied health professionals. According to the U.S. Bureau of Labor Statistics, employment of occupational therapists is projected to grow 17% from 2020 to 2030 [9]. With this projected increase, many prospective OT students and stakeholders may find special interest in the recent bids to move towards a single point of entry into the profession.

The implications of imposing new mandates without thoughtful consideration that is supported by objective data and supplemented with open and transparent discourse can be significant. The repercussions of such mandates may extend beyond affecting just patients, practitioners, and employers, but also the ability to recruit high quality candidates both domestically and internationally. We chose to conduct a systematic review in order to identify, evaluate, and summarize findings of all relevant studies related to our question of whether existing knowledge around this topic provides defensible policy decision making. As such, the main objective of this systematic review was to expound on this current issue in education by aggregating existing literature and synthesizing data related to mandating an entry-level doctorate for OT practice. In turn, we hope that this review clarifies some of the confusion created by the mandate changes by illuminating thought-provoking perspectives from a host of sources, which ultimately generates a more cohesive understanding for all interested parties. From a broader perspective, examining education requirements for clinical practice through a historical lens and how different levels of training affects new practitioner capabilities may help inform future policy and practice guidelines.

2. Materials and Methods

2.1. Eligibility Criteria

The articles included in the review were required to meet the following criteria: (1) publication date from 1 January 2008 or later; (2) North American OT programs only; (3) articles that specifically focused on OT and entry-level degree requirements; and (4) articles published in English. We only included published articles from 2008 and later due to the new accreditation standards for post-baccalaureate programs being implemented in 2007, as set forth by AOTA. We also elected to include articles from Canada given the country’s proximity to the U.S. and relative similarity of how OT programs are administered compared to countries in other continents. Given the relatively limited pool of relevant literature on this topic, we felt that this addition would provide further context to our question exploring defensible policy decision making by AOTA. We excluded articles that (1) did not discuss the entry-level degree dilemma and (2) had no full-text availability.

2.2. Information Sources and Search Strategy

From 20 May to 20 June 2021, a systematic search of three electronic scientific databases (Web of Science, PubMed, and Sports Medicine and Education Index) and the Google Scholar database was performed. Using the relevant database search engines, we selected “topic” for each search query in the Web of Science database, “title/abstract” in the PubMed database, and “anywhere” in the Sports Medicine and Education Index database. See

Table 1. Search queries used in database search.

Database	Search Queries Used
Web of Science	occupational therapy AND clinical doctorate; occupational therapy AND doctorate; entry-level occupational therapy AND doctorate; entry-level occupational therapy AND clinical doctorate; occupational therapy doctorate AND perceptions; occupational therapy doctorate AND united states; occupational therapy doctorate AND Canada; occupational therapy AND doctoral; occupational therapy AND clinical doctoral; occupational therapy AND postbaccalaureate; occupational therapy AND OTD
PubMed	occupational therapy clinical doctorate perceptions; occupational therapy doctorate perceptions; occupational therapy doctorate [Title/Abstract]); occupational therapy clinical doctorate [Title/Abstract]; occupational therapy OTD perceptions; occupational therapy [Title/Abstract] AND debate [Title/Abstract]; occupational therapy [Title/Abstract] AND entry-level doctorate [Title/Abstract]; occupational therapy [Title/Abstract] AND OTD [Title/Abstract]; occupational therapy OTD
Sports Medicine and Education Index	occupational therapy AND clinical doctorate; occupational therapist attitudes AND doctorate; occupational therapist perceptions of clinical doctorate; occupational therapy OTD; occupational therapy future NOT physical; “occupational therapy” AND “doctorate”
Google Scholar	occupational therapy AND clinical doctorate; entry-level occupational therapy doctorate; perceptions OR attitudes of occupational therapy doctorate; occupational therapy doctorate OTD; occupational therapy AND debate; occupational therapy doctorate AND occupational therapy masters program; occupational therapy masters program; entry-level OTD

for a comprehensive list of search queries used for each database. These search queries collectively identified 1,853 total records that required screening.

2.3. Selection and Data Collection Process

Of the 1853 records identified, 501 were removed before screening due to duplication and other reasons, such as relevancy. A total of 1352 records were screened and 1247 were additionally excluded after review of title and abstract. Of the 105 records that were assessed for eligibility, a further 93 were excluded due to not meeting the inclusion criteria. These steps were performed by both authors collaboratively and manually (i.e., no automation tools were used). The 12 leftover records were further assessed for eligibility by each researcher independently by reading the full text, and all records were found to meet the inclusion criteria. The final step included independent review of the references of each of the 12 articles by each researcher, which produced three additional records that met the inclusion criteria. Citation searching was last searched in August 2021. In total, 15 unique articles were located that met this systematic review’s requirements. See Figure 1 for the flow of information diagram, in accordance with the updated 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [10].

