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Background: Health and human service professionals with disabilities have unique experiences and knowledge to share with clients. However, people with disabilities continue to be underrepresented in rehabilitation education programs and professions. Research indicates that educators experience challenges in accommodating students with disabilities due to a myriad of professional program requirements. Research also suggests that educators reproduce ableist practices in these programs.

Objectives: To determine how the accommodation work of occupational therapy and physiotherapy educators is being organized by institutional expectations and practices and to critically reflect on how this impacts the accommodation process.

Methods: In this institutional ethnography informed study, 11 educators and 4 staff members from one Canadian university were interviewed about their work of accommodating students with disabilities in the university-based courses of the occupational therapy and physiotherapy programs. The analytic strategies of mapping, indexing and writing were implemented to reveal the problematic and the ruling relations governing educators.

Results: The problematic experienced by educators in this study is their struggle to reconcile 2 competing ruling relations in the accommodation process: the focus on students in the educational institution context with the focus on clients in professional and healthcare/social system contexts.

Conclusion: Critical consciousness is needed to recognize and reconcile this false dichotomy. Educators will need to be open to accommodations that may not resonate with their experience of the profession but assist students in learning and demonstrating their learning. However, educators require clarity from stakeholders in the professions about essential requirements for entry-level practice.

Introduction

Health and human service professions need to reflect the diversity in society.^1,2 Clients and their caregivers perceive positive impacts from working with health and human service professionals who have disabilities, including these professionals’ understanding, empathy, knowledge of systems, and potential to be role models.³ Students with disabilities in health and human service programs, and professionals with disabilities report having attributes that equip them to empathize with clients and address the barriers that clients experience.^4–8 However, disability is underrepresented in the health and human service workforce.⁹ While changes to legislation have resulted in an increase in the admission of students with disabilities in these programs,^2,4,10,11 their academic performance and graduation rates are lower than students without disabilities.^12–14

Recent research indicates that health and human service professionals reproduce ableist practices at different levels and in different ways.^1,15 Bulk and colleagues¹⁵ interviewed students with disabilities, a professional with a disability, and stakeholders including preceptors, faculty, and representatives from regulatory organizations to understand the barriers experienced by students with disabilities in professional programs. They found that societal marginalization occurred through a dominant discourse where disability is presented as a problem and both students and professionals with disabilities are devalued. Institutional marginalization was reflected in rigid program structures, bureaucracy concerning accommodations, and assumptions that professionals do not have disabilities. Interpersonal marginalization occurred through power differences between disabled and non-disabled peers and between disabled students and faculty. Easterbrook and colleagues¹ found that participants similar to those in the study by Bulk and colleagues, justified their ableist actions through assumptions about the rationality, autonomy and productivity of people with disabilities. Stakeholders questioned disabled students’ rationality when they expressed concerns about disabled students’ ability to practice safely. They limited student autonomy with inflexible programs and arguments about the limitations of the real world. They excluded or did not accommodate disabled students based on assumptions about their ability to complete the program and practice the profession.

Occupational therapy and physiotherapy professionals value the inclusion and participation of all members of society, particularly people with disabilities.¹⁶ However, in the role of educators, these professionals struggle to accommodate students with disabilities due to the myriad of requirements educational programs must address, such as professional competencies, accreditation standards and university degree-level expectations.^11,17 As mentioned, there is some literature that points to ableism as an explanation for the educators’ difficulties.^1,4,15

Institutional ethnography is a methodology that makes visible the intersection between people’s everyday experiences (ethnography) and organizational structures (institutions).^18–20 The premise of this approach is that the daily activities of individuals are controlled by institutional or ruling relations.¹⁸ In other words, the experiences and actions of educators in the accommodation process are organized by a complex set of institutional expectations. Institutional ethnography enables invisible ruling relations to become visible, revealing opportunities for transformation within organizational processes.¹⁸ Our purpose was to use an institutional ethnographic approach to understand how the actions of educators in professional programs are shaped by ruling relations governing the accommodation of students with disabilities and to critically reflect on how this impacts the accommodation process.

