Occupational Therapists' Experiences of working in Irish Schools - Arbetsterapeuters erfarenhet av att arbeta i Irländska skolor

 
Occupational Therapists’ Experiences of
       working in Irish Schools
   Arbetsterapeuters erfarenhet av att arbeta i Irländska skolor

                            Emil Heitz
                            Ida Jansson

               Occupational Therapy, bachelor's level
                               2020

                      Luleå University of Technology
                       Department of Health Sciences
Heitz, E. & Jansson, I.
       Occupational Therapists’ Experiences of working in Irish Schools. ​Examensarbete i
       arbetsterapi 15 hp, Luleå tekniska universitet, Institutionen för Hälsovetenskap, Avdelningen för
       hälsa och rehabilitering, 2020.

Abstract
Purpose. ​The purpose of the study was to describe Occupational Therapists’ experiences of
working in Irish schools.
Method. ​Convenience sampling was used to recruit the eight participants in the study. A
semi-structured interview was used to gain data about their experiences. The data was analysed
through latent and manifest content analysis inspired by Olsson and Sörensen (2011) and
meaning units were identified, condensed and labelled with codes.
Result. ​The analysis resulted in three categories: ​“Resources impact the delivery of service”
which shows how resources, within and outside of the participants control, impact the delivery of
service and the challenges that might lead to. ​“​Importance of communication and
understanding”​ describes the dynamic between the participants’, school-staff and parents.
”​Comparing school-based and clinic-based occupational therapy”​ where the participants share
their experiences and opinions of school-based and clinic-based Occupational Therapy.

Conclusion. ​Resources and communication have a beneficial effect on Occupational Therapy in
schools.​ ​Many factors add to the complexity of delivering the service. A preference of
school-based Occupational Therapy is seen, however, Occupational Therapy today is generally
more clinic-based. More research on the topic is needed.

 Keywords: Communication, Experiences, Irish schools, Occupational Therapy
Table of contents
Occupational Therapists’ Experiences of working in Irish Schools             1
   INTRODUCTION                                                              1

1. BACKGROUND                                                                1
    1.1 Occupational therapy                                                 1
    1.2 Occupational Therapy in schools                                      2

2. METHOD                                                                    5
    2.1 Procedure                                                            5
    2.2 Participants                                                         5
    2.3 Data collection                                                      6
    2.4 Data analysis                                                        6
    2.5 Ethical aspects                                                      7

3. RESULT                                                                    8
    3.1 Resources impact the delivery of service                             8
    3.2 Communication and understanding                                     11
    3.3 Comparing school-based and clinic-based Occupational Therapy        13

4. DISCUSSION                                                               15
    4.1 Result discussion                                                   15
       4.1.1 Resources impact the delivery of service                       15
       4.1.2 Communication and understanding                                16
       4.1.3 Comparing school-based and clinic-based Occupational Therapy   17
   4.2 Method discussion                                                    19

5. CONCLUSION                                                               20

ACKNOWLEDGEMENT                                                             21

REFERENCES                                                                  22
INTRODUCTION

Through our studies to become Occupational Therapists [OTs], we, the authors, have noticed that
there seems to be content missing, from a Swedish point of view, regarding OTs working in
primary schools. Articles we have read on the topic usually come from the USA, Australia,
Canada, South Africa, the UK or Ireland. To us, Occupational Therapy has a theory and structure
suitable for the school environment, and from our understanding, it would be beneficial to have
more OTs in Swedish schools. As the Swedish government rejected a motion in 2017 to include
OTs in school health care, there might be a need to widen the understanding of what OTs do and
why they are included in other school systems. When we look at a country like Ireland there
seems to be a place for Occupational Therapy in schools, so we want to contribute by presenting
experiences of OTs working in Irish schools.

1. BACKGROUND

1.1 Occupational Therapy
Taylor ​(2017) shows how Occupational Therapy is largely based on a person's roles, habituation,
volition, performance capacity and the environment in which the person is.
Activity or occupation has been used as a method of therapy for a long time, however it was not
until the late 19th century that Occupational Therapy started taking form. ​The Association of
Occupational Therapists of Ireland (AOTI, 2020) defines Occupational Therapy as a ​“healthcare
profession offering support to people with physical, psychological and social problems to enable
them to live life to the fullest. Occupational therapists help people to do the everyday activities
that they want to do and need to do when faced with illness, injury, and disability or challenging
life events.”

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Both ​AOTI’s (2020) and ​Taylor’s ​(2017) descriptions of Occupational Therapy are easy to put in
a school context. A child’s volition and motivation to attend in school; the performance capacity
in requirements of a curriculum; habituation in seeing the school as a Monday to Friday
occupation; the environment of being in a school setting and the role of being a student in
school; and in all this being able to live life to fullest.