2.4. Quality Appraisal and Data Items

While the evaluation of the methodological quality of the primary research is an important component of a thorough systematic review [11], several of the available tools (checklists, summary judgement checklists, and scales) are not intended to be used for non-empirical papers (e.g., reviews, theory-based). Of the 15 articles included in our systematic review, seven were overviews and/or commentaries and theoretical in nature. As such, given the subject at hand and the importance of leaving these articles in the review, both authors independently appraised the remaining eight articles that contained data.

The Mixed Methods Appraisal Tool (MMAT; Version 18) was used to rate the quality of eight of the 15 articles included in this systematic review [12]. The MMA is “a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews” [12] (p. 1) and includes quantitative descriptive studies as one of the five categories that can be appraised using this tool. Both authors collected data from the articles collaboratively through the process of creating a table in Excel and inputting relevant information from the articles. Relevancy of information was guided by our research question of whether existing knowledge around this topic provides defensible policy decision making. As such, variables for which data were sought included participant and study design characteristics, and the main findings, suggestions, and/or conclusions of the authors (see Appendix A). Suggestions and/or conclusions were provided in lieu of findings by authors who conducted commentaries and/or provided perspectives/opinions instead of conducting original research. This review was not registered.

2.5. Risk of Bias and Synthesis Methods

A risk of bias assessment was performed collaboratively by both authors for each included study using a judgement of low risk, high risk, or unclear risk, following the recommendation by Cochran Collaboration. The effect measures for each outcome used in the synthesis of results for the data-driven articles mostly included descriptive and frequency/percent reporting, with one article conducting Mann–Whitney U tests to compare non-parametric data between two groups, which produced “z scores”, and another article conducting chi-square analyses to determine relationships between the degree type that was being pursued and the reasoning behind it (see

Table A1. Summary of articles with data (n = 8).

Article Information	Design	N	Main Findings
Dickerson and Trujillo [20] Published: 2009 Article type: Original	Survey (mainly quan)	600 occupational therapists	- 68% of respondents disagreed or strongly disagreed with moving to the doctorate for entry-level practice, and only 19% were interested in pursuing the degree personally - “The most common reasons for low interest included the opinions that the doctoral degree would not further careers, practitioners could not afford to stop working to pursue another degree, and/or could not balance work, family, and education” (p. 52) - “Data shows the older, undergraduate-trained practitioner as more likely to disagree that the OT clinical doctorate degree should be the entry-level degree” (p. 51) - However, the study’s results suggested that “practitioners perceive those with a post-professional clinical doctorate to be more able to meet the demands of management, to have more credibility, and to be more current in evaluation, treatment and evidence-based practice” (p. 52)
Lucas Molitar and Nissen [21] Published: 2018 Article type: Original	Survey (quan)	388 OT practitioners and students	- The respondents included “current OT practitioners (clinicians or educators) and students in entry-level OT or OTA programs” (p. 1) - From their chi-square analyses, “a significant relationship was found between the student wanting their respective degree and choosing that degree path (masters: x²(1) = 92.892, p < 0.001); doctorate: (x²(1) = 140.147, p < 0.001))” (p. 9). They also found a significant relationship for “doctoral students to choose their degree more frequently than master’s students based upon the desire for personal development (x²(1) = 6.374, p = 0.012, interest in research (x²(1) = 8.691, p = 0.003), desire to teach (x²(1) = 26.547, p < 0.001), experience with advanced practice (x²(1) = 16.262, p < 0.001), and trends in occupational therapy (x²(1) = 11.766, p = 0.001). A significant relationship was found for master’s students to have chosen their degree more often because of cost (x²(1) = 9.830, p = 0.002)” (p. 9) - “A strong majority of participants reported that the entry-level doctoral degree should be offered but not required (n = 276, 75%). Sixty-nine (18.8%) of the participants reported the entry-level OTD should be the required entry-level degree and 23 (6.3%) participants reported that it should not be offered” (p. 12)
McCombie [17] Published: 2016 Article type: Original	Survey (quan + qual)	221 (144 occupational therapists; 77 OTAs)	- 77.5% of respondents disagreed with “moving to the entry-level doctorate as the single point of entry degree, with that percentage notably increasing (85%) when a yes/no format removed the neutral option available in the rating scale format” (p. 397) - “In general, participants did not view a move to the entry-level doctorate as beneficial to the profession, although this opposing opinion appeared to be more strongly endorsed by OTs with bachelor’s degrees than those with postbaccalaureate degrees” (p. 397) - Responses by occupational therapists and OTAs were comparatively similar; “greater disparity regarding attitudes toward the entry-level doctorate for OTs comes not from that between OTs verses OTAs but rather from within the OTs, specifically OTs with bachelor’s degrees verses OTs with master or doctoral degrees” (p. 397)
Mineo et al. [16] Published: 2018 Article type: Original	Survey (quan + qual)	53 OT faculty	- From the international faculty surveyed, “51% reported that a doctoral degree should not be required, 40% indicated that doctoral education should be at the post-professional level, and only 9% believed a doctorate should be required to enter the OT profession” (p. 6) - 49% of respondents “saw definite value in a doctoral education personally; however, they were also all OT faculty for whom a higher-level degree is most likely required or more highly valued. In addition, most of the participants reported having earned a doctoral degree themselves, further indicating a high value for them professionally” (p. 6). However, when asked to rate the value of a doctoral degree for the OT profession in their countries, the percentage dropped to 30%
Muir [13] Published: 2016Article type: Dissertation	Case studies through semi-structured interviews	14 supervisors	- This dissertation assessed OT supervisor perceptions of entry-level doctorate and MOT degrees - The results of this exploratory study indicated that entry-level doctorates “do not have higher skills and abilities; desire higher compensation, but do not receive it; sometimes bring attitudes of superiority; are not more respected because of their degree; and are negatively affected by higher debt load” (p. 4) - “Policy makers in the profession of OT should exercise caution in adopting the entry-level doctorate as the required entry-level degree until further evidence on the efficacy of the entry-level doctorate degree is clear” (p. 4)
Ozelie et al. [14] Published: 2020 Article type: Original	Retrospective cohort design	213 students	- This study provided preliminary data on how one university transitioned from the MSOT to the OTD by analyzing retrospective data from students collected from six cohorts between 2014 and 2019 - “The results of this study find that the transition to an OTD had no significant impact on admission rates, fieldwork reservations, or diversity” (p. 9) - There was a 5.4% increase in diversity rates since the transition to the OTD program, but a 7.75% decrease in the number of applicants, as well as 5.23% decrease in fieldwork reservations; however, “this minimal decrease may be largely attributed to a growing number of OT programs in this state” (p. 7)
Ruppert [18] Published: 2017 Article type: Original;Capstone Project	Survey (quan; cohort study)	52 OT program directors	- Respondents were program directors of entry-level professional OT programs - “While most respondents oversaw MOT programs, a greater number of respondents indicated support of the OTD degree (57.9%) over than the MOT degree (42.1%)” (p. 23) - “This study found that program directors were more likely to support the OTD degree type when they were a part of an institution that also had a DPT program” (p. 24) - Study also found that “many program directors (77.6%) valued the enhanced clinical, leadership, and research skills that graduates of OTD programs would receive” (p. 25)
Smallfield et al. [19] Published: 2019 Article type: Original	Survey (quan)	208 OT graduates	- This study compared professional outcomes of two entry-level OT degrees: MSOT and OTD; “the sample consisted of 146 MSOT graduates (70%) and 62 OTD graduates (30%)” (p. 1) - “MSOT graduates were significantly more likely to be clinicians (z = −3.57, p < 0.05) and OTD graduates were significantly more likely to be educators (z = −4.24, p < 0.05). OTD graduates were significantly more likely to use evidence-based practice (z = −2.29, p < 0.05) and conduct research (z = −4.19, p < 0.05)” (p. 1) - However, “no significant differences were found between the two groups in starting and current salaries, job titles, and self-perceived preparation for interprofessional practice” (p. 17)

