The Size and Structure of the Swiss Occupational Therapy Workforce. A Survey Study / Anzahl und Struktur der Ergotherapie-Arbeitsplätze in der Schweiz: eine Online-Befragung

In Switzerland, the shortage of skilled labour among health care professions is not just a looming threat, but a rapidly approaching reality (Rüesch et al., 2014). Demographic change and an associated rise in demand for health care services are likely to exacerbate this situation in the coming years (Bundesamt für Gesundheit BAG, 2019). The Federal Council's current health policy strategy has called for an increase in the number of health professionals being trained in Switzerland, but also for measures to increase job retention among professionals already practicing (Bundesamt für Gesundheit BAG, 2019).

Occupational therapy is no exception when it comes to this shortage of skilled health care labour (Rüesch et al., 2014). Knowledge about the current structure and size of the occupational therapy workforce in Switzerland is limited. The Swiss National Association of Occupational Therapists (EVS/ASE) included about 2,627 members in August 2022. However, occupational therapists (OTs) are not required to join the association, and only a limited number actually do, especially in the inpatient sector (EVS/ASE ErgotherapeutInnen-Verband Schweiz, 2022). Therefore, there is little empirical data on the actual size of the workforce, its geographical distribution, or its sociodemographic make-up.

There is also little empirical information on how many OTs work in different fields of practice. OTs treat a wide range of clients of all ages who “temporarily or permanently, due to accident, physical or mental illness or disability, psychosocial or developmental disorders, or environmental conditions are impaired or threatened by impairment in their independent living” (EVS/ASE & CESET Comité des Écoles Suisses d’Ergothérapie/ASSET Arbeitsgemeinschaft Schweizerischer Schulen für Ergotherapie/CSSET Comunità di lavoro delle Scuole Svizzere di Ergoterapia, 2005, p. 10, translation by author). We do not know if staff shortages are more pronounced in certain geographical areas or fields of practice.

In 2020, the World Federation of Occupational Therapists (WFOT) published the most recent figures on the global occupational therapy workforce. In their estimation, there are on average two OTs per every 10,000 people worldwide, with Denmark having the highest ratio of 22 per 10,000, and Tanzania having the lowest ratio of the countries, surveying at 0.001 per 10,000 (WFOT, 2020). The data they collected further indicates that 89% of the global occupational therapy workforce are women, that the fields of practice with the highest shortages of OTs are mental health, dementia, and stroke rehabilitation, and that the most important factors affecting OTs’ careers are wage disparities, the limited appeal of certain geographic locations, and a lack of career advancement and available positions (WFOT, 2020). The quality of this data, however, is somewhat unclear, as some of it is apparently based on estimation rather than empirical figures. There are also large differences between different countries that preclude drawing conclusions regarding the Swiss context.

While there is a federal registry of health professions that includes OTs (Gesundheitsberuferegister), this does not include all occupational therapists working as employees in inpatient settings. OTs are also not removed from the registry when they retire, or leave the profession for other reasons (S. Tanner, personal communication, 31.10.2022), which makes it unsuitable as a reference for the current size and structure of the OT workforce.

In planning and implementing effective countermeasures for OT staff shortages in Switzerland, empirical data on the size and structure of the Swiss occupational therapy workforce are an important basis. The Foundation for Occupational Therapy (Stiftung für Ergotherapie) has funded a research study to look into these matters, involving all three Swiss universities that provide bachelor's and master's degree programs in occupational therapy (ZHAW Zurich University of Applied Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, and SUPSI University of Applied Sciences and Arts of Southern Switzerland) as well as the EVS/ASE. The aim of this study was to collect data on the size and the structure of the Swiss occupational therapy workforce – its sociodemographic make-up, geographic distribution, and fields of practice. A secondary aim was to examine the characteristics (e.g., size, mean age, mean educational status) of OT teams that influence their turnover rates. The main explicit research questions were as follows: –

What is the sociodemographic make-up of the Swiss OT workforce in terms of age, gender, and level of education?

We determined that the best way to achieve the study's aims was to conduct a cross-sectional survey among Swiss OTs. The project team, which was made up of researchers from every Swiss university of applied sciences with an occupational therapy research unit, as well as representatives of the EVS/ASE and the Foundation for Occupational Therapy, defined the areas of interest for the survey in a meeting in April 2019. These areas included sociodemographic characteristics of the workforce, regional distribution, areas of work, levels of professional education, levels of full-time or part-time work, sources of funding, turnover rates, number of open positions, common difficulties when hiring personnel, and satisfaction with opportunities for further professional education. Due to the nature of some of the questions and the fact that not all OTs are affiliated with the professional association (EVS/ASE, 2022), especially in the institutional sector, it was decided that the survey would be best directed towards employers and team leaders, as well as self-employed OTs. It was expected that the maximum number of OTs could be reached in this way.

