WHO, WHEN, HOW: a scoping review on flexible at-home respite for informal caregivers of older adults.

BACKGROUND: As the world population is aging, considerable efforts need to be put towards developing and maintaining evidenced-based care for older adults. Respite services are part of the selection of homecare offered to informal caregivers. Although current best practices around respite are rooted in person centeredness, there is no integrated synthesis of its flexible components. Such a synthesis could offer a better understanding of key characteristics of flexible respite and, as such, support its implementation and use. METHODS: To map the literature around the characteristics of flexible at-home respite for informal caregivers of older adults, a scoping study was conducted. Qualitative data from the review was analyzed using content analysis. The characterization of flexible at-home respite was built on three dimensions: WHO, WHEN and HOW. To triangulate the scoping results, an online questionnaire was distributed to homecare providers and informal caregivers of older adults. RESULTS: A total of 42 documents were included in the review. The questionnaire was completed by 105 participants. The results summarize the characteristics of flexible at-home respite found in the literature. Flexibility in respite can be understood through three dimensions: (1) WHO is tendering it, (2) WHEN it is tendered and (3) HOW it is tendered. Firstly, human resources (WHO) must be compatible with the homecare sector as well as being trained and qualified to offer respite to informal caregivers of older adults. Secondly, flexible respite includes considerations of time, duration, frequency, and predictability (WHEN). Lastly, flexible at-home respite exhibits approachability, appropriateness, affordability, availability, and acceptability (HOW). Overall, flexible at-home respite adjusts to the needs of the informal caregiver and care recipient in terms of WHO, WHEN, and HOW. CONCLUSION: This review is a step towards a more precise definition of flexible at-home respite. Flexibility of homecare, in particular respite, must be considered when designing, implementing and evaluating services.

Tensions experienced by case managers working in home care for older adults in Quebec: first level analysis of an institutional ethnography.

BACKGROUND: Case managers play a vital role in integrating the necessary services to optimise health-related goals and outcomes. Studies suggest that in home care, case managers encounter tensions in their day-to-day work, that is, disjuncture between what they should do, in theory, and what they actually do, in practice. However, direct exploration of these tensions is lacking. As such, this study aimed to describe the tensions encountered by case managers in public home care for older adults in Quebec and their influence on day-to-day work. METHODS: An institutional ethnography was conducted through observations of work, interviews and a survey with case managers working in home care in Quebec. Data were analysed using institutional ethnography first-level analysis procedures. This included mapping the work sequences as well as identifying the tensions experienced by case managers through the words they used. RESULTS: Three main tensions were identified. First, case managers perceive that, despite working to return hospitalised older adults at home safely, their work also aims to help free up hospital beds. Thus, they often find themselves needing to respond quickly to hospital-related inquiries or expedite requests for home care services. Second, they are supposed to delegate the care to "partners" (e.g., private organisations). However, they feel that they are in effect managing the quality of the services provided by the "partners." Consequently, they go to great lengths to ensure that good care will be provided. Finally, they must choose between meeting organisational requirements (e.g., reporting statistics about the work, documenting information in the older adults' file, doing mandatory assessments) and spending time providing direct care. This often leads to prioritising direct care provision over administrative tasks, resulting in minimal reporting of essential information. CONCLUSION: The results are discussed using the three lenses of professional practice context analyses (i.e., accountability, ethics, and professional-as-worker) to formulate recommendations for practice and research. They suggest that, despite their important role, case managers have limited power in home care (e.g., with partners, with the hospital).

Which interventions with youths counter ageism toward older adults? Results from a realist review.

Age-related social biases - ageism - are developed at an early age. Interventions to counter ageism have been identified but little is known about their mechanisms, particularly in children. This study aimed to provide a comprehensive understanding of which interventions in youths are most effective, under which circumstances, how, and with what outcomes. Using 46 keywords in 6 databases, a realist review identified 24 studies published between 2000 and 2022 targeting youths under 18. A content analysis of these studies led to the construction of a Context-Mechanisms-Outcomes explanatory model. Contextual facilitators triggering mechanisms for changing stereotypes, prejudices and discrimination were: 1) enhancing knowledge about aging and older adults by providing nuanced information, 2) improving the quality of intergenerational contacts, 3) increasing opportunities to apply previously acquired knowledge in intergenerational interactions, and 4) promoting reflective thinking about experiences with older adults. However, stereotypes and prejudices appeared to be resistant and changes difficult to generalize. Insufficiently advanced cognitive development in children or viewing healthy and socially engaged older adults as unrepresentative of their age group were obstacles that reduced intervention effectiveness. Future studies should explore how advancing age influences interventions as well as the characteristics of older adults involved.

