Continuing education requirements among State Occupational Therapy Regulatory Boards in the United States of America.

PURPOSE: The purpose of this study is to compare and contrast the contents of each state's occupational therapy (OT) regulatory board requirements regarding licensees' acquisition of continuing education units in the United States of America.
METHODS: Data related to continuing education requirements from each OT regulatory board of all 50 states and the District of Columbia in the United States were reviewed and categorized by two reviewers. Analysis was conducted based on the categorization of the continuing education requirements and activities required, allowed, and not allowed/not mentioned for continuing education units.
RESULTS: Findings revealed non-uniformity and inconsistency of continuing education requirements for licensure renewal between OT regulatory boards and was coupled with lack of specific criteria for various continuing education activities. Continuing education requirements were not tailored to meet the needs of individual licensee's current and anticipated professional role and job responsibilities, with a negative bias towards presentation and publication allowed for continuing education units. Few boards mandated continuing education topics on ethics related to OT practice within each renewal cycle.
CONCLUSION: OT regulatory boards should move towards unifying the reporting format of continuing education requirements across all states to reduce ambiguity and to ensure licensees are equipped to provide ethical and competent practice. Efforts could be made to enact continuing education requirements specific to the primary role of a particular licensee. Finally, assigning the amount of continuing education credits to be awarded for different activities should be based on research evidence rather than arbitrary determination.

Introduction

In the United States (US), the license of individual occupational therapy (OT) practitioners is governed by each state’s regulatory board. It is the responsibility of a state regulatory board to review each OT applicant’s credentials in an effort to ensure that licenses are only issued and renewed to those who meet the obligations stated in the practice regulations [1,2]. One way for the OT regulatory board to have some assurance that licensees maintain their professional competence is to implement continuing education requirements for licensure renewal to practice in a particular state [1,3]. Each OT regulatory board has the autonomy to define acceptable continuing education or professional development activities (PDAs) for earning continuing education units (CEUs) [3]. While brief surveys of individual state’s licensure regulations on continuing education for OT licensees have been made 15 years ago [4,5], there is no up-to-date literature systematically comparing continuing education requirements across all OT regulatory boards in the US. In addition, some of the OT regulatory boards seem to have no clear continuing education requirements for licensure renewal. The purpose of this study is to compare and contrast each state’s OT regulatory board requirements regarding licensees’ acquisition of CEUs.

Methods

Study design

This descriptive study involved a cross-sectional survey research design.

Data collection

Two investigators (KAC and CMM) independently reviewed the continuing education requirements on each OT regulatory board website for the 50 states and the District of Columbia. Puerto Rico was not included as the website is not in English. Eighteen commonly accepted types of PDAs for earning CEUs, adapted from the Model of Continuing Competence Guidelines for Occupational Therapists and Occupational Therapy Assistants recommended by the American Occupational Therapy Association (AOTA) [6], and the Certification Renewal Activities Chart by the National Board for Certification in Occupational Therapy (NBCOT) [7], were identified (Appendix 1).

Statistical analysis

Using these 18 types of PDAs, the two investigators independently categorized the continuing education requirements of all 51 regulatory boards into four categories: mandated, allowed without a cap on the maximum hours, allowed with a cap on the maximum hours, and not allowed (or not mentioned) for CEUs. Inter-rater reliability was computed using Cohen’s kappa, which was conducted using the IBM SPSS for Windows ver. 22.0 (IBM Co., Armonk, NY, USA). The kappa statistic on the agreement between the two raters on each of the 18 PDAs ranged from 0.8 to 1.0, which is considered to be excellent [8]. Finally, two other investigators (SRH and HKY) collaboratively summarized the findings of the sorted categories of continuing education requirements and PDAs or continuing education activities required, allowed, and not allowed/not mentioned for CEUs.

Ethical approval

The study was approved by the institutional review board of the University of Alabama at Birmingham (IRB No. X141216003).

Results

Up until early 2016, 6 states’ OT regulatory boards had no continuing education requirements for licensure renewal. Of the 45 regulatory boards with mandatory continuing education requirements, the length of the licensure renewal cycle ranged from 1 to 3 years, with the majority of regulatory boards (35) requiring licensees to renew their license every two years. The number of continuing education hours required per renewal cycle ranged from 10 to 40 hours.