The inclusion criteria were therefore defined as: a) being a self-employed OT with or without employees; b) being an OT in a leadership position overseeing other OTs; or c) being a non-OT in a leadership position overseeing OTs – a and b not being mutually exclusive.

A total of 968 eligible respondents completed the survey, 866 of which were OTs and 102 of which were not OTs, but supervised them in leadership roles. Of the 866 OTs, 590 were self-employed independent OTs without employees, and 291 were OTs in a leadership position (among these numbers, 15 individuals fulfilled both these roles, coming to a total of 866 responding OTs). Respondents provided data on 2,156 employed OTs. All in all, we collected data on 3,022 Swiss OTs. The number of OT positions, however, is somewhat higher (n=3,345). This is attributed to differences in response behaviour among respondents (not all respondents answered all questions), as well as the fact that some OTs hold multiple part-time positions – for instance, an OT might be employee in an institution and a self-employed therapist. The response rate was 73.6% for medical institutions and 58.2% for OTs in private practice (with or without employees). For the other categories, no response rate could be determined (see Table 1).

Structure of the Swiss OT workforce

Based solely on our data, a ratio of 3.2 OTs per 10,000 inhabitants can be calculated for Switzerland as a whole. This figure only includes OTs working in traditional health care (i.e., medical institutions and private practices) and school settings (n=2,799) and is based on the 2021 Swiss population of 8.7 million. The rate of non-response, however, means this is an underestimation of the real ratio. Additionally, as we mentioned, we were not able to reach OTs employed by long-term care institutions.

There are significant regional differences regarding this ratio. A relatively high OT-per-capita ratio was found in the north- and southwestern regions of Switzerland. The OT-per-capita ratio is at its lowest in central Switzerland (see figure 1). For 17.8% of OTs in traditional curative health care and school settings (n=497), no data on their region was available. Of all OTs identified, 546 (16.3%) worked in other settings – for instance, in education, research, or the NGO sector (see figure 2).

Figure 1:

Figure 2:

OTs most often worked with clients who had difficulties in connection with injuries or illnesses of the upper limbs, neurological illnesses or injuries, and/or mental health challenges (see Figure 3). A total of 767 respondents provided information on how OT services were compensated. Financing was provided through compulsory health insurance (KVG/LAMal) for 67.7% of respondents, invalidity insurance (IV/AI) for 15.9%, and accident insurance (UVG/LAA) for 14.3% (see also figure 4).

Unfilled OT positions and turnover rates

A total of 320 respondents reported how many OTs had joined and/or left their institution or practice in the last 12 months. 54.7% (n=175) reported one or more OTs leaving, with a total of 353 people, while 67.5% (n=216) reported that they had hired one or more OTs in the past year, with a total of 429 people. This corresponds to a net workforce growth of 76 OT positions in 12 months – 2.5% of the number of OTs surveyed.

The average turnover rate for responding institutions (n=318) was calculated as 20.0% (SD=27.9). The median of reported turnover rates was at 9.6%, with the 25^th percentile at 0% and the 75^th percentile at 30.8%. Almost half the institutions (n=143) reported a turnover rate of 0%, largely explaining this extremely skewed distribution. A linear regression involving characteristics of OT teams revealed two main predictor variables for this turnover rate. The first predictor variable was the size of the team, which was highly significant (R²=−0.04, SE=0.02, t=−2.8, p<0.01). Larger teams had lower turnover rates. The second predictor variable was the mean age of the team (R²=−0.04, SE=0.01, t=−3.3, p<0.01). Teams with a higher mean age also had lower turnover rates.

A total of 326 respondents reported on whether they had unfilled OT positions in their institution or practice. For respondents who reported unfilled positions (45.1%, n=147), the mean unfilled percentage was 92.8% full-time equivalent (SD=84.2, range 10 – 550) – in other words, almost one entire full-time position. While we collected data on the equivalent of 1,840.8 full-time positions, the equivalent of 126.2 full-time positions (a quota of 6.4%) remained unfilled.

Difficulties filling open positions were discussed by 305 respondents. A total of 77% (n=235) reported a lack of applicants. Other frequent explanations were a lack of experience (38.7%, n=118), education (35.1%, n=107), or professional specialization (26.2%, n=80) among applicants. Only 17% (n=52) reported they had trouble finding applicants that were willing to work at higher work percentages.