1.2 Occupational Therapy in schools
The school situation is challenging for all children in many ways as pointed out by Missiuna et
al. (2017). It is not only about academic achievements and learning, it is also very much about
social interaction, cultural understanding, cognitive skills, and much more. The interplay
between school and home is different from child to child and the same goes for the support from
the parents. An OT has a holistic take (Taylor, 2017; Nicola-Richmond, Pépin & Larkin, 2016)
on the situation and could contribute with strategies and interventions for managing the whole
situation around school. Even though there are many possible interventions to help children,
according to Rodrigues and Francine (2018) there are often a lack of resources and of treatment
space in school settings. They go on to describe a lack of understanding from parents and school
staff about school-based and clinic-based therapy and how Occupational Therapy can be best
utilised to be a supporting factor for the curriculum.
Within the school environment it is important to understand the dynamic between the professions
as explained by ​Tracy-Bronson, Causton, and MacLeod (2019). Their participants (OTs,
Physical Therapists and Speech and Language Pathologists) describe the situation with
distinctive roles, for example the teacher is the expert when it comes to the curriculum and the
other professions are experts at providing therapy support. They go on to describe the importance
of knowing your role to be able to ensure the best possible guidance considering your experience
and background.

The Occupational Therapy role is largely based on activity ​and a client centered approach
(Fisher, 2009; Taylor, 2017). Clough (2019) suggests three different approaches to intervention:

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“Pull-out”, “Push-in” and/or consultation.​ Pull-out​ interventions refer to time with the child or a
group of children outside of the classroom environment. Therapists in the study often describe
Push-in​ interventions as sitting next to a child in the classroom and supporting the current class
agenda or providing alternative activities to improve performance in the classroom. With
consultation ​the main focus is often in the form of support for the teacher about an individual
child, where the OT discusses their abilities and difficulties followed by recommendations for
the teacher to help with class performance for that child. It is frequently used in combination
with pull-out interventions. In this study, Clough (2019) points out how OTs consider the
primary focus to be on helping children develop skills that can be transferred into the classroom.
The focus is therefore mainly to work towards skill-based goals instead of using activity in a way
to enhance personal growth.

According to Tracy-Bronson et al. (2019), when it comes to setting up goals, everyone involved
in the child's school day, including parents, plays an important part. By having a shared focus,
centered on the child, the result may lead to faster improvements in cognitive and social skills. It
cannot be assumed that all children will adapt and be able to learn just by putting them in a
school environment. Collaboration between everyone involved is key for educational results.
They continue by describing that being engaged in the school system as an OT may lead to other
positive impacts than intended. Providing supplemental support for one student can, in the long
run, benefit the whole class and increase the overall ​participation and social interaction, not only
for those with disabilities, but for all children in the class​. In 2017 a motion (Motion
2017/18:2505) from the Swedish Parliament suggested that OTs would be included in Swedish
school healthcare. The OT’s competence was described as suitable and even needed in the
Swedish school healthcare. The motion was however rejected, which indicates a knowledge gap
and that the Swedish Government does not consider Occupational Therapy to be a priority
addition to the educational system.

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According to Campbell, Missiuna, Rivard, and Pollock (2012) it is shown that OTs working in
classrooms develop a great understanding for which interventions are possible and useful in that
environment. This leads to OTs being forced to re-evaluate their own methods and that their
close work with teachers in the classrooms is eye-opening for them regarding which
recommendations are realistic and workable in an educational setting. This demonstrates the
importance of different professions collaborating and sharing the same focus.

An evaluation of a pilot project (Hutton, 2009) shows how trying new and different approaches
to “old school” thinking can be effective. An intervention named Occupational Therapy into
Schools (OTiS) was created with an aim to provide children with individual interventions that
would also affect the school as a whole. Working in a classroom environment, the OT would get
a good understanding of the school and the routines, and apply interventions suitable for the
school in question. For instance to increase participation of all children in physical activity,
writing and colouring. According to Hutton (2009), by sharing information on physical and
mental development of children and suggesting a different approach to sitting, the atmosphere in
a class can change from focussing on managing the children’s behaviour, to a relaxed
atmosphere focused instead on actual learning.

According to the reasoning above, Occupational Therapy has a clear role in schools in many
countries. However, when we look at the origin of most scientific articles on the subject, there is
a dearth of articles from a Swedish source. This, along with the motion being rejected by the
Swedish Government indicates a knowledge gap. If we looked at another country, where
Occupational Therapy in school is more common, what would their experiences be? On the basis
of the proximity principle we chose Ireland as a good place to look at and explore the
experiences of OTs working in schools.

Therefore the purpose of the study is to describe Occupational Therapists’ experiences of
working in Irish schools.

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2. METHOD
This is a qualitative study using a semi-structured interview, as described by Kvale and
Brinkmann (2014), in order to explore ​Occupational Therapists’ Experiences of working in Irish
Schools. ​The interviews were analysed through content analysis as described by Olsson and
Sörensen (2011).

2.1 Procedure
To gather participants the authors chose to use convenience sampling as described by Etikan,
Musa and Alkassim (2016).