Levers for Change and Unexpected Outcomes of a Participatory Research Partnership: Toward Fostering Older adults' Social Participation to Promote Health Equity.

Promoting health equity in aging requires ensuring older adults' effective access to community-based services fostering their social participation. This study aimed to (a) identify levers for change in community-based services to foster older adults' social participation and (b) explore unexpected outcomes of stakeholder engagement. Based in a large Canadian city, a critical participatory research partnership was formed in a district experiencing considerable health disparities. Four focus groups and seven individual interviews were followed by a collaborative workshop with 28 community stakeholders. Participants identified mainly systemic and organizational levers for change. These levers comprised changing performance indicators and the institutional culture of homecare to value services fostering social participation opportunities. Other levers included supporting individual change agency through participatory research involving community members. Stakeholder engagement led to five unexpected outcomes: "Marking a new beginning," "Expressing ourselves," "Feeling better," "Working together," and "Influencing the community." Recognizing levers for change is essential to understand how to develop services fostering social participation to promote health equity, with whom and in which contexts.

Social change agent training program tailored to occupational therapists' needs: a design-based study protocol.

BACKGROUND: As social change agents (SCAs), occupational therapists (OTs) are expected to defend the rights of their clients, advocate for and with them, and try to influence organizational and political decision-makers. However, OTs do not generally feel equipped to take effective action. The overall goal of this research partnership is to support practising OTs in acquiring the knowledge and skills required to act as SCAs through a specific SCA training program and a toolkit that summarizes the key training points. METHODS: The study will include three iterative phases (conceptualization, implementation and evaluation) and use a participatory process. The design of the training program and toolkit will draw on the expertise of the researchers (theoretical knowledge), a professional provincial partner and study participants (experiential knowledge). To evaluate the training program and toolkit, a self-administered evaluation questionnaire, facilitator observation grid and semi-structured guide designed to facilitate focus group discussions will be used. The quantitative and qualitative data will be analyzed using descriptive statistics and thematic analysis, respectively. The results of the initial implementation and evaluation phases will inform improvement of the training program and toolkit before starting the cycle with the following groups. DISCUSSION: In addition to training about 100 OTs, this study will produce three main benefits: 1) development of two products, namely the SCA training program and toolkit, that are easy to reuse and potentially transferable to other professionals; 2) ownership of these products by the partner through its close involvement in all stages of the study; and 3) development of a sustainable partnership between a team of researchers and a recognized organization with networks across Canada and internationally. These three spin-offs will provide a solid basis for an increasing number of permanent implementation initiatives, in Québec and elsewhere in Canada, not just in occupational therapy but also in other professions.

[Impact of accountability and performance optimization on the choice of occupational therapy interventions]. / Reddition de compte et optimisation de la performance : impacts sur le choix des interventions ergothérapiques.

The restricted range of OT interventions is incompatible with their holistic and patient-centred profession. Accountability and optimization may compromise the quality of their services, the scope of services offered, including prevention and health promotion activities, and, consequently, the achievement of the healthcare system objectives..

Participation needs of older adults having disabilities and receiving home care: met needs mainly concern daily activities, while unmet needs mostly involve social activities.