Figure 3:

Figure 4:

The aim of this study was to collect data on the size and structure of the Swiss occupational therapy workforce in terms of sociodemographic make-up, geographic distribution, and field of practice. In terms of gender, our results were unsurprising. Of the Swiss occupational therapy workforce, 90.1% are women. This closely corresponds to recent WFOT global numbers of 89% (2020), and one of our previous studies, in which 94.1% of the responding OTs were women (Klamroth-Marganska et al., 2021). Switzerland has the highest ratio of women compared to all of its bordering countries, with Germany at 86% (Deutscher Verband der Ergotherapeuten, 2017), France at 87% (Association Nationale Française des Ergothérapeutes, 2022), Italy at 70%, and Austria at 80% (WFOT, 2020). This is also mirrored in the proportion of female Swiss OT students, which in the last ten years has fluctuated between 88.5% and 92.6%, without a clear upward or downward trend (Bundesamt für Statistik, 2022d). This exceeds the percentage of women in nursing (86%) and physiotherapy (73%) in Switzerland (Merçay et al., 2021; Nast et al., 2017), revealing a persistent lack of gender diversity.

There are differences between self-employed independent OTs without employees, where the percentage of men is only 5.1%, and OTs in leadership positions, where men make up 15.5%. The latter reflects a larger societal imbalance, with 29.7% of the general Swiss male workforce in leadership positions, as opposed to only 18.7% of the Swiss female workforce (Bundesamt für Statistik, 2022a). The homogeneity of the Swiss OT workforce seems problematic, not only because it deprives the professional culture of a beneficially broader range of experiences and viewpoints (Taff & Blash, 2017), but also since there are some data that suggest that there is a greater deficit of skilled labour in highly gendered professions (see e.g., Hickmann & Koneberg, 2022).

The age range of the workforce corresponds with data we have previously collected. While self-employed OTs and OTs in leadership positions have a relatively high average age of 48.1 years (SD=9.6), two-thirds of employed OTs are younger than 40. This is roughly comparable to a mixed sample we surveyed in an earlier study (Klamroth-Marganska et al., 2021) where the average age was 44.7 years (SD=10.6). All in all, the results are also similar to the average age of Swiss physiotherapists, which Nast et al. (2017) calculated to be 45 years. The Swiss State Secretariat for Economic Affairs SECO (2016) found that 33% of all health professionals are 50 years or older, a larger proportion than the 30% among the general workforce. This indicates a greater need for additional persons entering the workforce in the near future. Our dataset, however, finds only 25% of OTs to be 50 years old and older, which is below the average rate reported by the SECO (2016). However, among self-employed OTs without employees, the percentage of persons 50 years old or older was exceptionally high, at 50%. This is partially explained by OTs often becoming self-employed later in life, when they have gathered some professional experience.

The distribution of linguistic regions within our data set was 61.5% German-speaking, 34.5% French-speaking, and 4% Italian-speaking. This is similar to the distribution (based on their home canton's main language) among EVS/ASE members: 64.9%, 28.4%, and 5.5%, respectively (EVS/ASE, 2022). It is also similar to the language distribution in the Swiss population on the whole: 62.3%, 22.8%, and 8%, respectively (Bundesamt für Statistik, 2022b). These existing findings strengthen the potential credibility of our data.

The percentage of OTs who completed their education in Switzerland is 65.5%. Among EVS/ASE members, this percentage is higher, at 76.7%. Although this is not a perfect measure of work migration, it indicates that about a third of the Swiss OT workforce has a migrant background. The percentage of all OTs who have completed the equivalent of a bachelor's degree or higher is 64.5%, similar to 62.5% of physiotherapists. However, only 2.8% have completed an MSc in occupational therapy, while 6.8% of physiotherapists have completed an MSc. This may create a disadvantage for OTs’ career prospects, as some specialized and/or leadership positions require an MSc. MSc or MAS degrees are also likely to be a requirement for Advanced Practice in Occupational Therapy (APOT) roles, which are expected to become more important in the coming years (Nacke et al., 2019). Only 0.1% of Swiss OTs have completed a PhD, as opposed to 0.5% of Swiss physiotherapists (Nast et al., 2017). Creating more adequately-compensated career opportunities – in APOT, for instance – for OTs with a MSc, MAS, or PhD education may not only motivate more OTs to pursue these programs, but also make the profession more attractive to young people entering the workforce.

The mean degree of employment of Swiss OTs was 67.9% full-time equivalent, or 28.9 hours per week. This figure is very similar in Germany, where OTs work 27 hours per week on average (Deutscher Verband der Ergotherapeuten, 2017). It also resembles the figure for Swiss non-physician health professionals working in hospitals, who in 2019 had a mean degree of employment of 69.3% (Merçay et al., 2021). There is a gender-specific difference that we were able to illustrate among self-employed OTs without employees and OTs in leadership positions. Swiss women are more likely to find themselves in precarious financial situations after retirement, as they are more likely to have worked part-time and consequentially received lower pension benefits (Pilgram & Seifert, 2009). Another reason for this is that Swiss pensions are partially based on contributions that are proportionally related to income.