Legend: ACOTE, Accreditation Council for Occupational Therapy Education; AOTA = American Occupational Therapy Association; DPT, Doctor of Physical Therapy; MOT, Master of Occupational Therapy; MSOT, Master of Science in Occupational Therapy; OT, occupational therapy; OTs, occupational therapists; OTA, occupation therapy assistant; OTD, Occupational Therapy Doctorate/Clinical Doctorate in Occupational Therapy.

).

The collaborative process used to decide which studies were eligible for each synthesis included first categorizing the studies into “with data” (e.g., original research) or “without data” (e.g., commentaries). For the data-driven articles, we created a table in Excel with the aforementioned variables and compared characteristics and findings between studies. For the articles without data, we also created a table in Excel to record key suggestions and/or conclusions provided by the authors, which we then used to compare between other non-data-driven articles. Microsoft Word was used to tabulate results of individual studies and syntheses (see Appendix A). Quantitative synthesis was used to synthesize results for the data-driven articles to provide scientifically rigorous summary information, while thematic synthesis was used for the non-data-driven articles to identify patterns in the suggestions and/or conclusions of the authors that might be important and relevant to our research question. Participant characteristics were considered when exploring possible causes of heterogeneity among study results. Given the nature of this systematic review, specifically the inclusion criteria and study designs, a sensitivity analysis was not conducted. Certainty (or confidence) in the body of evidence as it relates to the single vs. dual point of entry mandate was mainly assessed through risk of bias and indirectness of evidence.

3. Results

3.1. Study Selection

We located 15 articles published from 1 January 2008 to 20 June 2021 that focused on OT and entry-level degree requirements, and that aligned with our research question guiding this review exploring defensible policy decision making. Each of the four databases were last searched in June 2021, which produced 12 articles that met our inclusion criteria, and citation searching of those 12 articles was completed in August 2021, which yielded an additional three articles. Eleven of the 15 articles were published after 2013 (see Appendix A).