BACKGROUND: Participation is a key determinant of successful aging and enables older adults to stay in their homes and be integrated into the community. Assessing participation needs involves identifying restrictions in the accomplishment of daily and social activities. Although meeting participation needs involves older adults, their caregivers and healthcare providers, little is known about their respective viewpoints. This study thus explored the participation needs of older adults having disabilities as perceived by the older adults themselves, their caregivers and healthcare providers. METHODS: A qualitative multiple case study consisted of conducting 33 semi-structured interviews in eleven triads, each composed of an older adult, his/her caregiver and a healthcare provider recruited in a Health and Social Services Centre (HSSC) in Québec, Canada. Interview transcripts and reviews of clinical records were analyzed using content analysis and descriptive statistics based on thematic saliency analysis methods. RESULTS: Aged 66 to 88 years, five older adults had physical disabilities, five had mild cognitive impairment and one had psychological problems, leading to moderate to severe functional decline. Caregivers and healthcare providers were mainly women, respectively retired spouses and various professionals with four to 32 years of clinical experience. Participation needs reported by each triad included all domains of participation. Needs related to daily activities, such as personal care, nutrition, and housing, were generally met. Regarding social activities, few needs were met by various resources in the community and were generally limited to personal responsibilities, including making decisions and managing budgets, and some community life activities, such as going shopping. Unmet needs were mainly related to social activities, involving leisure, other community life activities and interpersonal relationships, and some daily activities, including fitness and mobility. CONCLUSIONS: This study highlights the complexity of older adults' participation needs, involving daily as well as social activities. Properly assessing and addressing these needs is thus necessary to improve older adults' health and well-being. Discrepancies in the various actors' perceptions of participation needs must be further explored. Additional research would help better understand how to optimize the contribution of community organizations and caregivers.

Are health promotion and prevention interventions integrated into occupational therapy practice with older adults having disabilities? Insights from six community health settings in Québec, Canada.

BACKGROUND/AIM: Increasingly, health-care systems should promote seniors' health and prevent disability. As they enable engagement in meaningful activities within the individuals' living environment, community occupational therapists have great potential to contribute to health promotion and prevention. Despite this potential, little is known about current health promotion and prevention activities in occupational therapy community practice. This study thus aimed to: (1) identify health promotion and prevention interventions used with seniors having disabilities, and (2) explore barriers to integrating such interventions into practice. METHODS: Secondary data analysis of a qualitative study was carried out using thematic saliency analysis. Eleven community occupational therapists working with seniors having disabilities were recruited in six community health settings in Québec, Canada. Observations of 12 home visits, followed by 12 semi-structured interviews, were conducted with occupational therapists. RESULTS: Most interventions involved optimising independence in personal care and mobility. Explicit health promotion interventions were limited and included enabling healthy lifestyles by increasing health literacy and empowerment. Meaningful activities (leisure, community participation) were not targeted. Barriers to integrating health promotion into practice were clients' complex health conditions and limited openness to change combined with organisational and professional obstacles, such as a misunderstanding of occupational therapists' role in health promotion. CONCLUSIONS: Health promotion and prevention interventions are not intentionally integrated into community occupational therapy practice with seniors having disabilities. As a result, seniors' needs to engage in meaningful activities might remain unmet. Overcoming barriers to integrating health promotion and prevention in practice could help improve population health and wellbeing.

[Agency: occupational therapists' perspectives on their sense of competence and their skills following training]. / Agentivité : perspectives des ergothérapeutes quant à leur sentiment de compétence et quant à leurs compétences à la suite d'une formation.

Context: To tackle the systemic injustices experienced by people in vulnerable situations, occupational therapists' agency, i.e. their power to act, is necessary. However, occupational therapists feel ill-equipped to exercise this power, and would like to develop their skills. The general aim of this research was therefore to document occupational therapists' perception of their skills before and after agency training. Methods: We used a mixed sequential explanatory design, comprising a quantitative component consisting of a pre- and post-training self-administered questionnaire and a descriptive qualitative component with group interviews. Results: A total of 103 occupational therapists completed the training between January 19 and October 19, 2019. Their sense of competence improved, especially for those with no prior training in agency. The skills perceived as having developed the most corresponded to the skills deemed a priority for development, namely effective communication, intentional collaboration, and observation and analysis. On the other hand, occupational therapists emphasized that they had not mastered the exercise of these skills in a real-life context. Conclusion: Although continuing education is one way of improving the skills needed to exercise agency, questions remain as to the optimal modalities for ensuring their full and lasting development.

Fear of Reprisal and Change Agency in the Public Health and Social Service System: Protocol for a Sequential Mixed Methods Study.

