Occupational therapists’ perspectives on an evidence-based,client-centered assistive technology intervention

Literature review

In recent years, a number of literature reviews and systematic reviews have been published within the area (Brandt et al., 2014, 2015, 2020; Larsson Ranada and Lidström, 2019; Socialstyrelsen, 2015). These reviews have diverse study populations and foci, ranging from studying the effects of various AT service delivery processes (Brandt et al., 2020) to an exploration of the impact of the delivery on satisfaction with AT in relation to daily occupations (Larsson Ranada and Lidström, 2019). Notwithstanding the diverse study populations and foci, the reviews point to two elements. One element that all the reviews suggest is that a client-centered approach in the service delivery process seems to positively impact user satisfaction with the AT itself and with the service delivery (Brandt et al., 2014, 2015, 2020; Larsson Ranada and Lidström, 2019; Socialstyrelsen, 2015). In the current study, the term “client” is defined broadly as both the person applying for ATs and the client constellation, which is others who live with, work with, or are closely connected to the person applying for the AT. However only those who experience issues with occupational performance in relation to interaction with the person applying are considered to be part of the client constellation (Fisher and Jones, 2017). Nevertheless, qualitative studies within the field of AT have shown that, although the occupational therapists are aware of and prefer a client-centered approach, they still find it difficult to practice in a client-centered way (Hedberg-Kristensson and Iwarsson, 2013). Qualitative research also shows that the clients experience the AT service delivery process to be multifaceted and complex (Gramstad et al., 2014) and that the experience of participation among clients is variable; while some clients feel that they participate actively in the entire service delivery process, others feel less involved (Gramstad et al., 2014; Hedberg-Kristensson et al., 2006).

The second element to which the reviews point is that a structured and systematic process conducted by professionals with experience in AT seems to be an important factor in an effective AT service delivery and in having satisfied users (Brandt et al., 2014, 2015, 2020; Larsson Ranada and Lidström, 2019; Socialstyrelsen, 2015). Some studies have suggested that, if service delivery is to be evidence-based, it should rely on systematic and structured procedures that should be based on guidelines, instruments, or models (Bernd et al., 2009; Triccas et al., 2019). Within this field, models are understood as symbolic representations of concepts that support and guide the AT service delivery (Bernd et al., 2009). Other studies have argued that there seems to be a lack of relevant instruments and models within the field (Friederich et al., 2010; Socialstyrelsen, 2015). However, Federici et al. (2014) have shown that, although the number of models has increased, the same growth has not been observed in service quality. This argument is supported by other studies and reports that suggest that instruments and systematic, structured models are not routinely used within the AT field (Brandt et al., 2014; Larsson Ranada and Lidström, 2019; Socialstyrelsen, 2015). There seems to be a lack of studies focusing on the application of an evidence-based, client-centered AT service delivery within occupational therapy practice.

An evidence-based, client-centered AT intervention

The current study is part of a larger project, in which an evidence-based, client-centered AT service delivery process that relied on structured models and instruments was developed and piloted in close cooperation with two Danish municipalities. The term AT service delivery process is in the current study defined as an intervention that “directly assists an individual with disability in the selection, acquisition, or use of an assistive technology” (Cook et al., 2020: 4). The AT service delivery process developed in the current study is hereafter referred to as the AT intervention.

The developed AT intervention was based on evidence-based practice—understood as the integration of the “best available research evidence,” “clinical experience,” and “knowledge and experiences of the clients” (Harvey and Kitson, 2015). These three elements of evidence-based practice were used as the basis for the development of the AT intervention (Harvey and Kitson, 2015). The “best available research evidence” was sourced through updated systematic reviews and literature reviews within the field (Brandt et al., 2014, 2015; Larsson Ranada and Lidström, 2019; Socialstyrelsen, 2015). “Knowledge and experiences of the clients” was obtained through a systematic review (Larsen et al., 2018) and a qualitative longitudinal study (Larsen et al., 2019, 2020)—both conducted as part of the larger project. Finally, the element of “clinical experience” was gained by the participation of practitioners, lecturers, experts, and researchers in the development of the AT intervention. Evidence-based practice has been criticized for focusing too much on experimental evidence, thereby overlooking individual needs, circumstances, and preferences (Greenhalgh et al., 2014; Rycroft-Malone et al., 2004). It has therefore been argued that the success of evidence-based practice depends on informed, shared decision making with clients and on the acceptability and fit of the intervention to the local context (Greenhalgh et al., 2014). Thus, these elements informed and inspired the understanding of evidence-based practice applied to the current study.