Methods

The Research Team

The research team includes educators: 2 occupational therapists, a physiotherapist, and 2 from disciplines outside of rehabilitation. The first author, who conducted the interviews and led analysis, is an educator in one of the programs and thus, had experiences coordinating courses, teaching sessions, tutoring, and accommodating students with disabilities. The first author was self-aware of their position as an insider within the current ideology (discourse in the field/profession) in order to critically reflect on the social relations of power in the accommodation process.²⁴

As an insider, the first author was also aware of texts and institutional language related to accommodations and teaching in professional rehabilitation programs. This knowledge is explicitly articulated in the results section herein; for example, by invoking the texts describing program structure and philosophy. To ensure that the first author did not fall prey to institutional capture, which is the unintentional uptake of institutional discourse that makes ruling relations invisible, they engaged in reflexive analysis of assumptions and judgments through journaling and discussion with the research team.^19,21

Institutional Ethnography

Institutional ethnography is both a theory and methodology.^21,22 It is materialist in nature, such that its focus is on the actual activities of people in their everyday lives.^22,23 The theory posits that institutions, which are embedded in broader social discourses, coordinate the activities of people who participate in work processes created for them but not by them.²⁴ By understanding what people do in their everyday lives, the researcher begins to understand how the work of people is socially organized.²⁰ Institutional ethnographers are interested in exploring and exposing the ruling relations of work, a particular subset of social relations.¹⁸ Ruling relations serve to protect and maintain interests broader than the local context under study.¹⁹ This is accomplished through ruling texts or taken-for-granted instruments that are activated by workers in a particular context and coordinate the actions of others elsewhere.²⁴ Thus, the results of an institutional ethnography have translocal implications for the individuals whose work is being explored. Dorothy Smith, the founder of institutional ethnography, conceptualizes work as both paid and unpaid, visible and invisible, and includes aspects that are often taken-for-granted.²⁵ In this study, we define the work of educators as engaging in the process of accommodating students with disabilities.

An institutional ethnography begins with a disjuncture or a disconnect between individuals’ experiences of the world, in comparison to the authorized knowing of these experiences, because the purpose of this method is to make visible the ruling relations that are causing the disconnect.¹⁹ Based on the literature, a disjuncture for educators in professional rehabilitation programs is the disconnect between the values of inclusion and participation in rehabilitation with the challenges experienced by educators when accommodating students with disabilities. Once the disjuncture is named, data is required to explicate it.²⁴ 

Data Collection

An institutional ethnography involves taking a standpoint in the accommodation process, which will reveal a particular set of tensions and specific knowledge understood by the standpoint informants.²¹ In this study, the standpoint is that of educators teaching in the occupational therapy and physiotherapy programs at a mid-size university in Canada. Ethics approval was obtained from the research ethics board at the university.

We recruited educators in university-based courses who had provided disability-related accommodations in the last 5 years. They included university-based faculty and adjunct faculty whose primary roles were clinical. Email invitations were sent to a purposive sample of educators who taught different courses using a variety of delivery formats to ensure a range of perspectives. Twelve of the 25 core faculty and 5 of the approximately 100 adjunct faculty in the rehabilitation sciences provided accommodations in the past 5 years and were invited to participate in the study.