BACKGROUND:  Since they are key witnesses to the systemic difficulties and social inequities experienced by vulnerable patients, health and social service (HSS) professionals and clinical managers must act as change agents. Using their expertise to achieve greater social justice, change agents employ a wide range of actions that span a continuum from the clinical (microsystem) to the societal (macrosystem) sphere and involve actors inside and outside the HSS system. Typically, however, clinical professionals and managers act in a circumscribed manner, that is, within the clinical sphere and with patients and colleagues. Among the hypotheses explaining this reduced scope of action is the fear of reprisal. Little is known about the prevalence of this fear and its complex dynamics. OBJECTIVE:  The overall aim is to gain a better understanding of the complex dynamic process leading to clinical professionals' and managers' fear of reprisal in their change agent actions and senior administrators' and managers' determination of wrongdoing. The objectives are (1) to estimate the prevalence of fear of reprisal among clinical professionals and managers; (2) to identify the factors involved in (a) the emergence of this fear among clinical professionals and managers, and (b) the determination of wrongdoing by senior administrators and managers; (3) to describe the process of emergence of (a) the fear of reprisal among clinical professionals and managers, and (b) the determination of wrongdoing by senior administrators and managers; and (4) to document the legal and ethical issues associated with the factors identified (objective 2) and the processes described (objective 3). METHODS:  Based on the Exit, Voice, Loyalty, Neglect model, a 3-part sequential mixed methods design will include (1) a web-based survey (objective 1), (2) a qualitative grounded theory design (objectives 2 and 3), and (3) legal and ethical analysis (objective 4). Survey: 77,794 clinical professionals or clinical managers working in the Québec public HSS system will be contacted via email. Data will be analyzed using descriptive statistics. Grounded theory design: for each of the 3 types of participants (clinical professionals, clinical managers, and senior administrators and managers), a theoretical sample of 15 to 30 people will be selected via various strategies. Data will be independently analyzed using constant comparison process. Legal and ethical analysis: situations described by participants will be analyzed using, respectively, applicable legislation and jurisprudence and 2 ethical models. RESULTS:  This ongoing study began in June 2022 and is scheduled for completion by March 2027. CONCLUSIONS:  Instead of acting, fear of reprisal could induce clinical professionals to tolerate situations that run counter to their social justice values. To ensure they use their capacities for serving a population that is or could become vulnerable, it is important to know the prevalence of the fear of reprisal and gain a better understanding of its complex dynamics. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/48400.

"What Services?": Stakeholders' Perceived Unmet Support Needs for Parents With Neurological Disorders.

Background. Knowledge about the needs of parents with neurological disorders who take care of young children is limited. Purpose. The overall aim of this qualitative study was to explore the perceived unmet parent needs, current supports, and potential solutions to optimize supports of parents with neurological disorders in early childhood in a Canadian setting. Method. Focus groups and individual interviews with parents (n = 8), spouses (n = 5), rehabilitation clinicians (n = 8), community partners (n = 7), and researchers (n = 7) were conducted with a total of 35 participants recruited using convenience sampling. Inductive iterative thematic analysis was performed. Findings. The participants identified the need for society to officially recognize parenting with disabilities, adjust public policies, increase the scope of public programs, consider child development and family well-being, and have barrier-free communities. Conclusion. Providing customized solutions that will adequately fill perceived service gaps is of utmost importance to address these families' needs.

Clinical reasoning process underlying choice of teaching strategies: a framework to improve occupational therapists' transfer skill interventions.

BACKGROUND/AIM: Clinical reasoning, a critical skill influenced by education and practice context, determines how occupational therapists teach transfer skills. Teaching strategies affect intervention efficacy. Although knowledge about the way teaching strategies are chosen could help improve interventions, few studies have considered this aspect. Therefore, the aim of this study was to explore the clinical reasoning process of occupational therapists underlying the choice of strategies to teach older adults transfer skills. METHODS: A grounded theory study was carried out with eleven community occupational therapists recruited in six Health and Social Services Centres in Québec, Canada. Data were collected through observations of teaching situations (n = 31), in-depth semi-structured interviews (n = 12) and memos, and were analysed using constant comparative methods. Memos were also used to raise codes to conceptual categories, leading to an integrative framework. Rigour was assured by following scientific criteria for qualitative studies. RESULTS: The integrative framework includes the clinical reasoning process, consisting of eight stages, and its factors of influence. These factors are internal (experiences and elements of personal context) and external (type of transfer, clients' and their environment's characteristics and practice context). CONCLUSIONS: The clinical reasoning process underlying the choice of strategies to teach transfer skills was conceptualised into an integrative framework. Such a framework supports clinicians' reflective practice, highlights the importance of theory and practice of pedagogy in occupational therapists' education, and encourages consideration and better documentation of the possible influence of practice context on teaching interventions. As such, this integrative framework could improve occupational therapists' transfer skill interventions with older adults.