3.2. Study Characteristics

Of the 15 articles included in the review, seven were not data-driven and focused on reviewing past literature, weighing the advantages and disadvantages of mandating an entry-level doctorate degree, rationalizing their position on the topic, proposing theoretical outcomes, and/or predicting future trends. Of the eight data-driven articles, six used surveys to gather data and the other two used a semi-structured interview approach [13] and a retrospective cohort design [14] to gather data. Two of the 15 articles had a Canadian focus, where Brown and colleagues [15] explored the entry-level degree dilemma in the Canadian OT system, and Mineo and colleagues [16] had the highest response rate in their survey regarding doctoral-level education from the Canadian OT faculty (n = 23). Participants across the articles included in this review ranged from OT practitioners and assistants, program directors, and supervisors, to current students, graduates, and faculty. In total, there were 1749 participants across the studies conducted.

3.3. Quality Appraisal

Using the ‘quantitative descriptive’ category, the eight articles that contained data were appraised using the MMAT. For criterion 4.1. (Is the sampling strategy relevant to address the research question?), 100% of the articles scored ‘yes.’ For criterion 4.2. (Is the sample representative of the target population?), 87.5% (7/8) articles scored ‘yes.’ For criterion 4.3. (Are the measurements appropriate?), 100% of the articles scored ‘yes.’ For criterion 4.4. (Is the risk of nonresponse bias low?), 75% (6/8) articles scored ‘yes.’ Finally, for criterion 4.5. (Is the statistical analysis appropriate to answer the research question?), 100% of the articles scored ‘yes.’ Both independent raters had the same scores. As such, the articles with data included in this review were of generally high quality.

3.4. Risk of Bias

While risk of bias to the suggestions and conclusions offered in the seven studies without data is unclear, the authors found the risk of bias in all eight articles with data to be moderately high, which affects certainty in the body of evidence presented. A common limitation noted in six of the eight studies was the inability to generalize results [13,14,16,17,18,19], namely due to the composition (e.g., participant backgrounds and career aspirations, participant geographic location, features of the insitution/program) and the size of the sample. The generalizability drawback is an important issue, as each institution and OT program may differ between their curricula, and more broadly, professional, regional, geographic, and cultural variations across state populations may also confound results [17,19]. Another common limitation explicitly noted in four of the eight studies was the survey instrument [17,18,20,21], specifically questioning the content validity [20], susceptibility to inherent recall bias due to the nature of self-report [21] or the instrument being self-designed, potentially leading participants to support a position due to response items being worded in a structually biased manner [17], and forcing responses on all items which may have biased responses related to perspectives and opinions [18]. Importantly, a potential of volunteer response bias was present in all eight studies where participants who held a relatively strong opinion on the mandate may have been more inclined to take the time to complete and return the survey. This was explicitly noted as a limitation in three of the studies [13,17,21]. Other notable limitations stated in the studies included examining a recently transitioned program, which may have resulted in different outcomes than insitutions with more established programs [14], an abundance of statistical tests that increased the likelihood of Type I errors [17], and potential bias by the researcher [18].

3.5. Thematic Areas (Results)

Guided by our research question and objective, we identified three overarching thematic areas addressed in the manuscripts included in our review that are presented below. As entry mandates continue to be a topic of debate among practitioners and stakeholders, the construction of these themes was logical and occurred organically.

3.5.1. Should an Entry-Level Doctorate Be Mandated for OT Practice?

Of the eight data-driven articles, five explicitly asked the respondents to offer their opinion on whether an entry-level doctorate should be mandated for OT practice. Four out of the five articles reported that a majority of respondents disagreed with the mandate [16,17,20,21]. A total of 1262 individuals were surveyed across those four studies, which included occupational therapists, occupational therapy assistants (OTAs), educators, and students. The lone article with data that reported majority support for the mandate was by Ruppert in 2017, who hypothesized that there would be common themes and predictive factors regarding entry-point preference [18]. Of the 194 program directors invited to participate in the study, 52 program directors of entry-level professional OT programs completed the survey and it was found that 57.9% of the respondents supported the OTD degree over the MOT degree, with a majority citing the “enhanced clinical, leadership, and research skills that graduates of OTD programs would receive” [18] (p. 25). It is important to note here, however, that the researcher acknowledged their potential bias on the subject matter and that someone with a different view may have achieved slightly different conclusions, along with finding that program directors were more likely to show support for the OTD degree if they were part of an institution that also had a related doctoral program [18].

3.5.2. Arguments for Single Point of Entry

In addition to position statements posted by AOTA over the years that have provided varying rationales for transitioning toward a doctoral-level single point of entry for occupational therapists, e.g., [22], as highlighted in the Ruppert article [18], this review identified literature that has demonstrated some support for mandating an entry-level doctorate for OT practice. Dickerson and Trujillo used a national, random survey method in which the “survey instrument was constructed by the authors and reviewed by several occupational therapist educators for clarity and appropriateness” (p. 48). Of their 600 occupational therapist respondents (30% survey return rate), 93% were female, the mean age was 40 years (standard deviation [SD] = 9.71), and 59% had an undergraduate degree in OT as their highest degree. While they found that 68% of the 600 occupational therapists surveyed disagreed or strongly disagreed of moving to the doctorate for entry-level practice [20], they also noted that “practitioners perceive those with a post-professional clinical doctorate to be more able to meet the demands of management, to have more credibility, and to be more current in evaluation, treatment and evidence-based practice” (p. 52). Perhaps the strongest proponents of the mandate were Wells and Crabtree [4] who, in their exploratory review commenting on the likely impact of AOTA’s policy both within the U.S. and internationally, urged that “AOTA recognize that a two-point entry only maintains an unwanted status-quo and confusion” (p. 21). Further, they asserted that “the international community is best served by preparing the OTs with the highest standards of education and training with credentials comparable to their peers” [4] (p. 21). Case-Smith and colleagues’ commentary further served to provide rationale for the development of professional occupational doctorate programs, proposing five key outcomes for doctoral-trained practitioners (see