The inclusion criteria for this study were Occupational Therapists, currently working in Ireland
and having experience of working in Irish schools.

A missive containing information and instructions about the study and an invitation to participate
in a research project, was created by the authors. A contact with a university in Ireland was
established and the missive was then forwarded from that university to a network of OTs
working in schools. These OTs were either clinically based and doing outreach in schools or
based full time in a school environment. Respondents contacted the authors via email to confirm
their interest in participation and a return email was sent to set up a time for conducting the
interview. A total of eight OTs showed interest and were recruited in this process.

2.2 Participants
Both male and female OTs were included in the study. The period of time since the participants
received their Occupational Therapy degree varied between 4 and 37 years. A common factor for
them all was that they had experience of working with school age children in a clinical

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environment. They also had experience of working in Irish elementary schools. A majority of
them are currently clinic-based and a few had experience of being school-based. All of the
participants had supplemented their education with training in paediatrics, pedagogy or other
areas related to children.

2.3 Data collection
Five of the individual semi-structured interviews were conducted by both authors taking turns as
the role of the interviewer and the other author as an active observer. Three of the interviews
were conducted by only one of the authors. As an example, all the interviews contained the
question ​“Could you tell us about a typical day at work?”.​ The questions touched on different
topics and required the authors to be responsive in the interview to encourage the participants to
speak freely about their experiences. The interviews were conducted over digital communication
platforms (Skype, Zoom) between February 2020 and April 2020 and lasted between 40 and 70
minutes. The semi-structured interview guide was used more as a support than as guidelines to
follow. The interviews did not have a set time and ended when they reached data saturation and
when the participant felt there was nothing else to add. Interviews were audio and video
recorded, in an attempt to keep the interpretations of the experience as close as possible to the
original due to having body language and expressions included in the data. The participants were
informed that participation was voluntary and could be aborted, for any reason, at any time.

2.4 Data analysis
The authors listened to the interviews in full. The interviews were then transcribed and the
material was read several times. Participants' identities were anonymized by replacing their
names with codes. The data was analysed through content analysis as explained by Olsson and
Sörensen (2011). Meaning units were identified, condensed, and labeled with codes, as
exemplified in Table I. The codes were then categorised by looking at similar codes with similar
condensed meaning units, in order to find experiences that could be linked together.

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Table I. Examples of meaning units, condensed meaning units and codes, transitioned into categories.

             Meaning unit                    Condensed meaning                   Code             Category
                                                   unit

 The way that we work then is that         We go in for the child on     Waiting list        Resources impact the
 we only go in for that particular         top of the waitlist. Other                        delivery of service
 child when they come on top of the        children in that class will
 waitlist, you have to be on the           have to wait to be on top
 waitlist firstly, and then if there’s 6   of the waitlist.
 kids in that class you might be
 seeing one and six months later you
 might be see a second child in that
 class

 I had a lot of years where I was          I was in the same school,     Professional        Communication and
 every monday and tuesday in the           I got to know the other       relationships and   understanding
 same school, so I got to know the         professions and we            teamwork
 teachers, I knew the schedules, we        developed teamwork.
 had a drama therapist and we had a
 psychologist and a language teacher,
 so we started to develop teamwork

 There is so much OTs could be             OTs have a massive role       OTs time spent in   Comparing
 doing with children in school. It’s       and a lot to offer.           school              school-based and
 such a massive role and I do think        Relationships would                               clinic-based
 sometimes if they were in schools         improve if OT’s were in                           Occupational
 either for a full day or a full week,     schools for longer                                Therapy
 the relationships would build up          periods.
 much better.

2.5 Ethical aspects
In agreement with Olsson and Sörensen (2011), it is important to pay attention to the
participants' integrity and autonomy in a study. We informed all our participants in a missive, the
purpose of the study, that the interview would be recorded and transcribed, that their
participation was totally voluntary, that they could interrupt the interview whenever they felt
they needed to and that their personal information would be anonymised. This was in order to
protect the integrity and autonomy of the participants.

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However, when dealing with individuals' experiences and sharing them in a comfortable setting,
there is a risk of emotions becoming overwhelming. When reflecting upon situations where you
are proud of what you have accomplished or situations where you feel that you could have done
things differently, we have to be prepared to offer the support needed in a safe environment,
thereby mitigating the risk.

The gains of the study could be to widen the knowledge about school related Occupational
Therapy through the experiences of OTs working in school settings.

All gathered information was used only for the purpose of this study and was handled with
confidentiality. Unauthorised persons did not have access to any piece of information during or
upon completion of the study. All data was deleted upon completion of the study.

All this taken into consideration, we think that the gains outweigh the risks.

3. RESULT
Throughout the analysis of the interviews, a pattern crystallized which led to three categories:

   ● Resources impact the delivery of service
   ● Communication and understanding
   ● Comparing school-based and clinic-based occupational therapy

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3.1 Resources impact the delivery of service
       Examples of resources visible in the result are time, family and the OT’s
       competence. Resources affect the outcomes in different ways and can be either
       beneficial or obstructive.