The Occupational Therapy Intervention Process Model (OTIPM) was used as theoretical framework for the development of the AT intervention (Fisher, 2009). The model was chosen because the OTIPM has been used previously within the field of AT (Kassberg and Skär, 2008; Linden et al., 2010), and because studies have shown that the model can be used to guide an improvement process and lead to an integration of evidence-based knowledge in practice, with long-lasting achievements (Sirkka et al., 2014a, 2014b). In line with the OTIPM, the AT intervention entails the following three phases: evaluation and goal setting, intervention, and re-evaluation. Each phase comprises a number of steps, and each step contains a detailed explanation of: how the occupational therapists are to perform throughout this step, including descriptions of instruments and methods, along with questions to support the professional reasoning; what is to be achieved during this step; what is the result of this step; and lastly, how this step is documented (Fisher, 2009). During the evaluation and goalsetting phase, the focus was on establishing collaborative relationships between clients and therapists, and on the clients’ expressed need to engage in occupations with positive personal value. Structured instruments, such as Individually Prioritised Problem Assessment (IPPA) (Wessels et al., 2002) and non-standardized performance analysis (Fisher, 2009) were employed in this phase. During the intervention phase, emphasis was placed on enabling the clients to participate actively in choosing, modifying, and implementing of the AT into their valued occupations. Finally, in the re-evaluation, the focus was on the clients’ needs for further training, adjustment, or follow-up.

During the entire AT intervention, importance was placed on increasing the clients’ competence to participate in the process. This was done by enhancing the predictability of the process, for example, offering the clients verbal and written information about the AT intervention to enable them to understand the predictable aspects of the process, and explore and compare their expectations with their occupational therapists.

The evidence-based, client-centered AT intervention was developed and piloted in two Danish municipalities over a period of 10 months. As the current study focuses on the municipal occupational therapists’ perspectives on the AT intervention, the purpose is therefore to investigate the occupational therapists’ perspectives on the evidence-based, client-centered AT intervention.

Study context

The study was conducted in cooperation with two Danish municipalities during the period 2015–2018. To ensure that the knowledge generated would be relevant in diverse settings, the selected municipalities varied according to, for example, number of inhabitants—one municipality had fewer than 25,000 inhabitants, while the other municipality had more than 100,000 inhabitants; size—one municipality was larger than 300 square kilometers while the other one was under 200 square kilometers; and type of district—one municipality was a rural district while the other was an urban district (Patton, 2015).

Participants

The participants in the focus groups were the occupational therapists who had participated in the overall project and in the pilot of the evidence-based, client-centered AT intervention; each had piloted 2–3 cases. The occupational therapists were selected for the overall project based on the criteria of having an interest in and a motivation for engaging in developmental work. Eleven occupational therapists had participated in the overall project and conducted the piloting. They were therefore invited to participate; one occupational therapist was unavoidably prevented from attending on the day of the interview. Thus, 10 occupational therapists from the two municipalities participated in the focus groups; five from each. Two were men and eight women; they were between 27 and 61 years of age; their professional work experience ranged between four and 35 years; and their experience within the field of AT service delivery ranged between 2.5 and 24 years.

Ethical considerations

The participants were orally informed about the research study and were told that participation was voluntary and that they could opt out at any time without any adverse consequences for their employment. Written informed consent was obtained from the participants.

Data collection

The data collection was carried out within 2 weeks of the end of the pilot. Interactions with the focus groups were held separately for the two municipalities to ensure situated knowledge generation (Harvey and Kitson, 2015). They were conducted in municipal settings and lasted approximately 2 hours each. The first author functioned as moderator, while the last author observed the dynamic interactions and took notes. A funnel-based approach with less structure in the beginning and more structure toward the end was used to investigate the participants’ perspectives on the AT intervention (Halkier, 2012). In accordance with focus group methodology, both focus groups opened with an introduction, explaining the purpose, and giving information about the focus group, the moderator role, and ethical issues (Halkier, 2012). Consistent with the funnel-based approach, the moderator started out by asking mainly descriptive questions (Spradley, 1979), with the purpose of gaining insight into the participants’ experiences of using the evidence-based, client-centered AT intervention in specific situations. Later, the descriptive questions were followed by structured and contrast questions, where the participants were encouraged to discuss the revealed perspectives and opinions (Halkier, 2012; Morgan, 1997; Spradley, 1979). All types of questions were combined with various exercises (Halkier, 2012). As an example of an exercise, the participants were asked to write down some notes about how, in cases where the AT intervention was used, it impacted on delivery, and then share these stories and perspectives with the rest of the participants.