Table A2. Summary of articles without data (n = 7).

Article Information	Design/Article Type	Main Suggestions/Conclusions
Brown et al. [25] Published: 2015	Commentary	- Several potential advantages (e.g., assist practitioners with career advancement opportunities) and disadvantages (e.g., an example of credential creep/degree inflation) of moving to an entry-level OTD - “The authors believe that before mandating entry to practice singularly through clinical doctorates a thorough discussion and debate involving all concerned parties, including educators, researchers, managers, students, employers, consumers, state, and national regulatory bodies (e.g., NBCOT and state licensure boards), and professional associations (national and international) should occur” (p. 248) - “How and to what extent this potential mandate impacts OT education internationally needs to be considered broadly and thoroughly as well” (p. 249)
Brown et al. [24] Published: 2015	Commentary	- Similar to Brown et al. [24] - “Many forces at work, internal and external to the profession, make it likely that the entry-level OTD will be mandated in the not-to- distant future. Such a move will have reverberations at the local, state, national, and international level professionally” (p. 5) - Authors proposed reasons for moving to an entry-to-practice doctorate degree, particularly noting that “the health care system is inherently hierarchical and competitive, and if OT wants to maintain or improve its status in that pecking order, it will likely need to adopt the entry-level clinical doctorate” (p. 3) - Authors encouraged “an open, informed, transparent, multi-perspective, comprehensive debate on all fronts about the ongoing education paradigm shift that is being considered by AOTA and ACOTE” (p. 5)
Brown et al. [15] Published: 2016	Overview	- Same as Brown et al. [24]
Case-Smith et al. [23] Published: 2014	Commentary	- Authors’ aim was to present a rationale for the development of professional occupational doctorate programs. They developed the following proposed outcomes for doctoral-trained practitioners: “(1) Demonstrate advanced clinical skills; (2) attain proficiency in outcomes measurement and analysis and synthesis of outcomes data; (3) routinely use standardized evidence-based practice clinical guidelines that translate research into practice; (4) develop, implement, and lead health promotion services; and (5) excel as partners in interprofessional teams” (p. 55) - Authors believe that “the development of professional OTD programs will prepare OT graduates to address emerging health care trends and population changes” (p. 59)
Coppard et al. [26] Published: 2009	Perspective/Opinion	- This overview argues in favor for both master’s- and doctorate-level entry into the profession - “With OT maintaining two points of entry, the profession may attract students who are not willing or able to absorb the time and financial obligation of an entry-level doctorate, but who are interested in entering the profession” (p. 13) - “The projected demand for an increased number of occupational therapists who are more representative of the diverse global population and who have a variety of skill levels supports continuing the option of two paths of entry not the profession as an OT” (p. 14)
Fisher and Crabtree [27] Published: 2009	Commentary (general cohort theory)	- Authors concluded that the “arguments against moving to an entry-level doctoral degree on the basis of the possibility of increasing the gap between associate degree programs and doctoral-level programs, or on the basis of the possibility of placing a barrier to our educational programs, are not effectively applied to the entry-level doctorate in OT” (p. 659) - Authors addressed two main arguments related to moving to the entry-level clinical doctorate in OT: (1) that the entry-level doctorate would place the profession out of reach of people who are socially or financially disadvantaged and (2) that the entry-level doctorate may be too costly in terms of time and money and therefore reduce enrollments in educational programs. However, they believe that “close examination exposes these arguments as concerns to be addressed, not barriers, and that our profession can successfully overcome them” (p. 659) - Authors conclude that “we cannot afford to maintain entry-level systems that address neither the needs of the profession nor the generational cohort of students who will likely become the profession’s future” (p. 659) and that continued discussion is necessary
Wells and Crabtree [4] Published: 2012	Overview/Exploratory review	- “This paper evaluates the probable impact of AOTA’s current policy on the profession both within the US and internationally” (p. 17) - Authors argue that entry to OT practice should be singularly at the doctoral-level and cite evidence in the literature “for AOTA to recognize the educational trends in healthcare and quickly learn to thrive in it” (p. 21) - Authors urge that “AOTA recognize that a two-point entry only maintains an unwanted status-quo and confusion” and that “the international community is best served by preparing the OTs with the highest standards of education and training with credentials comparable to their peers” (p. 21)

Legend: ACOTE, Accreditation Council for Occupational Therapy Education; AOTA = American Occupational Therapy Association; DPT, Doctor of Physical Therapy; MOT, Master of Occupational Therapy; MSOT, Master of Science in Occupational Therapy; OT, occupational therapy; OTs, occupational therapists; OTA, occupation therapy assistant; OTD, Occupational Therapy Doctorate / Clinical Doctorate in Occupational Therapy.