Time is a resource often mentioned and primarily, the lack of time. This shows in long waiting
lists, high workloads and many referrals coming in, due to more children in need of extra support
in school. One participant reflects on the experience shared about being able to do a block of
sessions towards a set goal and achieving great results from it, when realizing that it had been a
long time since the workload and resources allowed that to happen. With less time for each
client, there are still a lot of smaller successes, although the major successes, where the OT feels
they can put in all their time and effort, are fewer. A wish for resources to spend the time needed
in school is something frequently mentioned, also the insight that the organisational structures
presently do not allow that.

       “From our perspective it would be wonderful to have the resources to spend more
       time in school​. ​If you think about how much time children spend in school and
       how much of their occupational lives are in school, yeah, it would make sense to
       have OT’s in schools. I don’t know, I don’t think it’s going to happen here for a
       while, I just think the funding isn’t there.”

The client’s family is described as an important resource in supporting the child in everyday life
and in implementing interventions. The parents are often the persons that care the most for their
child and are committed to that child being the best version of themselves. With a resource like
that, the OT’s job is really just to guide them in the right direction. ​One example of this
experience is a participant describing​ a child who showed very little interest in playing with toys.
The parents were of the impression that if you hand the child a toy, he would know what to do
with it. The OT then started modelling how to play with toys and encouraged the parents to
participate. The boy started to copy and interact more. It turned out to be enough with one single
session and then a follow up six weeks later, since the parents could continue the training by

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themselves. Small adjustments can sometimes have a big impact. Therefore a conscious strategy
is implemented, in some clinics, where OTs are moving away from the role as “experts” and
instead putting the light on the parents’ knowledge and expertise on the child. On the other hand
the family, or even the school can sometimes be an obstructing factor in terms of the OT’s
delivery of service to a child. Family-centered practise is mentioned when setting goals, where
the goals and needs of the child in school can become second to the goals of the family.

        “Sometimes schools will have different priorities to the parents and they find it
       difficult to accept that, right now this is what’s important in this family's life and
       the priorities could be around something like homelessness and their priority
       might be to secure a home and we’re trying to support them with that. The school
       will say, ‘we would like his handwriting to improve’ and you’re agreeing with
       that but there’s so much going on for this family.”

A good foundation of resources makes it easier to reach set up goals and it also promotes higher
goal setting, according to the participants. The resources provided by schools vary a lot. Some
schools have great resources in the form of playrooms, materials and even the staff’s level of
experience, while others lack most of it. When working with children, there are a lot of factors
affecting the situation and there are things to consider that are outside of the OT’s control.

       “I suppose there’s challenges everywhere. I had a child, 6 years old, non verbal,
       with no school placement so he was at home everyday and I had him for a block
       of OT. It was very different because the child had no routine, I suppose the
       parents were very limited, they were both working full time, they had a kind of
       tutor coming to the home for the child. I suppose it was a difficult one to manage
       because there were a lot of things outside of my control.”

One participant points out how children sometimes are their own best resource within a
class environment, in terms of how they support and teach each other. OTs working with
children, need an open mind and to think in a playful manner to allow children to reach
their full potential. Another participant puts it as being the “fly on the wall” by sitting
back and observing in the classroom to see those small things that the teacher might not
be able to see due to having their focus on teaching. The participants also recognise that

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not all interventions require extensive resources. Sometimes all that is needed is
creativity and inventiveness.

       “Doing simple things like just changing where that child is in the
       classroom, their proximity to the teacher or their proximity to the
       bathroom… They’re small things that can have a very fast and rapid effect
       and sometimes create the most functional change.”

The participants see competence as a vital resource. Continuing professional development [CPD]
and continuous training is something that is valued. After receiving their degree in Occupational
Therapy there was still an expressed need for continued training, in order to be able to work with
children and especially children with Autism. Some expressed a piece missing when it comes to
paediatrics in college, but there were also participants who had done more about paediatrics than
others, even so they also felt a need for continuous training. Pedagogy was mentioned as a part
missing from college, or something that could have been emphasised more, with the idea of
pedagogy being of great use when it comes to influencing or impacting the developmental
process. There is no set standard on specified training which means that it is up to each
individual OT to decide what is needed in their practise of work. Among our participants,
understanding of sensory integration is commonly needed and is beneficial in practise. They also
said that it would be difficult to work in a school without having had that additional training. It
takes time to get experience and build up a bank of resources and strategies, however additional
training can help getting a head start.

3.2 Communication and understanding
         When the client is a child it is of great importance that school staff, parents,
         OTs and other allied professions understand each other and have working
         communication. This is a continuous challenge.