While we sought the standpoint of educators, we recognized the value of input from other key stakeholders in the accommodation process who could provide second-level data about organizing structures that are beyond the knowledge of the standpoint informants.²⁴ We therefore invited 4 additional participants from the Human Rights office, the Ombudsperson office, the Disability Services office, and the Rehabilitation Department who had worked with student occupational therapists or physiotherapists with disability-related accommodations in the last 2 years. These staff members were noted by the standpoint informants to be key actors in the accommodation process, or chain of action.²⁶

We conducted in-depth semi-structured interviews approximately one hour in length, to understand informants’ daily work activities and experiences related to the accommodation process. These day-to-day experiences were a gateway into the social relations of their accommodations work.²⁷ The first author interviewed each informant, probing for references to specific texts (documents and expectations) guiding their actions.²⁶ Since a pre-determined interview guide is contrary to the spirit of an institutional ethnography, we developed broad questions to capture the social relations emerging in the data,^24,26 including: 1) Where does the accommodation process begin for you? 2) What do you do in the accommodation process? 3) How do you accomplish this work?

All interviews were recorded and transcribed verbatim.²⁶ Each informant was assigned a pseudonym to ensure anonymity. Documents were also collected as data in this study, including texts noted by informants that shaped their actions in relation to supporting students with disabilities. This included texts that were explicitly named, as well as implicit references to program texts that shaped educators’ actions. Interviews and document analysis continued until the chain of action related to the accommodation process, and the social relations of the phenomenon were mapped.^24,26 In the study, this process ended when no new actors or actions were identified.

Data Analysis

Where data collection explores the ruling relations or institutional structures as they impact the daily experiences of participants, data analysis explains how the process unfolds.¹⁸ From the data, researchers discover and explicate a research problematic, which then organizes the research analysis process.²¹ This problematic is characterized as a dissonance between informants’ knowing and experience versus the authorized knowing as seen in the data.²¹ To discover the problematic, we reviewed each transcript to notice instances when the informant described tensions in their accommodation work between what they experienced and how it was represented. We noticed when these same tensions were being described by different educators located in different places and at different times in the accommodation process and wrote about these accounts to better understand the problematic. This problematic provided a focal point for further analysis.

Three common analytic strategies assist in orienting to the data and understanding how the problematic occurs: mapping, indexing, and writing.²¹

• Mapping is a concrete action that involves identifying and sequencing the actors and their actions in the work We reviewed each informant’s transcript for their entry point into the accommodation process and mapped the subsequent chain of actions, including who was involved and how.
• Indexing is an analytic strategy that clusters data into linked occurrences.²¹ This strategy ensures that researchers remain in the materiality of the study as abstraction and theorizing are avoided.²¹ We focused on the work of informants by indexing the rich descriptions they provided of work that was linked to others. For example, informants in different roles described the work involved in student appeals and human rights complaints. We indexed their descriptions together as quotes in a Word document, rather than preparing interpretive summaries.
• Analysis continues through writing, with a preliminary sketch of the overall argument concerning the ruling relations.^21,24 The argument is built using “chunks” of data written as analytic points, presenting evidence for the overall argument. As more points are added, the overall argument is refined until the final version fully explains the data in relation to the work process and the relations of power that privilege some approaches and marginalize others.²⁴ By writing about the analytic points that explicated how educators’ work was being organized, the way in which these ruling relations operated were made visible.

Results

The Informants

Six educators (5 core and 1 adjunct faculty) from the occupational therapy program and 5 educators (all core faculty) from the physiotherapy program participated in the study. Their teaching experience ranged between 5 to 40 years; their practice experience in their profession ranged between 10 to 45 years. Informants worked with clients across the life span with expertise in: musculoskeletal/orthopedic health; cardiology/respirology health; mental health; chronic diseases; neurorehabilitation; and social determinants of health. Nine informants had served multiple educational roles (eg, Program Head, Term Chair, Tutor, and Course Coordinator); 2 had experience in one role only. In addition to the educators, 4 staff members from campus offices participated in the study, including Disability Services, Human Rights, and the Rehabilitation Department. These informants had been in their roles from 4 to 31 years, and three had a professional designation prior to this role. They confirmed the accommodation process explicated by the educators but did not offer any new insights beyond the reach of the standpoint sample.