In a number of surveys of 273,096 members of the general Swiss population between 2010 and 2015, one-third of women working part-time did so because they were also taking care of children (Abrahamsen et al., 2017). Creating an environment that supports women in taking on higher degrees of employment – for instance, by improving access to affordable childcare – could not only improve their financial security after retirement, but also counter workforce shortages.

Merçay et al. (2021)'s study of Swiss hospitals (2021) counted 1,501 OTs working in medical institutions as of 2019. Considering the non-response rate of 26.4% that we saw among medical institutions, our count of 1,267 OTs in this setting seems reasonable. We calculated a ratio of OTs per 10,000 inhabitants of 3.2, which is an underestimation of the real ratio due to a non-response rate of 26.4% to 41.8% from medical institutions and private practices, respectively. The actual ratio is likely to be between 4.3 and 5.5 per 10,000 inhabitants. Even taking into account the non-response rate, this ratio is still lower than in Germany, which has a reported rate of 7.3 OTs per 10,000 inhabitants (Council of Occupational Therapists for European Countries, 2022), but it is markedly higher than in France or Italy, which have respective reported ratios of between 2.1 and 2.2, depending on the source, and 0.4 OTs per 10,000 inhabitants (Association Nationale Française des Ergothérapeutes, 2022; COTEC, 2022).

Among neighbouring countries, the Swiss ratio most closely resembles the situation in Austria, where there are 4.8 OTs per 10,000 inhabitants (COTEC, 2022). To add some context, all these figures are still markedly lower than the rates in Nordic countries like Denmark (22 OTs per 10,000), Sweden (12 OTs per 10,000), or Norway (9 OTs per 10,000). The cantonal distribution we outlined may be subject to some irregularities due to varying response rates. However, if we compare the 10 cantons where we found the most OTs with the 10 cantons having the most EVS/ASE-members, nine out of 10 are the same, adding to our data's plausibility (EVS/ASE, 2022). While there seems to be a net growth in the workforce, almost half of the responding institutions or private practices had unfilled OT positions at the time of the survey. We identified a quota of 6.4 unfilled full-time-equivalent OT positions, which is in stark contrast to the quota of 0.9 identified by the Swiss State Secretariat for Economic Affairs SECO (2016) and more than triple the general quota of open job positions in Switzerland, which was 1.9 during the fourth quarter of 2021, which was main period of our survey (Bundesamt für Statistik, 2022c).

Respondents who commented on their difficulties filling open OT positions most often cited a lack of applicants, which is unsurprising considering the quota of open positions we have calculated. Factors leading to this staff shortage are likely a rising demand for OT services (for instance, due to demographic change), and an unknown number of OTs leaving the profession before retirement. We do not know the extent of these factors, however, or the reasons OTs prematurely leave the profession.

We have collected the first comprehensive data set on the size and structure of the Swiss occupational therapy workforce in terms of its sociodemographic makeup, geographic distribution, and fields of practice. The availability of data like this is crucial for planning and implementation of effective measures to counter skilled-labour shortages in any profession (Dolder, 2010; Rüesch et al., 2014). We have confirmed that there is a profound and persistent lack of gender diversity in occupational therapy exceeding that in other health professions, and that there is a low mean degree of employment, consistent with the situation in other health professions. We have also shown that the number of OTs who pursue an MAS or MSc is still small compared to other health professions. These findings raise certain questions: How can we achieve greater gender diversity in the workforce? How can we generate an environment where women are likely to work at higher degrees of employment? Lastly, how do we facilitate further education of OTs? Other questions that remain open are the number of OTs who leave the profession prematurely, their reasons for doing so, and possible measures that could keep them in the field. Also, while the rate of OTs per 10,000 inhabitants is an important indicator of health-care service density, other indicators, like the number of clients that are on waiting lists to receive OT services, or the time they have to wait to receive these services, would allow for a more well-rounded picture of OT provision in Switzerland.

We have also shown that occupational therapy seems to be less widely accessible in Switzerland than in Germany, but more so than in France and Italy. This is complicated, however, by what seem to be pronounced regional differences within Switzerland. This is an issue we will pursue in more detail in future publications. The high quota of open positions that we found adds urgency to measures against staff shortages in occupational therapy. If this situation differs between geographic regions and fields of practice, we will investigate this in more depth in future publications.