) in which they believed that “the development of professional OTD programs will prepare OT graduates to address emerging health care trends and population changes” [23] (p. 59). Relatedly, three major themes emerged from the responses of the occupational therapists and OTAs who were in support of the mandate (albeit only 15% of the overall sample, which included 144 occupational therapists and 77 OTAs from two northeastern states with an average of 17 years in professional practice [SD = 11.31]) in McCombie’s study [17]. These included maintaining equality/credibility with other professions such as PT, advancing research and evidence-based practice, and advancing specialty skills within the profession [17]. These data were collected through a multipart survey which contained a series of 18 item statements regarding a possible move by the profession to the entry-level doctorate. Brown and colleagues [15,24] also listed several potential advantages of moving to an entry-level OTD in their overview/commentary, such as career advancement opportunities and higher salaries, while Brown and colleagues also acknowledged that “the scope of practice of occupational therapy has become more complex, and the skill set required to meet these demands can be met only with new graduates with well-honed clinical reasoning, problem-solving, interprofessional, evidence-based practice, and leadership abilities” [25] (p. 2). In addition, they recognized the hierarchy and competitive nature of the health care system and stated that “if OT wants to maintain or improve its status in that pecking order, it will likely need to adopt the entry-level clinical doctorate” [25] (p. 3). Of note, Brown and colleagues [15], whose purpose was to expand the conversation of mandates in Canada, believe that “if the OTD is mandated as the single point of entry to practice in the United States, more than likely, entry-level clinical doctorate programs in occupational therapy will be launched outside the United States where the health care and political systems support such changes” (p. 314).

In practice, Ozelie and colleagues investigated how one university transitioned from the MSOT to the OTD by analyzing retrospective data from 213 students collected from six cohorts over five years using a convenience sample, and found that the transition did not have a significant impact on admission rates, fieldwork reservations, and/or diversity [14]. As it relates to occupation selection, Smallfield and colleagues [19] collected data through an online survey which yielded 208 responses from one OT program (146 MSOT graduates; 62 OTD graduates). Through descriptive and Mann–Whitney U analyses used to compare groups, they reported that “MSOT graduates were significantly more likely to be clinicians (z = −3.57, p < 0.05) and OTD graduates were significantly more likely to be educators (z = −4.24, p < 0.05)” and “use evidence-based practice (z = −2.29, p < 0.05) and conduct research (z = −4.19, p < 0.05)” [19] (p. 1). Of particular interest, however, was their finding of insignificant differences between these two groups as it relates to several key factors, such as “starting and current salaries, job titles, and self-perceived preparation for interprofessional practice” [19] (p. 17). The authors noted that degree satisfaction was a key takeaway from their study for OT educators where a majority of participants (from both degrees) were pleased with their degree choice, with the implication being that both groups felt adequately prepared to work.

3.5.3. Arguments for Dual Points of Entry

While this systematic review identified literature containing some support for mandating an entry-level doctorate for OT practice, most participants across the studies included in this review were not in favor of the OTD mandate and agreed that OT should maintain dual entry into the profession. Of the 600 occupational therapists surveyed in Dickerson and Trujillo’s study [20], “the most common reasons for low interest included the opinions that the doctoral degree would not further careers, practitioners could not afford to stop working to pursue another degree, and/or could not balance work, family, and education” (p. 52). Several primary themes emerged from the responses of the occupational therapists and OTAs surveyed by McCombie who were against OT moving to the entry-level doctorate as well, noting increased expenses, increased time, expectation that the advanced degree would not result in increased pay for occupational therapists, fewer graduates, belief that the degree was not necessary given most clinical educations take place in the clinic rather than classroom, that OTD should be an option and not a requirement, and that the mandate appears simply to be a move designed to keep up with other health care professions [17]. Although a relatively small portion of the occupational therapists and OTAs surveyed by McCombie [17] who were in support of the single point of entry mandate felt that it would advance specialty skills within the profession, along with Smallfield and colleagues reporting that OTD graduates were more likely to conduct research [19], 53 international OT faculty from eight countries, 79% of which reported being full-time faculty, surveyed by Mineo and colleagues, explained that the profession needs entry-level therapists to be generalists and that a doctorate degree would be more appropriate for later specialization, while also noting that skilled researchers should not be required for clinical practice [16]. The cost and time concerns in particular appeared to be a recurrent theme, as Coppard and colleagues, Fisher and Crabtree, and Brown and colleagues also acknowledged the financial and time demands that would be placed on prospective students, creating unnecessary and avoidable barriers [15,25,26,27]. However, Fisher and Crabtree argued that the aforementioned disparities are “necessary reasons to develop strategies to minimize barriers to and gaps in education; they are not sufficient reasons to decide against the entry-level doctoral degree in occupational therapy” [27] (p. 659). Of note, in Brown and colleagues’ commentary [25] and overview [15], they also listed other thoughtful arguments against moving to an entry-level OTD mandate, such as the move potentially creating workforce shortages due to the increased length of education required and it being an example of credential creep/degree inflation.