A moderator guide was used to structure the focus groups. In accordance with Gadamer’s hermeneutics, it was acknowledged in the current study that the researcher’s pre-understanding influenced the study. The researchers’ theoretically based pre-understanding, in the form of literature on client-centered practice, was used to inform the moderator guide (Cott, 2004; Fisher, 2009; Gupta and Taff, 2015; Hammell, 2013; Mroz et al., 2015; Sumsion and Law, 2006). However, an awareness that the pre-understanding also defines the boundaries of the researchers’ horizon of understanding also shaped the study, in that the methodological principle of becoming aware of one’s pre-understanding and placing it at risk during the interviews was also sought. As an example, before the focus groups, the first author engaged in a reflective process with the other authors where the experiential, empirical, and theoretical pre-understandings on which the questions were based were discussed. Furthermore, during interactions with the focus groups, both first and last authors were aware of and willing to adopt and pursue perspectives and themes that were brought up by the participants. The focus groups were carried out with an openness and sensitivity toward the participants’ situations and horizons and a flexibility to adapt the interview structure to reach a new understanding.

The interactions with focus groups were audio-recorded and transcribed verbatim by an experienced transcriber. As the transcribing process involves both interpretive and technical decisions, the transcriptions were based on a written guideline, including decisions on how to handle, for example, anonymity, breaks, overlapping speech, emotional outbursts, and intonations (Kvale and Brinkmann, 2015). The guideline was developed by the first author, and presented and discussed with the transcriber prior to the transcription.

Data analysis

The analysis was conducted as a process of decontextualization and recontextualization, inspired by Dahlager and Fredslund (2008), and carried out in four steps: general impression; identifying meaning-bearing units; operationalization; and, recontextualization and hermeneutic interpretation. In the first step: general impression, the whole text was read several times to get a preliminary understanding of the text. In the second step: identifying meaning-bearing units, the focus was on “what” the text says; this is described as a meaning categorization process. In this process, the meaning-bearing units were each assigned a theme. During the third step: operationalization, the themes identified at step two were ordered and operationalized, to determine whether some themes should be incorporated into one, or be divided into sub-themes. At the fourth step: recontextualization and hermeneutic interpretation, the focus was on how the text could be understood in relation to the study aim and relevant theory. During this step, the attention moved from the parts to the whole, from the individual to the general and from text to context. Thus, at this final step, the preliminary analysis became subject to a further analysis (Dahlager and Fredslund, 2008). The analysis was conducted by the first author and discussed with the other authors after the first step and again after the fourth and final step.

A more refined collaboration with clients

The analysis of the text showed that, in providing the AT intervention, some of the occupational therapists found that their collaboration with clients changed. “They (the clients) are given some responsibility, in that they have to help define what they really want to be able to do again. I think that makes the interaction different (I, 1, B).” The quotation seems to indicate that, by involving the clients in the process, some of the occupational therapists felt that the collaboration was refined. They no longer considered themselves as experts in charge of the entire process; instead, the responsibility was shared between the occupational therapists and the clients. This led to enhanced collaboration, with the purpose of identifying strengths and problems regarding occupational performance and clarifying the clients’ motivation. “It is the clients that contribute to the formulation of (. . .) the occupational challenges that are most important for them and that we therefore must concentrate on (I, 2, C).” It was the impression of some of the occupational therapists that the use of client-centered instruments, such as the IPPA, refined the collaboration and facilitated a client-centered approach, in which the clients’ needs and desires were in focus: “I believe that the clients feel that they are heard and seen in a different way than in the traditional way. It has something to do with the IPPA form (I, 1, A).”