The Texts

The only text explicitly invoked by all the informants was the students’ accommodation plans. In most instances, this plan was the entry point for the educator in the accommodation process. Informants received email notification regarding student accommodation plan(s), which they reviewed to understand their responsibilities in ensuring barrier-free access to learning for each student. Each plan varied depending on the student’s needs and the accommodations as articulated by the staff at Disability Services.

The informants explicitly indicated that there were no texts from the rehabilitation field involved in their accommodation work. However, they identified content from texts in the program and university when explaining this work. As an insider, the first author was familiar with the content. The texts, their purpose and the context in which they were invoked by informants is listed in the Table.

Table: Ruling Texts

Additional texts were identified by 2 informants (educators) who had specific gatekeeping roles in the accommodation process. However, to ensure anonymity, their reflections were combined with that of all the educators without identifying and analyzing the specific role of the texts they mentioned. We recognize the limitations of not including these text-action-text sequences, and refer to the study as being informed by institutional ethnography.

The Problematic

The problematic in institutional ethnography is the knowledge of the standpoint sample of being there in opposition to the authorized knowing of their experience.²³ Educators implemented disability-related accommodations as indicated in the “authorized knowing” inscribed in students’ accommodation plans. Often the process was smooth, particularly in courses that focus on theory, evidence, foundational knowledge, and healthcare/social systems. However, educators struggled with some accommodations that they believed prevented students from demonstrating the requirements of the course, program, and/or profession.

The occupational therapy and physiotherapy programs are underpinned by the philosophy of problem-based learning (PBL). As described in term handbooks, within the small group Problem-Based Tutorials (PBT) course, students learn collaboratively through group discussion of clinical scenarios while the tutor facilitates the learning process. Several educators, namely tutors and PBT coordinators, expressed concerns when students had accommodations that included leaving the group, not speaking during tutorial time, or meeting with the tutor one on one outside of PBT time. They reported that the group experience is not strictly about the content being learned but also the learning process. Term handbooks indicated that tutorials include designated time to give and receive feedback on content and process at an individual and group level. This feedback is part of a formative and summative group evaluation process. One educator, Meghna, described her challenges with an accommodation affecting this group experience:

“…the student wants an opportunity to meet one on one with the tutor to discuss performance…what’s in the group is discussed in the group, including individual students’ performance…students can feel, if they are struggling, can feel like they are being picked on but then is that a disability-related accommodation or is that…‘I don’t want to be centered out’?…I do think there are some requirements to be in a professional preparation program…and in our program, part of it is you have to be prepared to work in small groups and be evaluated on your small group performance.” Meghna

As identified in term handbooks, one goal of PBT courses is to build skills that prepare students for professional practice in healthcare teams. Occupational therapists and physiotherapists collaborate on patient care plans and require process skills to work effectively on teams. Thus, the students’ group process skills, such as communication, are evaluated. Some educators reported feeling challenged to evaluate students who are accommodated in such a way that they are not demonstrating the skills in the manner intended (ie, meeting the tutor separately rather than communicating issues in the group context). As a tutor, Meenal was concerned about whether foundational skills could be accommodated:

“how much are you able to…how much can the school accommodate someone who does not have the social…skill set, communication skill set, to be able to work in a field that demands that? How much accommodation can be made for that?” Meenal

Term handbooks are written by educators teaching courses, including PBT, in the term. The philosophy of PBL is described along with how it is implemented in the course/program.

In PBT, some educators explained that some student behaviors were perceived to be unprofessional, unless the student chose to disclose a disability-related reason for their behavior. For example, fidgeting, absences, taking additional breaks and wearing sunglasses were cited by a few educators as unprofessional behaviors presented in tutorial. For the tutor and peers to understand, the student disclosed that their behaviors were either part of their disability or how they managed their disability. While program handbooks indicate that students are not required to share any personal information in the programs, several educators stated that disclosure often occurs in PBT.