The perceptions of 14 OT supervisors, who had observational knowledge of clinical performance and experiences with the two degree groups, on entry-level doctorates were also investigated by Muir in their dissertation through semi-structured interviews [13]. The researcher concluded that OT supervisors in this study did not view an entry-level Doctor of Occupational Therapy (eOTD) as an asset for various reasons. As it related to differences in skills and abilities, Muir’s findings suggested minimal difference “between new therapists with the MOT and the eOTD with regard to knowledge for entry-level practice, providing direct patient care, use of or conducting of clinical research, supervisory and management skills, or advocacy for patients” [13] (p. 177). Compensation was also explored, and Muir reported no difference in starting salaries for the different degree levels at most of the facilities investigated [13]. Despite this finding and the high cost of education, supervisors did note that the OTD graduates generally do expect a higher salary when they first graduate in comparison to MOT graduates. Muir also examined the concept of recognition and found that OTD graduates were not more respected than MOT graduates either by other professionals or by patients, although they did, however, display a higher frequency of challenging attitudes of superiority and entitlement, despite their lack of abilities or experience [13]. See Table A1 and Table A2 (Appendix A) for a summary of key findings, suggestions, and conclusions of all studies included in this review.

Despite the preponderance of beliefs that argue against mandating an entry-level doctoral degree as identified through this systematic review, continued dissention on the subject matter remains. A good example of this is Lucas Molitor and Nissen’s 2018 study that surveyed 388 OT practitioners and students (45 clinicians, 87 educators, 248 students, and 8 not reported) and reported that 75% of the respondents were against the mandate and supported dual entry into the profession [21]. However, the authors cautioned these results should also be properly contextualized by indicating that there are “differences in views regarding entry-level degree requirements among groups based upon role type (clinician, educator, student) and current degree earned” (p. 15), while promoting further education and maintaining that “the benefits of a mandatory entry-level clinical doctorate would be beneficial as the profession moves towards this as the mandated degree” [21] (p. 16). As such, further discussion on mandates to practice OT is warranted.

3.6. Reflection

This systematic review included seven qualitative articles that did not contain quantitative data; four commentaries which provided more in-depth analyses [23,24,25,27], two overviews/exploratory reviews [4,15], and one perspective/opinion [26]. While there was minimal interpretation of qualitative data by the authors, the positions taken by the authors of the articles and the rationales behind their positions were largely transparent and comprehensible, which minimized subjective interpretation during our content analysis of their arguments and reflections. Both authors have some experience either working with OTs directly through past data collection, teaching, or volunteering, being part of a pre-OT student club, developing undergraduate and graduate curricula, and/or applying for OT graduate programs. As such, given the scope of this systematic review, we did not feel that our own experiences and knowledge of the topic affected interpretation of the articles and synthetization of data, including the reporting of mostly descriptive statistics.

4. Discussion

The purpose of this systematic review was to aggregate existing literature and synthesize data related to mandating an entry-level doctorate for OT, and in turn, clarify some of the confusion created by the mandate changes and generate a more cohesive understanding for all interested parties. This was guided by our research question exploring whether existing knowledge around this topic provides defensible policy decision making. This is the first degree-level systematic review related to this topic, and a current issue in education. As revealed above, the answer to the question should an entry-level doctorate be mandated for OT practice? is not obvious nor is there a consensus among practitioners and stakeholders, complicating the decision-making process for policy makers. Since AOTA’s new standards for post-baccalaureate programs were implemented in 2007, compelling arguments both in favor and against the mandate from a variety of OT practitioners and students have been voiced. Despite this, while a majority of the participants from the articles included in this review supported maintaining two entry points into the profession, the authors advocate that more evidence-based research focusing on objective measures, rather than perceptions, of the clinical performance outcomes between the two OT degree groups is needed to ensure that patient needs continue to be effectively addressed and policy decision making is justifiable. While qualitative commentaries and opinions from experts can certainly provide important context to the discourse surrounding this topic, the amount of quality data that has been generated in this area is relatively limited given the sparsity of original research studies identified in this review. For this reason, the authors argue that the discourse around this topic must be more scientifically driven in order to facilitate more defensible policy decision making.