By using the client-centered and occupation-based models and instruments, some occupational therapists found that they gained a more nuanced understanding of the clients, and thereby a different side to, or some new aspects of, the clients that they had previously not noticed to the same extent: “In some cases, they (the clients) almost become the disease itself. We move away from that, because you become more aware of their resources (. . .) You get a much broader picture of them (. . .) a better insight into them as individuals and their abilities (I, 2, A).” The quotation seems to illustrate that it was the occupational therapists’ impression that, by applying the client-centered AT intervention, some of them felt that they gained a more nuanced picture of the clients and their everyday life.

Advantages of using theoretical frameworks, structured models, and instruments

By using the theoretical framework and structured methods, some of occupational therapists felt that they attained a more thorough evaluation of the clients’ situation and occupational performance problems. “It started with a height-adjustable toilet seat and, in many cases, it would have just been ordered for them. And then a request would come again, fourteen days later, and then again three weeks after, one month after, and three months after, about all the other small ATs. I think it would have been like that. Because it turned out there were a lot of other problems. I don’t think that this would have been picked up on the phone. (I, 1, C).” The quotation shows that the occupational therapists found that conducting the evaluations in a holistic way was time-efficient, as they were able to provide the clients at once with all the AT they needed, instead of on multiple occasions over a longer period. Time consumption was an important issue for the occupational therapists. In the short term, the AT intervention was time consuming; however, some of the occupational therapists considered it an investment in saving time and money in the long run.

Many of the occupational therapists found that the AT intervention enhanced their professional competences, which they experienced as satisfying. A participant gave the following example of enhancement of professional competences: “The scientific terms and ways to set things up as an occupational therapist, it isn’t usual practice, not for me, at least. So, in that way, I think you need to recall it again, but I think that it gives a boost to my professional competencies (I, 1, C).” The quotation shows that, previously, some of the procedures had been based on tacit knowledge, but by using theoretical frameworks, such as the OTIPM and non-standardized occupational performance analysis, the occupational therapists found that their professional assessment and reporting was strengthened. Instead of writing two lines about an observation, which would typically describe walking distance and breaks, the occupational therapists conducted an occupational performance analysis that focused on the quality of the performance. “The quality of walking (. . .) normally we would write two lines about how the client can walk hundred meters with four breaks and blah blah blah. Now we write more about quality and effort and safety and all that. If we reject the application and the client complains. Then I also think it gives a good description for the National Board of Appeal (I, 2, C).” By strengthening the professional assessment and reporting, some of the occupational therapists felt more comfortable and competent when discussing issues such as rejections of applications with other healthcare professionals, clients, or the appeal board.

Challenges in using the AT intervention

Overall, the occupational therapists experienced positive elements of working in an evidence-based, client-centered manner; however, they could also foresee some challenges, if it were to be implemented in the two municipalities. Some occupational therapists found that it was difficult to involve experienced clients in the process: “After all, some clients are trained in this system. They think: this person is from the municipality, so now I have to tell about this, that and the other (I, 2, C).” As expressed by the quotation, according to the occupational therapists, the difficulties arose mostly because some clients had specific expectations of the occupational therapists, as representatives of the municipalities, based on their previous experiences of municipal healthcare professionals.

Even though the occupational therapists found that their language changed to a more professional language, they also considered the terms used in the non-standardized performance analysis to be challenging. As expressed by the following quotation: “E: I’ve thought, when I’ve read the things I’ve written, well this makes sense. B: I thought the concepts used were very unfamiliar and they weren’t so descriptive (I, 2, E and B).” They were unsure if their colleagues who were not part of the project would be able to understand their documentation of the non-standardized performance analysis.

Regarding the various elements of the AT intervention and the target group, it was the occupational therapists’ experience that some of the elements, such as enhancing the predictability of the process, should be used on all applications, while others could be used when relevant: “It makes good sense if they are new clients, because then you make an assessment of their everyday lives in a different way, than if you just focused on the AT they have applied for (I, 2, B).” As shown by the quotation above, the occupational therapists considered that relevant cases would all be new cases. They also argued that it would be relevant in complex cases and ones where there had been an immense change in the client’s situation. However, they also found it difficult to use the AT intervention in some cases: “I think it should be individuals, who can participate actively (. . .). They must be cognitively well-functioning (I, 1, D).” The occupational therapists emphasized that it was challenging to use the AT intervention in cases where the client’s cognitive functioning was reduced or when the clients were not able to express themselves.