Occupational Therapy Practice in Palliative and End-of-Life Care in Québec.

Background. There is an emerging evidence base about the scope of occupational therapy in palliative and end-of-life care, but little is known about this practice in Québec or barriers impeding it. Purpose. To describe Québec occupational therapists' practice in palliative and end-of-life care and barriers they encounter. Method. Using the Québec regulatory board members list, we invited occupational therapists working in palliative and end-of-life care to answer an online survey comprising 24 closed- and 5 open-ended questions. We analyzed data using descriptive statistics and content analysis. Findings. The 67 survey participants mainly optimized comfort and safety in meaningful occupations such as mobility, transfers, and hygiene. Barriers to their practice included organizational obstacles and unfamiliarity with their role. Implications. Findings highlight the need to improve education and awareness among occupational therapists and other healthcare professionals about the scope of what occupational therapists can do in palliative and end-of-life care.

A realist review of the home care literature and its blind spots.

RATIONALE, AIMS AND OBJECTIVES: There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. METHOD: We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analysed according to a realist review approach. RESULTS: A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable. At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models' effectiveness. CONCLUSION: We conclude by providing advice for supporting the design and implementation of stronger home care delivery systems. Our analysis suggests that doing so implies a series of sequential steps: identify what system-level goals the model should achieve and which populations it should serve; identify what type of services are likely to achieve those goals in order to establish a basket of services; and finally, identify the best ways and specific means to effectively and efficiently provide those services. Those same steps can also support ex-post evaluations of existing home care systems.

A Scoping Review of the Implementation of Local Health and Social Services for Older Adults.

BACKGROUND: Implementing elder-dedicated local health and social services (LHSS) is primary for older Canadian adults to age in place. However, there is currently no synthesis of the factors (barriers and facilitators) involved in LHSS implementation. OBJECTIVE: This study aimed to synthesize current knowledge about the institutional factors involved in elder-dedicated LHSS implementation by describing them and their influence. METHODS: A scoping review was conducted using eight databases and the grey literature. Data were analyzed thematically. RESULTS: A total of 23 documents led to the identification of 15 inter-influencing factors (12 barriers and 11 facilitators). Indeed, 20 connections were noted among factors, mostly among barriers. DISCUSSION AND IMPLICATION: Although some barriers and facilitators also affect the implementation of services dedicated to the general population in Canada, the interplay between agism and power issues needs to be taken into consideration for a successful elder-dedicated LHSS implementation.

Occupational Therapists as Social Change Agents: Exploring Factors that Influence Their Actions.

BACKGROUND.: When acting effectively in their social change agent (SCA) role, occupational therapists can impact population health and occupational justice. However, empirical evidence of the influence of personal and environmental factors on their ability to act as SCAs is scarce. PURPOSE.: To explore personal and environmental factors that influence the ability of occupational therapists to act as effective SCAs. METHOD.: We conducted a descriptive interpretive qualitative study with 18 Québec occupational therapists recognized as successful SCAs. We collected data through semi-structured interviews with three focus groups and analyzed them thematically using a lexicon. FINDINGS.: We identified nine cross-cutting personal factors, including discovery, effective communication, and planning, that enable occupational therapists to act as successful SCAs. Six thematic groups of environmental factors facilitated or hindered their actions. IMPLICATIONS.: To act effectively as SCAs, occupational therapists need to consider personal and environmental factors involved in their change project.

Acting as Change Agents: Insight Into Québec Occupational Therapists' Current Practice: Actions menées à titre d'agents de changement : aperçu des pratiques actuelles parmi les ergothérapeutes du Québec.

BACKGROUND.: Change agents' actions have been studied mainly from a theoretical perspective. PURPOSE.: This study aimed to empirically identify occupational therapists' actual change agent actions. METHOD.: As part of a research partnership with the Canadian Association of Occupational Therapists-Québec chapter, we conducted this cross-sectional pilot study using an online survey. FINDINGS.: The change agent practices of our 103 participants involve many types of actions but show underinvestment in mass communication. Mass communication actions are more frequent when participants have greater experience, additional academic degrees, and training in change agency. Also, occupational therapists with additional academic degrees and change agency training tend to use a wider variety of actions. Finally, our participants' actions principally target actors in the clinical context, rarely political actors. IMPLICATIONS.: Our results suggest that occupational therapists can and will invest in the full range of change agent actions provided they can acquire the necessary knowledge and skills.