As suggested by Muir, “the profession should not move to requiring the doctorate without closely examining the actual knowledge and skill differences between graduates with the different degrees” [13] (pp. 210–211). Nevertheless, Mineo and colleagues [16] and Smallfield and colleagues [19] both acknowledged that the question of whether this transition should occur has ignited a long and heated debate within the OT profession. This review demonstrates that 15 years after the 2007 mandate, consensus has still not been reached and provides reason for the recurrent modifications to degree-level requirements to practice OT by AOTA and ACOTE. For example, majority support for maintaining dual entry into the system was reported by Dickerson and Trujillo (2009) [20], Lucas Molitor and Nissen (2018) [21], and Mineo and colleagues (2018) [16]—a nine-year difference between the studies. In contrast, Ruppert (2017) reported that a majority of OT program directors supported a single point of entry at the doctoral-level (although this study had relatively fewer participants) [18], while several articles that provided commentaries and overviews also endorsed the mandate [4,15,23,24,25].

Despite the articles included in this systematic review that contained data being generally high quality, as indicated above, several articles reported some noteworthy limitations to their studies which may have biased their findings. With respect to our systematic review, the nature of our inclusion criteria may have slightly affected the overarching narrative. More specifically, by choosing to exclude articles that were published prior to 2008 and articles that focused on OT programs outside of North America, the representativeness of the findings may have been artificially reduced. However, our intention was not to focus on the impact of entry-level differences more broadly, but rather add to our understanding of what drives policy decision making by AOTA. Nevertheless, there appears to be continued heterogeneity among practitioners and stakeholders as it relates to mandating a single point of entry into the profession, and concerningly, an overall lack of scientific underpinning to arguments presented.

The standards for evidence in policy decision making should be high and has been widely recognized by practitioners and stakeholders. Ruggeri and colleagues [28] recently presented a framework to limit misinformation risks and promote applying scientific rigor to policy, citing the demands that the COVID-19 pandemic placed on robust policy making and serving as a reason for creating the Theoretical, Empirical, Applicable, and Replicable Impact rating system (THEARI). The THEARI rating system ranges from one (theory only) to five (impact validated), and importantly, “its purpose is to provide guidance for scientists and policymakers to classify what qualifies as evidence and potential appropriateness for application” [28] (p. 3). For example, the lowest rated validation level is Theoretical, where a scientifically viable concept has been proposed but lacks empirical testing or validation, whereas the highest rated validation level is Impact, where findings have been validated at the highest conceivable power (i.e., populations) through real-world testing and replication of effects in multiple settings [28]. This system appears to be remarkably generalizable across disciplines and illustrates the importance for robust evidence-based policy. Based on the results of our systematic literature search, the limited availability of data on OT clinical performance differences between the two degree groups is problematic, particularly when contextualized in relation to the far-reaching effects that policy changes may have. More specifically, using the THEARI rating system, it appears that several articles identified in our review fall into the lower-rated validation levels.

In addition to recommending more evidence-based research on clinical performance differences between the two degree groups that better informs policy decisions, such as conducting prospective cohort studies, we suggest that future researchers should also consider educational philosophy by increasing their focus on identifying the personal aspirations of students who decide to pursue a doctorate degree versus those that complete their education with a master’s degree. It would also be valuable for researchers to consider the potential differences in skills being taught between the two degree options in OT programs, and if pursuing a doctorate translates to a comparably added benefit in a clinical setting, as it generally does in an educational one. Clement acknowledged these points by highlighting the difference between research and clinical or practice-oriented doctoral education [29], while Muir went a step further by suggesting that if research work is correlated with lower clinical skills, “the profession may need to think about division of labor—with researchers who focus on designing studies to gather evidence, and practitioners who collaborate with them, but focus on patient care” [13] (p. 215). On the other hand, Case-Smith and colleagues also recognized the importance of broadening skills across disciplines, such as health care professionals developing communication techniques in order to be able to effectively present relevant and accurate information [23].

More broadly, the implications of imposing new mandates must be thoughtfully considered and evidence-driven. This review illuminates the need for more scientifically rigorous studies in which evidence can be utilized to inform policy discussions and updates. Many questions remain to be answered about understanding the nuances and repercussions of such mandates, for instance their impact on candidate recruitment and what it means not only for patients, practitioners, and employers, but also for prospective domestic and international students. Objective data on skill- and ability-based differences between graduates with a doctorate or master’s degree would likely mitigate some of the aforementioned limitations, such as self-reporting and volunteer response bias, and better assist practitioners and stakeholders in providing effective healthcare policies.

5. Conclusions

The theoretical and practical implications of degree mandates for entry-level clinical practice are substantial for educational programs. Ramifications of frequent changes to educational requirements for entry-level practice must be carefully contemplated, which impacts prospective and current students and educators alike. While ongoing discourse regarding entry requirements to practice OT is needed, the authors call for more evidence-based research that focuses on objective measures, rather than perceptions, of the clinical performance outcomes between those with an MOT or MSOT and an OTD. Contextual factors contribute to the persuasiveness of the arguments and should be considered when analyzing the literature as well, such as study design, who the participates were, and the features of the OT program(s) under question. From a broader allied health and education perspective, the overarching goal should ultimately focus on improving patient care to ensure their needs continue to be effectively addressed. As such, decisions regarding entry-level mandates to practice OT must be evidence-driven and scrutinized by appropriate stakeholders to ensure scientifically driven implementation of policy that holistically benefits the profession.