Courses that focused on clinical skills raised concerns for the educators. Some educators did not support accommodations for certain clinical skills exams, such as the Objective Structured Clinical Examination (OSCE), including accommodations for breaks, extra time, completing the exam alone or using a proxy. They explained that they are attempting to examine students on their ability to problem-solve, adapt to changing environments, and be efficient and effective in a safe manner. Ishar explained that these skills are being evaluated because they are required for the licensing exam and clinical practice:

“…it’s because it’s a professional program where there’s a practical exam upon completion which dictates whether or not you can practice as a physiotherapist and there are no accommodations provided in those situations. I think we’re following suit…it’s not really setting them up for success as physiotherapists being that they need to go and do these exams and use physical skills as part of their practice.” Ishar

Ultimately, the main tension among educators was that they believed they were educating and evaluating students to be qualified professionals providing safe and effective occupational therapy and physiotherapy services to the public. This was in contrast to messaging received from campus office staff that their responsibility was strictly to provide students with an education in occupational therapy or physiotherapy:

“…what comes back is ‘your job is only to make…or to give students an education. Your job is not to create professionals.’ And I will argue back saying ‘no, my job is to create professionals, that’s what we’re all about.’ But [Disability Services] will just say, ‘no you are just giving them a degree.’ So, they don’t see why we can’t implement these different things.” Myria

Thus, the university is organized to focus primarily on students and the supports they need to learn and demonstrate an understanding of subject matter and associated skills. Whereas educators are focused on the outcomes of an education in occupational therapy and physiotherapy, which is the ability to provide rehabilitation services to clients. There are 2 ruling relations that explain how educators in professional programs come to know this problematic: the focus on students in the education context and the focus on clients in the professional and healthcare/social system contexts. We will explain how each is governing the work of educators and how, in combination, they are creating tensions in the educators’ work.

Focus on Students

Educators identified offices on the university campus designed to support students, such as Disability Services where accommodation plans are developed and Health Services where students can access medical/health care. Other offices they cited support the broader university community, such as the Human Rights office and the office of the Ombudsperson. However, some educators explained that in their accommodation experience, the staff from these offices advocated for students, rather than attempting to understand and resolve issues collaboratively with educators. Myria described her experiences:

“…there are some students who do not respond to what the program has to say but they will respond to what [Disability Services] has to say. I’ve always felt in this particular context, that it’s an us versus them. So, it’s [Disability Services] and the student fighting the program…that’s the perception whereas it’s like why can’t we all just work together here? I think perhaps [Disability Services] feels the program doesn’t have the students’ best interest at heart. I don’t know, perhaps. Maybe it’s that, you know, I’m going to fight for disabilities and you don’t understand disabilities even though we are rehab professionals.” Myria

“…the [Office of the Ombudsperson] has this big sign that says, ‘Problem with evaluation? Contact us.’…That’s not a neutral office.” Myria

The perceived lack of collaboration set up a challenging context for educators to engage in accommodation work. While they appreciated the importance of supports for students, they did not always agree with the accommodations provided by Disability Services. Educators described complaints and appeals initiated by students with disability-related accommodations that lasted for several years and involved stress and additional work. These “cautionary tales” resulted in educators feeling pressured to accommodate students. They expressed concern about the potential consequences of students filing human rights complaints or academic appeals. Nisha explained their thought process:

“I don’t know if that’s good or bad but often my yardstick that guides my decision making is what would happen on appeal…and is there a way to mitigate the need for an appeal and just save everybody time.” Nisha

The university’s accommodation policy includes retroactive accommodations, which are granted after a course is finished. Some educators indicated that in these instances, students did not have disability-related accommodations before or during the course. Rather, after the student failed a course, they received a retroactive accommodation whereby the failure was removed from their transcript. In their interviews, educators understood students’ right to privacy and had not requested more information; however, they were surprised at being shut out of the process. Anya described her experience of retroactive accommodations:

“…there have been those occasions over the years where my grades have been overturned…where students have been permitted to pass where I felt very strongly that they should not, that they should fail…and situations with these retroactive accommodations where they were granted and…I just felt like at some level, “don’t you want to pay attention to the person who is the educator, who is experienced and has taught…and evaluated hundreds of students?” Anya

While identified as infrequent, educators’ experiences of retroactive accommodations illustrated for them the privileging of the focus on students in the university. Educators appreciated the importance of supporting students and noted that recently, they have increased their focus on student mental and physical health and well-being, through eliminating unnecessary barriers to education. Most educators reported implementing universal design in learning (UDL) principles such as lengthening the duration of the term while maintaining the same workload for students and giving all students more time to complete written exams when efficiency is not being evaluated. Their rationale was to improve students’ experiences in the programs, recognizing that disability-related accommodations would still be needed. Abha explained the changes with the most recent cohort:

“By reorganizing your exam week to have double time for everyone and having 24 hours between exams…we’ve tried to apply [UDL] to all of our exams. So rather than…before we might have had an exam in the morning and an exam in the afternoon, that was one hour each. Now, we give everybody 2 hours for each of those exams and we split those exams over different days…that’s accommodated in this past cohort, I think almost everybody…” Abha

The educators who discussed implementing UDL, reported it as a positive experience. However, in addition to their responsibilities to students, educators indicated that they felt a responsibility to their professions and saw the programs as bridges to students serving the public where the focus is on clients.

Focus on Clients

For decades, rehabilitation professionals have been stating that their professions are underpinned by a client-centered philosophy where the client’s needs and goals guide therapists’ actions.²⁸ In their interviews, educators explained that students are not their clients and that there is no text from the rehabilitation field helping them navigate the accommodation process. However, they draw on their professional skills in this process. Myria, for example, shared how she matched student accommodations to academic requirements:

“…what I’m doing at the time is just trying to problem-solve in my head. So, there’s no…there’s no roadmap or there’s no anything; I’m using my…my best professional judgement in situations in trying to support the student.” Myria

The educators’ professional judgement included their understanding of rehabilitation practice as registered occupational therapists and physiotherapists and having knowledge of their responsibilities to the public. They provided examples of how their practice experience guided them in implementing students’ accommodations that were novel. For example, Karam described a situation where a student’s accommodation involved the student developing their own memory aid and then sending it to the educator for approval prior to each exam. When they reviewed the aid, Karam noted:

“…it’s somewhat probably my skills as an OT knowing what is doing something too much for somebody [versus] what is a cue to help a task happen…and I made that decision based on how you remediate tasks…” Karam

Karam appeared to be drawing on the skills employed by occupational therapists in practice to discern the appropriateness of the student’s memory aid in writing the course exam. Some educators also described how they drew on practice experience to determine temporary accommodations. In these situations, the student did not have a formal accommodation plan from Disability Services; however, they required accommodations immediately. The educator, in the role of course coordinator, determined how best to accommodate the student, while maximizing their engagement in the learning process. Dhruv provided an example from their clinical skills course:

“…if a student has a brace on [their] leg, [they’re] not able to provide the support that a patient would need for a transfer, a patient with stroke or a patient with, you know, ataxia, but they could do manual skills for upper extremities, for example, right? So, it’s all…depending on the risk…” Dhruv

Addressing risk and safety were prominent in the interviews with educators who coordinate clinical skills courses. Educators felt that part of their role was ensuring all students were safe to engage in clinical learning and enter placement/practice. They did not indicate that students with disabilities are more likely to be unsafe, only that it in some situations such as the one described by Dhruv, it was an important consideration.