Of the regulatory boards that enforced CEU requirements, most either modified (through expansion and re-categorization) the types of PDAs that AOTA and NBCOT suggested or added another dimension such as clinical practice, administration/management, and academic/education. Seventeen regulatory boards specifically required at least half of CEUs earned be related to patient care objectives, or delivery of OT services directly related to clinical practice. Of these, 6 required at least two-thirds of the required continuing education hours be related to direct patient care. Twenty-two regulatory boards allowed licensees to earn continuing education credits in the area of administration/management and education related to OT practice, with 3 boards not imposing a maximum continuing education hour limit. The rest did not mention whether continuing education credits can be earned from these two areas.

Most regulatory boards had a cap on the maximum number of hours that can be earned from different PDA categories. As indicated in Table 1, 42 regulatory boards had no maximum limit on the number of continuing education hours that the licensee can earn from continuing education courses, with 3 regulatory boards not allowing all continuing education hours to be earned solely from continuing education courses. In contrast, 30 regulatory boards imposed a cap on the number of continuing education hours the licensee can earn from presentation and instruction, and 14 did not impose a limit.

Table 1.

Summary of the distribution of different types of professional development activities required per licensure renewal cycle across 45 occupational therapy regulatory boards with mandatory continuing education requirements in the United States

Type of PDA	Total no. of regulatory boards allowing a particular PDA for CE credit	No. of regulatory boards allowing a particular PDA for CE credit without a limit in each licensure renewal cycle	No. of regulatory boards allowing a particular PDA for CE credit with a limit in each licensure renewal cycle[a)]	No. of regulatory boards do not mention or not allow a particular PDA for CE credit
Attending
CE courses	45	42	3	0
Academic coursework	43	38	5	2
Self-study	38	27	11	7
In-service training	36	20	16	9
Independent study	20	0	20	25
Specialty certification	14	9	5	31
Study group	11	1	10	34
Apprenticeships or fellowship training	5	4	1	40
Presenting
Presentation and instruction	44	14	30	1
Publishing
Publication	41	17	24	4
Research	28	9	19	17
Development of instructional materials	18	7	11	27
Grant writing	7	0	7	38
Professional service
Mentorship	19	0	19	26
Involvement in professional organization	18	0	18	27
Volunteering	14	0	14	31
Professional manuscript review	8	0	8	37
Fieldwork supervision	35	7	28	10

PDA, professional development activity; CE, continuing education.

Including the board determines the number of credit hours.

Eight regulatory boards granted the same amount of CEUs for the presenter as for the attendees, which means a 1-hour presentation was counted as 1 continuing education hour with no allowance for preparation times credit. The majority (21) granted double the continuing education hours for each hour of presentation, and one state allowed triple the amount of presentation time for CE hours. Fifteen other boards did not explicitly state whether preparation times were allowed or not, and did not specify how many continuing education hours the licensee can claim for each hour of presentation, or the maximum continuing education hours allowed.

As indicated in Table 1, 27 regulatory boards allowed self-study hours to be counted toward CEUs without a cap for the maximum, 11 had a cap and 7 did not mention whether self-study was allowed to be counted toward CEU or not. Whereas, 17 regulatory boards did not have a cap on the number of continuing education hours licensees can earn from publication, 24 imposed a cap, and 4 did not mention whether publication was allowed to be counted toward CEU or not. In 16 states where self-study had no maximum cap for earning continuing education credit, the category of publication either had a maximum cap or was not mentioned (or not allowed) as counting toward continuing education credits. Furthermore, in 3 regulatory boards, the amount of maximum continuing education hours allowed for the category of volunteer service was more than that of the category of presentation or publication.

A similar stringent conversion between preparation time and continuing education hours for presentation also applied to publication. In one extreme example, one publication as a lead author was equivalent to one continuing education hour. Typically, achieving a passing score on an assessment after reading an article in self-study or writing a short reflection report after reading an article in an independent study could also earn one continuing education hour in those regulatory boards where self-study or independent study was allowed to be counted toward CEU.