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Many of the participants witness how an understanding of the school, knowing what a classroom
situation can be like and being familiar with the vocabulary and culture of the school, is helpful
to prevent misunderstandings and miscommunication. A lot of the work is quite consultative and
involves providing strategies to both teachers and parents. Some of the participants describe
situations where they have provided teachers with programmes, but the intervention has not been
implemented, because the teachers have not understood how or why it should be done. As it is
necessary that the teacher understands what the OT presents, it is also important that the OT has
a good understanding of the teacher, the group and the possibilities for implementing things on a
group level. The mutuality in understanding each other's roles and competence areas creates a
collaborative environment of problem solving and finding solutions together, according to some
participants. Working in teams with other professions is described as meaningful and developing.
One participant puts it into words like this:

        “It supported me to work in an environment where I understood firstly what
        teachers were saying and what their needs were. And I understood the need to
        listen to them. I also understood the need to really collaborate with them on a
        peer to peer level, as colleagues.”

The participants also give examples of cases where the collaborative work carries the child and
their development further than they would have come if professions only had worked on their
specific area. One example of this synergy effect is seen when one of the participants collaborate
with a Speech and Language Therapist [SLT]. They work together with a non verbal child. The
OT’s work got the child to a point where he was ready to engage in communication and the SLT
got a much better starting point than if they had not been working together. Communication is
essential in many ways and this cooperation made a huge difference for the family.

The participants imply that it is important for OTs to recognise and understand that the role of a
parent is not to be a therapist, it is to be a parent. The responsibility of a parent involves
parenting firstly; cooking, cleaning, hanging out and even watching TV. When OTs demonstrate
that they understand the family situation and communicate this to parents, it is helpful and
appreciated. Good communication between the OT, parents and school lead to positive results. A

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participant gives an example, where a six year old girl was being sent home from school every
day because she was upset. The parents wanted to give her a soother to keep her in school, but
the school's point of view was that a soother could have an impact on her speech. There was a lot
of miscommunication and the OT came in almost as a mediator to sort out the communication
between parents and school. The OT explained and clarified the goal. It was for the child to stay
in school. When the parties understood each other, strategies were implemented of using the
soother for a short time when needed and then to distract the child with something else, so that
she eventually could give the soother away and stay calm. This strategy and clarification of the
goal, resulted in the girl staying in school and not being sent home any more.

Participants claim that some teachers expect OTs to do pull-out interventions to the extent where
the child is more or less taken away from their context. And when it is explained that the most
effective contribution actually is strategies, environmental changes or programmes for the school
staff to implement, the teachers have lost interest in using the help of the OT. Explaining why
different interventions are suggested and taking the time to inform the teachers about the needs
of the particular child, can, according to the participants make a huge difference to compliance.
One participant says:​“Just those little kind of explanations and going through the reasoning
behind it, can really make a difference, instead of me saying he should be on the trampoline
every morning and they don’t understand why.” ​Many interventions can be a gain for the whole
class, like quiet spaces or movement brakes. This is understood by some teachers, while, due to
lack of resources or communication, sometimes recommended movement breaks every 20
minutes become the weekly Physical Education. Another example of lack of communication is
when teachers are following a programme for six months, not knowing if it is right for the child
and there is no follow-up from the OT during that time. The participants all emphasise that to
achieve improvement, everyone involved needs to keep the child and the child’s individual needs
in focus and have a good understanding about the process.

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3.3 Comparing school-based and clinic-based Occupational Therapy
       School-based and clinic-based Occupational Therapy offer different approaches.
       School-based can focus more on changing the environment around the child and
       clinic-based focuses more on compensating interventions.

The experience among the participants is that nowadays occupational therapy is more commonly
clinic-based, than school-based. In clinic-based work with school age children, the norm is a
family-centred focus where parents describe areas of problems and goals are set around those
problems. Assessments are usually made in the clinic, while both observations and later
interventions often take place in school or at home. The experience is that oftentimes
interventions and suggestions are welcomed by teachers. The participants who have experience
of both clinic-based and school-based work with children, have a tendency to see advantages
with the school-based way of working. Others appreciate being clinic-based and going out to
different schools, although some express that by being clinic-based you can spend less time on
travels between clients. However most of the participants express that more time in schools for
the OT would be beneficial for the children. Conflict situations do occur when teachers do not
have the time or when they feel that the intervention will not work. Sometimes OTs are expected
by school staff to “fix” a situation without the school staff seeing their part in the process.

       “There wouldn’t be this almost grabbing of the OT when they come in for 1 hour a
       month, so from that point of view I do think if they were on staff alongside teachers and
       Special needs assistant, that there would be a greater knowledge around our role and if it
       was resourced enough it wouldn’t be that kind of “grab them”.”

According to some participants the autism diagnosis is increasing and the schools are in greater
need of Occupational Therapy, which creates a higher workload for clinic-based OTs. They
express problems in building up good relationships with schools and school staff, since they are
responsible for so many schools and have so little time to spend in each school. Going to
different schools every day crates an uncertainty in the communication with the schools.