Part of the accommodation work of educators in the occupational therapy and physiotherapy programs is grappling with the disconnect they witnessed between the student context at the university with their understanding of the clinical practice context. Anya articulates this concern:

“…it’s a very stressful job. So, you’re…you’re going to have to be able to cope with multiple demands and time pressures and sad situations and all of the kinds of things that sometimes the students have difficulty dealing with…If you are struggling this much with the program, are you actually going to be able to be in this profession?” Anya

Anya and other educators identified that students’ future employment situations are beyond the scope of their role. Educators stated that while there are a variety of ways to practice in the professions, they were unsettled by the prospect that some students may struggle in practice, particularly since they understood the programs to be bridges to practice.

Discussion

The disjuncture in the literature between the professional philosophy of inclusion and participation versus the challenges expressed by educators and the ableism identified by researchers, was not the problematic that emerged in the data. The problematic experienced by educators in this study is the tension between the university structures that focus on students and the professional and health care/social system structures that focus on clients. In this institutional ethnography informed study, educators expressed that student interests are privileged while client interests are subordinated by the university in the accommodation process. Their experiences with student appeals and complaints, lack of collaboration from campus offices, and having their course grades overturned demonstrate the activation of students’ interests.^21,23 For the purposes of explicating the ruling relations and how they organize educators, we described the ruling relations individually. Separately, these ruling relations appear to be not only important but necessary.

University staff and faculty have a mandate to focus on students and their success in academia. Professionals have a mandate to focus on clients and their health and well-being. However, when both sets of ruling relations are brought together in the context of professional rehabilitation programs within a university, their appears to be a competition of priorities, resulting in a dichotomy where the interests of one or the other is privileged. We argue, however, that the existence of the dichotomy needs to be challenged. There are discourses within rehabilitation practice that focus on both clients and students, such as safety. Educators in professional programs teach students to ensure the safety of both their clients and themselves during service delivery. To serve the public, rehabilitation professions require a healthy and diverse workforce, which means that greater attention is needed to recognize situations where educators struggle with competing priorities and to build bridges between these ruling relations that value both clients and students.

Schrewe and Frost²⁹ discuss a tension between the need for diversity among medical professionals and the standardization of medicine, including the essential requirements of being a physician. They state that separately, these issues make sense, but together, they are in conflict. Schrewe and Frost suggest developing an approach that explores the essence of the profession and holds the space for both individuality and professional standardization. Rehabilitation professionals also need to come together and clarify the essential requirements of each profession while upholding the values of inclusion and diversity.

Academic accommodations remove barriers for students so they may engage in the learning process while maintaining academic standards. These academic standards are non-modifiable essential requirements of the program.³⁰ Differentiating essential and non-essential requirements is challenging in health and human services professions.¹³ Some professional programs identify the profession’s competencies as the essential requirements.³⁰ Occupational therapy and physiotherapy programs in Canada have not explicitly done this; however, even if they do, competencies tend to be broad, encompassing a wide range of practice settings, professional roles, and client populations. Such variation and breadth present challenges in defining essential requirements.

For example, competence in “communication” can be an essential requirement; however, this competency requires vastly different skills from a professional working with a client who is disoriented and confused versus engaging with a client experiencing suicidal ideation. It is unclear which skills are essential for practice, and skills courses were a major area of concern for informants in this study. There needs to be clarity on the minimum expectations for entry-level occupational therapists and physiotherapists to ensure that unnecessary barriers are removed for students with disabilities and to support educators who avoid raising concerns about accommodations due to fear of appeals and complaints.

Educators need to consider how they make individual decisions about disability-related accommodations. Very few of the educators in this study cited any texts that served to assist them in determining which accommodations removed barriers while also upholding essential requirements. Thus, educators relied on their own understanding and experience of professional requirements to make decisions about accommodations. However, educators have not experienced all the ways in which the professions can be practiced. Not experiencing or seeing certain disability-related accommodations in practice does preclude their existence or the potential for their existence. There may be disability-related accommodations that have not yet been imagined, possibly because current practice may be operating on pre-existing systemic ableism. These systems must be interrogated, beginning with the texts that are written by educators (ie, term and program handbooks). Educators need to be open to possibilities that facilitate the contributions that occupational therapists or physiotherapists with disabilities can make to advance the professions.³¹