An ethics or legal issues course was required within each renewal cycle by just 6 regulatory boards, and was allowed by 5. Even though 3 other boards included the words ethics or ethical in their statement of continuing professional competence, they did not require a course on ethical or legal issues for licensure renewal. Finally, certain topics on job-related educational or professional activities were legislatively mandated or allowed for continuing education credit in some regulatory boards, but explicitly not allowed in other (Table 2). Raw data file is available from Supplement 1.

Table 2.

Specific education topics that are mandated, allowed and not allowed for counting toward continuing education units for licensure renewal by occupational therapy regulatory boards

Continuing education topic	No. of regulatory boards mandate this topic	No. of regulatory boards allow this topic	No. of regulatory boards do not allow this topic
Patient abuse recognition and reporting training	1	1	1
HIV/AID education[a)]	1	2	1
Universal precaution or infectious control education	0	1	5
Cardiopulmonary resuscitation	0	5	12
Ethics	5	2	0
Laws and rules governing occupational therapy practice	3	4	0
Cultural competence	1	2	0
Documentation related to reimbursement and billing	0	8	3
Marketing, private practice, or business growth	0	3	4
Personal skills or general health	0	2	2

Human immunodeficiency virus infection and acquired immune deficiency syndrome.

Based on the summarized description of continuing education requirements across the 51 OT regulatory boards, four areas of concerns were identified: (1) Non-uniformity and inconsistency of continuing education requirements for licensure renewal between OT regulatory boards coupled with lack of specific criteria for various PDAs. (2) Continuing education requirements were not tailored to meet the needs of individual licensee’s current and anticipated professional role and job responsibilities. (3) There was a negative bias toward presentations and publications allowed for CEUs. (4) Few regulatory boards mandated continuing education topics on ethics related to OT practice within each renewal cycle.

Discussion

This study revealed that state OT regulatory boards have created more types of PDAs beyond those suggested by AOTA and NBCOT to allow licensees to earn CEUs. This policy seems to acknowledge the value of a variety of educational or professional activities that the licensee engaged either within or outside their job responsibilities to maintain professional competence.

Given that each OT regulatory board has the autonomy to define rules and regulations for continuing education requirements, it is not surprising to find that uniformity for such requirements does not currently exist across all the boards [9]. Not only do some regulatory boards have a cap on the maximum continuing education hours earned from certain PDAs per renewal period, while others do not, but the guideline criteria related to continuing education requirements for different types of PDAs is not uniform between boards. The criteria for the maximum continuing education hours that the licensee can earn in each type of PDA are not specific enough or simply not available in several regulatory boards, which leave a lot of room for clarification from licensees who apply for licensure renewal for the first time in a particular state.

The NBCOT has created a user-friendly template of Certification Renewal Activities Chart outlining and assigning continuing education credit to various acceptable PDAs for certificate renewal [7]; however, only two regulatory boards currently take advantage of this pre-existing system. Instead, most boards have some format with missing specific information or even confusing requirements. Often only the (maximum) continuing education value for a particular item within a PDA was stated but not the maximum credit allowed for that PDA, or vice versa. In order to establish more consistency, regulatory boards could establish a consortium to try to facilitate a more uniform reporting format for various acceptable PDAs used for continuing education credit and interpretative guidelines for continuing education requirements [9].

There is currently no difference in CEU requirements for licensees with different job positions/titles and responsibilities such as clinicians, academicians, or administrators/managers. Several regulatory boards purposefully require the majority of continuing education hours directly related to clinical practice activities or delivery of patient care OT services, which seems appropriate when the licensee’s sole responsibility is direct patient care with no administrative or management duty. For licensees whose primary role is an administrator or a manager, such requirements may unnecessarily limit them from seeking out continuing education opportunities relevant to their job demands [10]. This requirement may also indirectly deter clinicians from moving up to management and administrative levels as they may not have developed enough knowledge and skills from continuing education activities to equip themselves for this role. With the current trend and emphasis in OT toward public health, management and administrative duties related to patient care policy is as important as direct patient care in terms of the protection of healthcare consumers [1]. The fact that placing a stringent limit on or excluding certain continuing education activities may be beneficial for some licensees gives support to the idea continuing education requirements should be tailored specifically to the differing job demands of various licensees [11].