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Interventions tend to be focused on either compensating for the child's disabilities or to learn new
skills.

School-based Occupational Therapy, on the other hand, is described as potentially more flexible,
making relatively quick interventions possible, such as changing the environment the child is in,
instead of changing the child. Also the possibility to make changes sooner in the intervention
programme is mentioned, as is the advantage of being able to make small inserts that can have
the most functional change for a child. It is also considered being educational, working alongside
with school staff, in terms of increased understanding of which interventions are realistic and
beneficial in the school environment. On the other hand one of the participants reflects that when
an OT is school-based, the work might be focused on school related issues only, but when an OT
is clinic-based, every issue is addressed.

4. DISCUSSION

4.1 Result discussion
The purpose of this study was to describe Occupational Therapists’ experiences of working in
Irish schools. The result indicates that available resources impact the OT’s delivery of service.
Furthermore the result shows the importance of communication and understanding between the
OT, other professions and parents. The result also addresses a difference between school-based
and clinic-based Occupational Therapy approaches. ​Occupational Therapy has an important role
in the Irish schools system, where resources, communication and understanding play a big part,
although just like Sweden, todays’ practise is mostly clinic-based​.

4.1.1 Resources impact the delivery of service

The result indicates that OTs want to spend more time in schools, although it is not possible due
to resource issues. Rodrigues and Francine (2018) point out how the delivery of Occupational

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Therapy can be difficult due to time constraints. The pressure of having a waiting list or to
always know that there is a queue of new cases waiting to be addressed is currently a part of
being an OT. The result shows that a lot can be done in short sessions by implementing strategies
and through consultation, although there is still a wish to be able to take the time needed for each
case and let the holistic approach work in practise. Nicola-Richmond et al (2016) point out that a
holistic approach is an important concept in Occupational Therapy among practitioners.

As the result describes, it is always important to have the individual child in focus. The Model of
Human Occupation (Taylor, 2017) emphasises the use of a client-centred approach, where the
focus is on the needs of the individual. On the other hand, the result showed a family-centred
focus in relation to goal setting. Hanna and Rodger (2002) point out the importance of building
relationships with parents in a family-centred approach and the gains of learning from the
expertise that the parents bring to the situation. Even though the needs of the child are in focus, it
is necessary to remember that the context of the child is the family. To be able to achieve what is
best for the child, the goals need to be suitable for the entire family. The result shows that a
client-centered approach is somewhat of a theoretical standard. In praxis, the family-centered
approach appears to be the most used.

The result stresses the importance of continuous training even after receiving the Occupational
Therapy degree. The occupation is broad which means it is impossible to prepare Occupational
Therapy students during their degree studies for everything they encounter in practise.
Nicola-Richmond et al. (2016) raises the question about not having enough “practising in
context” in the academic arena, where both students and clinicians thought it was more difficult
to close the gap between theory and practise than what the academics did. The result shows that
it is easier to work in a school when having additional training to work with children since it
takes time to get experience and build up a bank of resources and strategies. In agreement with
Tracy-Bronson et al. (2019) the result shows how interventions implemented can benefit the
whole class. It is considered important to have a client-centred approach, however what would
happen if the focus remains at the individual child only? The child is a part of a bigger picture

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and the result explains how children sometimes are their own best resource within the class
environment, which is something to take into consideration when implementing strategies and
interventions.

4.1.2 Communication and understanding

Rodrigues and Francine (2018) point out how communication and planning between OTs and
school staff can be difficult. The respondents in their study felt that they had to explain and
educate parents and staff about the role of an OT. This is also seen in the result of this study. The
result also indicates that miscommunication between parents and school may push the OT into a
role of a mediator, which according to Berryhill and Vennum (2015), is a role that a therapist
should take, although they are referring to a school-based family therapist. This indicates though
that in the communication between school and the parents, a school-based therapist can ease the
communication just by being a neutral third party.
The best possible service is achieved when all concerned professions have clear roles and a close
collaboration (Campbell et al., 2012; Tracy-Bronson, et al., 2019), but as mentioned earlier
interprofessional communication can be difficult. The result shows how interventions issued by
clinic-based OTs sometimes do not get implemented by the school staff. In these situations, the
child may not get access to the recommended intervention due to miscommunication between
OTs and teachers. The absence of follow-ups and lack of understanding are seen as the main
cause. On the other hand, the result also shows that inventive strategies are being used to avoid
this happening. For instance explaining to and informing the teacher about the needs of a child,
about the intervention and in what way those match, which can increase compliance. This is
supported by Vincent, Stewart and Harrison (2008).

Understanding is described in the result as a vital component that must go both ways, teachers
understanding OTs and vice versa. The best outcomes are described as appearing when different
professions come together and work in teams. Teamwork makes solving and solution finding
easier and can according to the result bring the client further than when professions work

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separately. A high quality of care and outcomes is seen in interprofessional collaborative practise
(Whiting & Muirhead, 2019).