In their interview, for example, Ishar states that there are no accommodations for the practical licensing exam; however, a review of the exam application and information indicates that alternative accommodations are possible on a case-by-case basis.³² Perhaps the availability of accommodations is not well-known or the access to accommodations is difficult, but the misconception that these do not exist can have a negative impact on students who require accommodations in order to demonstrate their knowledge and skills in their programs and on licensing exams. Educators can improve the accommodation process by knowing the accommodations that exist, considering others that could be possible, and advocating with students for systemic changes in practice where needed.

Another area for change is clarifying when or if disclosure of disability-related needs and accommodations is required in professional programs and practice. In PBT courses, content and process were relevant to professional practice, thereby making the unique structure of the course (ie, small group self-directed learning) essential to the programs. However, findings indicate that disclosure by students with disabilities in PBT was required for students to avoid receiving feedback that their presentation was unprofessional in the course. This feedback is significant because students are evaluated on professionalism in PBT. It seems that the implicit requirement to disclose is in conflict with the student’s right to privacy.

Jarus and colleagues³ interviewed clients and caregivers about their perceptions of receiving health and human services from disabled professionals. Their findings indicate that clients and caregivers felt disclosure was appropriate when relevant; for example, when the professional’s behavior could be perceived as unprofessional. The issue of disclosure may be nuanced in practice, such that there may be instances when it is more or less relevant to share personal information. However, there is also a need to revisit the definition of professionalism and whether it is underpinned by normative assumptions. There may be a need to consider more broad and expansive understandings where disclosure would be less of an issue.

Rigor

Members of the research team ensured the alignment of institutional ethnography theory and methods with the study design.²² The overall argument about conflicting ruling relations in the process of accommodating students with disabilities, is grounded in analytic points from the data. In the description of results, we explicated the connections between the overall argument, analytic points, and data gathered (ie, quotations). With respect to transferability, we have provided a detailed description of the local context. Institutional ethnography has a “generalized and generalizing nature,” which examines social relations that apply beyond the local context.^19(p42) In other words, since all accredited occupational therapy and physiotherapy programs in Canada are delivered via post-secondary university campuses and each profession has an accrediting organization, regulatory organizations and an organization that administers the professional licensing exam, the educators in other programs may also experience tensions due to the ruling relations described in this study.

Limitations

This study was limited by the lack of data from students. While the standpoint sample involved educators, students are key stakeholders in the accommodation process and may have added second-level data to understanding the accommodation process. Further, second-level data was collected with the university as the “institution”; however, findings indicate that professional organizations also influence the accommodation of students with disabilities in rehabilitation programs. Thus, recruiting informants from professional and regulatory organizations may have added insights related to ruling relations that focus on clients.

Conclusion

Dorothy Smith’s¹⁹ institutional ethnography methodology provided a means to explore the accommodation work of educators in professional rehabilitation programs. While providing disability-related accommodations, educators in this study were influenced by 2 ruling relations: 1) the focus on students in the university context; and 2) the focus on clients in the professional and healthcare/social system context. This created a false dichotomy where educators perceived that only one set of interests could prevail. Educators were not guided by a clear understanding of the essential requirements of their professions. Rather, they invoked their knowledge and experience of the rehabilitation professions. However, rehabilitation practice may be rooted in systemic bias that has yet to be unearthed and addressed. To prepare students in professional programs to provide services to the public, students need to be supported in their own health and well-being. This means knowing which, if any, parts of the professions and programs cannot be accommodated, remaining open to unimagined possibilities for accommodation, and working with students to bridge the focus on students with the focus on clients.

We would like to thank the educators for openly sharing the details of their work in the accommodation process and Dr. Elizabeth Marquis for sharing her expertise throughout the research process.

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