All regulatory boards impose rules regarding the maximum hours that can be earned in PDAs related to volunteer service provision for CEU within each renewal cycle. This seems reasonable as these activities may provide a minimal learning component related to practice or promoting a licensee’s knowledge and professional competence. However, it is unclear what the underlying rationale is for a cap on the maximum number of CEUs earned from presentation and instruction and publication, as well as what seems to be a low assigned value to these types of PDAs. It is undeniable that delivering a presentation and providing instruction (including the preparation time) or publishing an article demands far more time than attending someone’s presentation or reading an article and answering some questions at the end. However, preparation time for presentation and instruction and publication is often being discounted. Furthermore, in some states, volunteer service provision has a higher maximum continuing education hours earned than presenting or publishing which suggests that those regulatory boards place a low value on presenting and publishing.

With an increasing emphasis of continuing education content on clinical practice and patient care in many regulatory boards, relying on practitioners to engage in and disseminate any patient-oriented research activities or their clinical experience through presentations and publications is vital. A continuing education requirement policy that acknowledges the actual amount of time to prepare a professional presentation, a lecture, and a manuscript for publication may encourage more practitioners to educate others through presentation and publication.

Perhaps the most alarming finding is that only 5 state boards require licensees and 2 boards allow licensees to take a 1-2 hour course on ethics related to OT practice to count toward continuing education credits in each renewal cycle (Table 2). The importance of ethics viewed by AOTA is illustrated by the association having an entire committee of 12 esteemed members of the profession dedicated to developing and updating the standards of the profession’s code of ethics periodically that apply to practitioners, both inside and outside of clinical practice [12]. The underlying reason why so few regulatory boards currently require licensees to periodically renew their knowledge and understanding of ethical issues is unknown.

There were some limitations of the results. As most regulatory boards are continually modifying and updating continuing education requirements for OT licensure renewal, not all information reported in this review is up-to-date. Some boards provide inconsistent information, therefore, categorization of PDAs is challenging. For example, several boards indicate a maximum cap of continuing education hours for publication, but not presentation, and vice versa. It is unclear whether not being mentioned means no cap or not. It is also unclear whether the terminology used as to the types of PDAs (e.g., self-study versus independent study) means the same thing between boards. Finally, no confirmation from individual regulatory boards to verify continuing education requirements was sought.

It is understandable that some legislatively mandated continuing education topics are out of the control of individual OT regulatory boards as these continuing education topics applied to all licensed health care providers working in that state. The purpose of this review is not to call for absolute unanimity in continuing education requirements or to advocate for licensure portability between OT regulatory boards across the US. Instead, this review attempts to facilitate awareness of certain key issues in continuing education requirements, to call for each OT regulatory board to improve the clarity of their continuing education requirements, and adopt some reasonable guidelines that have evidence-based justifications or rationale. Increasing the clarity of continuing education requirements not only can help increase licensees’ compliance, but also reduce the incidence of unnecessary inquiry from the licensees.

Based on the findings from this study, four specific recommendations are suggested for the OT regulatory boards: first, they should adopt a uniform continuing education requirement reporting format which includes a table with each column clearly stating the type of PDA (providing a definition when appropriate), value of each PDA, maximum values/units allowed per renewal cycle, specific restrictions, and verification documentation; second, given that the rationale of continuing education requirements is to maintain and improve the licenees’ professional competence to provide safe and effective practice and to protect healthcare consumers, allowing licensees to tailor the topics and subject matter of continuing education activities or PDAs that match their current and anticipated practice requirements and job demands may better achieve this objective [11]; third, each board should assign the amount of continuing education credits to be awarded for different types of PDAs, especially presentation and professional publication, be based on research evidence rather than what appears to be arbitrary determination; and fourth, it each board should request licensees to participate in a continuing education course on ethics related to OT practice in at least every other renewal cycle.