4.1.3 Comparing school-based and clinic-based Occupational Therapy

By OTs and school staff having a shared focus, centered on the child, faster improvements can
be seen (Tracy-Bronson et al., 2019). The result reinforces this by highlighting the opposite; poor
relationships between OTs and school staff can ​have a negative effect on children​. In
clinic-based practise inaccurate interventions in school sometimes continue for a long time, other
times the children do not even get access to the delegated interventions. The understanding of the
competence and the role of an OT is, according to the result, wider and the relationships function
better, when school-based. The lack of understanding from parents and school staff about how
Occupational Therapy can be a supporting element, is described by Rodrigues and Francine
(2018). The result indicates that this is less of a factor when OTs are school-based, but stands out
more when they are clinic-based.

Time is an important overall resource, as mentioned earlier, although time is also a variable of
importance when comparing school- and clinic-based practises. When OTs are school-based
there is no time needed for transport between the clinic and different schools. The result also
implies that there is access to more time both for assessing the client and for adjusting
interventions in the school-based service.

Working closely in classrooms makes the OTs reevaluate their methods and in the long run,
develop a greater understanding for which interventions are possible and useful in that particular
environment (Campbell et al., 2012). This understanding is, in the result, pointed out as valuable
knowledge. Smaller, but more effective adjustments can be implemented faster, when knowing
and understanding the classroom situation. This suggests a better delivery of service, than when
the service is being clinic-based. Benefits found in the result regarding clinic-based Occupational
Therapy are variation and a greater opportunity for a holistic approach. The working

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environment is dynamic when going to different schools and to avoid standardisation and
generalisability it is important to stay as close to the natural environment of the individual as
possible (Innes & Straker, 2002). The result points to an awareness of the risks of becoming an
advocate for the school or falling into a pattern of focusing on academic achievements, instead of
what is important for functioning in everyday life. These risks, as described by Campbell et al.
(2012) could possibly be lower when the OT is independent from the school and has their base in
a clinic. All different environments which the individual child is in must be considered and not
only the school environment. The holistic view of an OT should include all of the client’s life
areas (Taylor, 2017; Nicola-Richmond et al., 2016). School-based or clinic-based might not be
the critical question, but whether it is possible for the OT to always have a holistic approach.

4.2 Method discussion
A qualitative method was chosen since the purpose was to gather experiences. Quantitative
methods were discussed, but would probably have given results not matching the purpose of this
study.

According to Höglund-Nielsen and Granskär (2017) strategies for recruiting participants have an
impact on the trustworthiness of the result. We chose convenience sampling, which may have led
to a bias, since the participants may not be a representative part of all OTs matching the criteria
of inclusion. We aimed to get a broad and varied material, but can in retrospect see an
over-representation in participants with experience in autism related work. This may have
impacted the transferability of the result.

The anonymity of the participants was ensured by using coded names during the process.
Occupational therapy is a female dominated profession, therefore to further respect the
anonymity and prevent from traceability, we chose not to reveal the number of male and female
participants. There is a possibility that the reliability is affected by this. Our goal is that both

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male and female readers can relate to and learn from the participants' experiences and that
parallels can be seen to related situations.
Our aim was to keep the data as close to the original as possible by video recording the
interviews. We wanted body language and facial expressions included in the gathering of the
data. Having a video conversation recorded, might on the other hand, make participants nervous
or uncomfortable and it is possible that the outcome would have been greater and more nuanced
if the interviews had been conducted through personal meetings.

The data was analysed through latent and manifest content analysis as explained by Olsson and
Sörensen (2011). When meaning units are condensed, there could be a risk of losing relevant
information, hidden in details. To prevent this from happening, the transcriptions were re-read
several times during the process of forming categories.

Since our native language is Swedish, there was a risk of linguistic misunderstandings and
therefore a hazard that inaccurate information could have been communicated. This may have
affected the trustworthiness. It was however dealt with by ensuring a good amount of time set
aside for transcription. Any linguistic uncertainties could be solved by either contacting the
participant or by reassuring the meaning of the context by using adequate literature.

5. CONCLUSION
The purpose of this study was to describe Occupational Therapists’ experiences of working in
Irish schools. When analysing the result, we find that in accordance with previous research,
resources and communication have a beneficial effect on Occupational Therapy in schools.
Many factors add to the complexity of delivering the service, regardless of whether the service is
school- or clinic-based. A preference of school-based Occupational Therapy is seen, especially in
terms of having enough time, both for the client and for establishing functioning relationships
and good communication with the school staff. Despite this, Occupational Therapy today is
generally more clinic-based than school-based.

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More research is needed to explore whether the result is applicable to Swedish circumstances and
if OTs could have a role in Swedish schools.

ACKNOWLEDGEMENT
We would like to thank our tutor, Maria Prellwitz, Associate Professor of​ Occupational therapy,
for supporting us and believing in us. We would also like to thank our patient and understanding
families, for making this study possible.

