Introduction

Occupational therapy ‘auxiliaries’ are currently trained in several countries, notably the USA, Britain, Canada and South Africa. For the purposes of clarity, the term ‘auxiliary staff’ will be used as a collective term, to include occupational therapy assistants (OTAs), occupational therapy technicians (OTTs) and community rehabilitation workers (CRWs). These workers are often classified as support staff and mid-level health workers. The OTT, for example, is equivalent to that of some certified OT assistants (COTAs) as trained in the USA. The different states in the America provide training of different durations (one to three years), but it would seem that the scope of practice of the COTA, however, remains consistent and corresponds to that of the OTT.

An Internet search shows substantial numbers of references to COTAs (CA.Gov. 2013). It is obvious that training is widespread throughout the USA and that this category of staff is well regulated with an expected 30% growth in employment from 2008 to 2018. However, auxiliary staff are often not available nor trained to assist in occupational therapy interventions in many parts of the world, and volunteers may be used to fulfil many of the tasks usually allocated to auxiliary staff. South Africa has been proactive in the training of occupational therapy auxiliary staff to assist with the intervention programmes in mental health care and other areas where their services are considered to be vital.

During the 1960s to 1980s in South Africa, professional nurses were frequently allocated to organise and manage areas such as the industrial contract areas and recreational activities, in the absence of a qualified occupational therapist. For many years, mental health care facilities ran productive workshops and handcraft areas, producing high-quality products, without the aid of an occupational therapist. The staff allocated to these areas were usually called ‘therapy nurses’ or were qualified tradesmen, such as carpenters. They provided a variety of constructive and recreational activities with the main aim of occupying, training and stimulating patients. It must be acknowledged that many newly qualified occupational therapists benefited from the vast experience of these ‘therapy nurses’ and technicians.

As a result of the increase in the numbers of occupational therapists and the formalisation of training for auxiliary categories (support staff), occupational therapy departments are now better staffed. Staff numbers are, however, rarely adequate to provide the needed service, especially in medium- and long-term units.

The need for auxiliary staff also does not seem to have decreased with the increase in numbers of qualified occupational therapists, but seems to be the opposite, largely due to the extension of occupational therapy services into new areas of practice, the opening of new departments, specialisation within the profession and demand for occupational therapy services in the private sector and different levels of health care provision.

The role of the occupational therapist, particularly within mental health care facilities, is often that of manager, planner and organiser of programmes and services for entire populations of patients. They, therefore, make use of auxiliary staff to implement many aspects of direct service provision within the psychosocial field of practice. The primary health care approach, as now implemented in most countries, presents exciting challenges to the occupational therapist and auxiliary staff. It demands that comprehensive mental health and psychiatric services be provided at a community level.

There has been a substantive shift in attitude and approach towards auxiliary staff who are currently accepted as valued members of the profession, with a specific role and contribution which is certainly not inferior but rather complimentary to that of the graduate occupational therapist.

Current situation

The South African National Department of Health has approved, as part of the human resource plan, mid-level worker (MLW) categories of staff in the majority of health professions. Mid-level workers in occupational therapy include occupational therapy assistants, who have completed a one-year certificate course and are also required to register but are not consistently referred to as MLW due to the duration of their training, and the occupational therapy technician and the community rehabilitation worker, who have each completed two years of training. These acronyms will be used hereafter.

Occupational therapy auxiliaries were trained to function mainly within institutional settings, whilst CRWs were trained to practise within a community setting. In South Africa, the trend is for the professional to train only one category, that of the OTT, who has advanced occupational therapy auxiliary specific skills, as well as community development and community-based rehabilitation skills, and who is able to function effectively in both facility-based services (FBS) and community-based services (CBS). Training for OTAs, COTAs as trained in several states in America, and CRWs are no longer offered, but these workers may, with additional training, apply to do the Health Professionals Council of South Africa board examination to enable registration as an OTT.

As the situation in South Africa differs from that in other parts of the world, South African occupational therapists are directed to the reference list for relevant material.

Ethical and legal context

Auxiliary staff must comply with the professional requirements of the country in which they practice, such as scope of practice, registration, annual payment of fees, ethical rules and other professional conduct requirements.

Tasks and functions of auxiliary staff and practical considerations

The appointment of auxiliary staff enables the occupational therapist to spend a greater part of the day in direct service provision and, together with auxiliary staff, carry greater patient loads. It enables the occupational therapist to establish programmes for large numbers of patients, which can be implemented by auxiliary staff, and to develop and provide a variety of services within a variety of settings. Auxiliary staff can therefore assist the occupational therapist to establish a more effective and efficient service and will contribute to the overall development and maintenance of occupational therapy services at institutions, clinics or centres. This includes the development of community outreach programmes.

Guiding principles

The OTA (one year training) is trained to work according to the prescription of the occupational therapist. His/her main contribution therefore lies within the implementation phase of intervention.

The OTT, on the other hand, has either specialised activity skills, a trade qualification, advanced occupational therapy auxiliary skills and/or training in community rehabilitation and development. Such a person, therefore, is able to work within prescribed protocols of intervention, for example, for the treatment of a person with a stroke (cerebral vascular accident), and may implement these based on assessment findings.

Occupational therapy auxiliaries are trained to deal with the non-compliant, routine, repetitive and medium- to long-term ‘standard’ types of cases. Any clients with multiple handicaps or diagnoses that are treatment resistant or have an unusual client picture and are actively ill would generally not be seen without direct occupational therapy intervention. The occupational therapist retains the responsibility to plan, institute and terminate interventions and programmes. The auxiliary staff therefore assist the occupational therapist with those aspects of implementation and departmental organisation which do not require constant and/or direct intervention or all the theoretical knowledge, skill and expertise of the occupational therapist. This, however, does not imply that the occupational therapist makes all the decisions. Rather, planning is done collaboratively with auxiliary staff.