Do rehabilitation professionals need to consider their clients' health literacy for effective practice?

OBJECTIVE: To discuss the importance of integrating health literacy into rehabilitation practice. BACKGROUND: The effectiveness of rehabilitation interventions and clients' long-term health might depend on various factors, including health literacy. Health literacy is defined as the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings over the life-course. Rehabilitation professionals are often uniformed about and neglect health literacy in their interventions. METHOD: The scientific and grey literature on health and, more specifically, rehabilitation and health promotion was reviewed. The MEDLINE, OTDBASE, CINAHL, AMED and MANTIS databases were searched by combining the keyword (1) 'health literacy' with the keywords (2) 'rehabilitation', 'physical therapy', 'occupational therapy' or 'health promotion'. RESULTS: Health literacy is one of the foundations of individual health and might have an impact on interventions, the individual and society. All papers addressing both health literacy and rehabilitation (n = 10) specifically mentioned that rehabilitation professionals need to consider their clients' health literacy. Rehabilitation is particularly linked to health literacy because both stress the importance of (1) capacities, functioning, participation and empowerment of clients; (2) holistic approach; (3) client-centred practice; (4) teaching of information and methods; and (5) access to services and equity issues. CONCLUSIONS: Based on these results, we think it is important that rehabilitation professionals be aware of the importance of health literacy and intervene to improve it. The challenge is now to better understand how health literacy influences the effectiveness of rehabilitation and health outcomes.

Community occupational therapists' clinical reasoning: identifying tacit knowledge.

BACKGROUND: Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community-dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions. AIM: To synthesise current knowledge about community occupational therapists' clinical reasoning. METHOD: A scoping study of the literature on community occupational therapists' clinical reasoning was undertaken. RESULTS: Fifteen textbooks and 25 articles, including six focussing on community occupational therapists' clinical reasoning, were reviewed. Community occupational therapists' clinical reasoning is influenced by internal and external factors. Internal factors include past experiences, expertise and perceived complexity of a problem. One of the external factors, practice context (e.g. organisational or cultural imperatives, physical location of intervention), particularly shapes community occupational therapists' clinical reasoning, which is interactive, complex and multidimensional. However, the exact influence of many factors (personal context, organisational and legal aspects of health care, lack of resources and increased number of referrals) remains unclear. CONCLUSION: Further studies are needed to understand better the influence of internal and external factors. The extent to which these factors mould the way community occupational therapists think and act could have a direct influence on the services they provide to their clients.

Institutional context: What elements shape how community occupational therapists think about their clients' care?

Clinical reasoning (CR) is the cognitive process that therapists use to plan, direct, perform and reflect on client care. Linked to intervention efficiency and quality, CR is a core competency that occurs within an institutional context (legal, regulatory, administrative and organisational elements). Because this context can shape how community therapists think about their clients' care, its involvement in their CR could have a major impact on the interventions delivered. However, little is known about this involvement. Our study thus aimed to describe the elements of the institutional context involved in community therapists' CR. From March 2012 to June 2014, we conducted an institutional ethnography (IE) inquiry in three Health and Social Services Centres in Québec (Canada). We observed participants and conducted semi-structured interviews with 10 occupational therapists. We also interviewed 12 secondary key informants (colleagues and managers) and collected administrative documents (n = 50). We analysed data using the IE process. Of the 13 elements of the institutional context identified, we found that four are almost constantly involved in participants' CR. These four elements, that is, institutional procedures, organisation's basket of services, occupational therapists' mandate and wait times for their services, restrictively shape CR. Specifically, occupational therapists restrict their representation of the client's situation and exploration of potential solutions to what is possible within the bounds of these four elements. In light of such restrictions on the way they think about their clients' care, therapists should pay close attention to the elements of their own institutional context and how they are involved in their CR. Because of its potentially important impact on the future of professions (e.g. further restrictions on professionals' role, reduced contribution to population health and well-being), this involvement of the institutional context in CR concerns all professionals, be they clinicians, educators, researchers or regulatory college officers.