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REFERENCES

AOTI: The Association of Occupational Therapists of Ireland. (2020). ​What is OT.​ Retrieved
2020-05-30 from https://www.aoti.ie/what-is-ot

Berryhill, M. B., & Vennum, A. (2015). Joining Forces: Bringing Parents and Schools Together.
Contemporary Family Therapy, 37(​ ​4)​, 351-363.

Campbell, W. N., Missiuna, C. A., Rivard, L. M. & Pollock, N. A. (2012). “Support for
everyone”: Experiences of occupational therapists delivering a new model of school-based
service. ​Canadian Journal of Occupational Therapy, 79,​ 51-59. doi: 10.2182/ cjot.2012.79.1.7

Clough, C. (2019). School-based occupational therapists’ service delivery decision-making:
Perspectives on identity and roles, ​Journal of Occupational Therapy, Schools, & Early
Intervention, 12​(1), 51-67. doi:10.1080/19411243.2018.1512436.

Etikan, I., Musa, S.A. & Alkassim, R.S. (2016). Comparison of Convenience Sampling and
Purposive Sampling. ​American Journal of Theoretical and Applied Statistics, 5​(1), 1-4. doi:
10.11648/j.ajtas.20160501.11

Fisher, A.G. (2009). ​Occupational therapy intervention process model: a model for planning and
implementing top-down, client-centered, and occupation-based interventions​. Fort Collins,
Colorado: Three Star Press.

Hanna, K. & Rodger, S. (2002). Towards family-centred practice in paediatric occupational
therapy: A review of the literature on parent–therapist collaboration. ​Australian Occupational
Therapy Journal​ ​49(​ 1), 14–24. doi:10.1046/j.0045-0766.2001.00273.x

                                                                                                  22
Hutton, E. (2009). Occupational therapy in mainstream primary schools: an evaluation of a pilot
project. ​British Journal of Occupational Therapy, 72(​ 7), 308-313.

Höglund-Nielsen, B. & Granskär, M. (red.) (2017). ​Tillämpad kvalitativ forskning inom hälso-
och sjukvård​. (Tredje upplagan). Lund: Studentlitteratur.

Innes, E. & Straker, L. (2002). Workplace assessments and functional capacity evaluations:
Current practices of therapists in Australia. ​Work,​ ​18(​ 1), 51-66.

Kvale, S. & Brinkmann, S. (2014). ​Den kvalitativa forskningsintervjun.​ (3. [rev.] uppl.) Lund:
Studentlitteratur.

Missiuna, C., Pollock, N., Campbell, W., DeCola, C., Hecimovich, C., Sahagian Whalen, S., ...
Camden, C. (2017). Using an innovative model of service delivery to identify children who are
struggling in school. ​British Journal of Occupational Therapy, 80(​ 3), 145-154.

Motion 2017/18:2505. Arbetsterapeuter i elevhälsan i skolan. Retrieved 2020-01-06 from
https://www.riksdagen.se/sv/dokument-lagar/dokument/motion/arbetsterapeuter-i-elevhalsan-i-sk
olan_H5022505

Nicola-Richmond, K. M., Pépin, G., & Larkin, H. (2016). Transformation from student to
occupational therapist: Using the Delphi technique to identify the threshold concepts of
occupational therapy. ​Australian Occupational Therapy Journal,​ ​63(​ 2), 95-104.
https://doi-org.proxy.lib.ltu.se/10.1111/1440-1630.12252

Olsson, H. & Sörensen, S. (2011). ​Forskningsprocessen: kvalitativa och kvantitativa perspektiv​.
(3. uppl.) Stockholm: Liber.

                                                                                                   23
Rodrigues, S. M., & Francine, M. S. (2018). Current Practice Patterns and Perceived Needs of
Occupational Therapy Practitioners in Middle Schools.​ J​ ournal of Occupational Therapy,
Schools, & Early Intervention​, 12​(1)​, 1​ 44-155.
https://doi-org.proxy.lib.ltu.se/10.1080/19411243.2018.15120

Taylor, R.R. (2017). ​Kielhofner's model of human occupation: theory and application​. (Fifth
edition.) Philadelphia: Wolters Kluwer.​66

Tracy-Bronson, C. P., Causton, J. N., & MacLeod, K. M. (2019). Everybody has the right to be
here: Perspectives of related service therapists. ​International Journal of Whole Schooling, 15​(1),
132-174.

Vincent, R., Stewart, H., & Harrison, J. (2008). South Australian school teachers’ perceptions of
occupational therapy reports. ​Australian Occupational Therapy Journal 55(​ 3), 163​-171.

Whiting, C. C., & Muirhead, K. (2019). Interprofessional Collaborative Practice between
Occupational Therapists and Behavior Analysts for Children with Autism. ​Journal of
Occupational Therapy, Schools, and Early Intervention,​ ​12(​ 4), 466-475.

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