Abstract
This study presents two knowledge translation programs that target both occupational therapists and managers in the educational system. The programs promote a shift in school-based occupational therapy services toward a focus on participation and environment.
Participation, defined as “involvement in life situations” (World Health Organization, 2013), incorporates the individual’s attendance to and engagement in various activities (Imms et al., 2016). It is central to the inclusion in education of children with disabilities (Maciver et al., 2019) and is linked to better mental and health outcomes, such as increased academic achievement and social involvement in adulthood (Augustine et al., 2022). School participation includes classroom-based, organized (e.g., clubs), and unstructured activities (e.g., play). Most students with disabilities experience participation restrictions in all school life areas (Coster et al., 2013; Lamash et al., 2020) stemming from complex interactions between their personal and environmental factors. Flexible structures and organizations, knowledgeable staff, positive attitudes on the part of staff and peers, and accessible usable spaces have been identified as participation facilitators (Maciver et al., 2019). Lack of individualization and rigid routines and unsupportive attitudes on the part of staff and peers have been identified as participation barriers (Maciver et al., 2019).
The World Federation of Occupational Therapy (2016) defines school-based (SB) occupational therapists’ practice as occupation based and educationally relevant. Occupational therapists identify students’ strengths and resources and address learning and participation challenges in meaningful SB occupations. Despite an accumulating number of evidence-based interventions to improve participation (Anaby et al., 2018; Kramer et al., 2018), they are often not well integrated into occupational therapy practice (Anaby et al., 2017; Graham et al., 2020; Kolehmainen et al., 2020).
One such intervention is the Pathways and Resources for Engagement and Participation intervention (PREP; Law et al., 2016), a client-centered, partnerships-based and strength-focused approach aimed at enhancing participation in self-chosen real-life activities by modifying environmental aspects only (physical, social, attitudinal, and institutional). PREP involves five steps: (1) Make goals, (2) map out a plan, (3) make it happen, (4) measure process and outcomes, and (5) move forward. PREP has been found to be effective with children who have different health conditions and various settings (Anaby et al., 2018; Burrough et al., 2020; Hoehne et al., 2020; Waisman-Nitzan et al., 2022). However, practice changes slowly, and therefore concrete knowledge translation (KT) efforts are required (Upton et al., 2014).
The Participation-focused KT (P-KT) framework, which is grounded in the principles of recognized KT models, can accelerate the incorporation of participation evidence into practice (Anaby et al., 2022). These principles emphasize a synergy across three ecological levels: (1) micro (individual, e.g., child/family/therapist), (2) meso (organization), and (3) macro (outside the organization), each of which addresses different stakeholders, requirements, and strategies and builds on intersectoral partnerships. The P-KT framework also underlies a readiness-for-change continuum and thereby fosters motivation for change toward adopting participation-based practices across all stakeholders.
In our previous study (Part 1; Waisman-Nitzan et al., 2022), we examined changes in knowledge, perceptions, and practice behaviors of 39 SB occupational therapists who completed a 30-hr PREP KT program. The findings indicated an increased knowledge of participation- and environment-focused interventions combined with self-perceived changes in practice, including an environmental perspective, expanding partnerships, and redirecting a focus on participation. However, to create substantial change with regard to participation-based practices, a multilevel approach involving collaboration with different stakeholders, including organizational decision makers, is required. In the present, qualitative study (Part 2), guided by the P-KT framework (Anaby et al., 2022), we aimed to further understand the perspectives of occupational therapists and occupational therapy managers—important stakeholders representing distinct ecological levels in the Israeli Ministry of Education (IME)—on the implementation of new participation knowledge. To be specific, we examined stakeholders’ perspectives upon completion of a KT program on implementing participation-based practice (i.e., PREP) in inclusive schools.
Method
Design and Procedure
Guided by P-KT principles, a researcher–stakeholder partnership with the IME was formed to jointly develop PREP implementation KT programs in the unique context of inclusive education, including special classes integrated into schools or regular classes. By leveraging an existing reform for professional development supported by the IME, KT programs were tailored to the needs and contexts of two stakeholder groups within the ministry: (1) occupational therapists and (2) occupational therapy managers providing services for children with disabilities in inclusive educational settings (see Supplemental Table A.1 for the programs’ characteristics, available online with this article at https://research.aota.org/ajot). To complement findings from the Part 1 study and present evidence for a multilevel KT program adhering to the P-KT framework, a subsample of SB occupational therapists who completed the therapists’ KT program took part in focus groups. Managers participated in a PREP KT program and then completed an open-ended questionnaire. To ensure varying perspectives, both stakeholder groups were asked to share their perceptions of facilitating PREP in inclusive schools.
Two focus groups, lasting 60 to 90 min, were held online. They were led by an occupational therapist external to the study who is an expert in service delivery and qualitative research. We developed an interview guide on the basis of our expertise in PREP, inclusive education, and KT programs (see Supplemental Appendix A.1). Secure conferencing software was used, and data were transcribed. Aliases (in the form of initials) were used to ensure confidentiality.
The KT program for managers included two remote PREP information sessions totaling 5 hr over a 2-wk period that introduced PREP’s principles and research evidence. Illustrative real-life cases were presented by a therapist who had completed the PREP KT program and implemented PREP in their own context or school in the Part 1 study. After the KT program, the managers completed a semistructured online questionnaire developed by the research team, with topics similar to those in the interview guide for therapist focus groups. The study was approved by the ethics committee of the IME and the institutional review board of McGill University.
Participants
This study (Part 2) included two samples of stakeholders in the educational system: (1) 7 occupational therapists working in inclusive schools who had completed the 30-hr KT program (Part 1 study) and (2) 39 occupational therapy managers representing 37 support centers (across Israel) who had completed the managers’ 5-hr KT program. All participants were female.
Therapists who agreed to participate in the focus groups were recruited by means of convenience sampling from 39 therapists from the Part 1 study (n = 7, 18% of therapists). Two therapists had 4 to 10 yr of experience, and 5 had >10 yr of experience. Managers were recruited from a group of 45 occupational therapy managers who were taking an online course held by the IME. All managers had >10 yr of experience supervising a range of 15 to 50 occupational therapists per region. They were responsible for occupational therapists’ placement, professional training, and development, and they reported to nationwide-level supervisors in the ministry. They also advocated for occupational therapy to educational managers and supervisors in the IME and therefore were in a position to influence practice. Informed consent was obtained from all participants.
Data Analysis
We performed a content analysis to explore the therapists’ and managers’ perspectives on PREP implementation; specifically, data from two units of analysis (therapists’ focus groups’ transcripts and managers’ semistructured questionnaires) were systematically organized separately according to Graneheim and Lundman’s (2004) four steps: Data were repeatedly read for general understanding of perspectives. Then, meaning units reflecting perceptions of PREP implementation in inclusive educational settings were identified. Meaning units were condensed while maintaining their core and were coded according to the micro, meso, and macro P-KT framework levels, serving as theoretical assumptions for the analysis. Meaning units were grouped within ecological levels, in each level of the P-KT framework, to form subcategories reflecting the level. Main themes were formed by mapping subcategories within each level across the two units of analysis. This allowed us to understand the contribution of the two distinct KT programs to a multilevel change in knowledge and perceptions of different stakeholders in the educational system.
Trustworthiness
The study followed the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007). Credibility was ensured through the study design, which adhered to the P-KT elements (KT interventions and methods were tailored to each group and level), allowing for the revelation of various issues per ecological level. Including various stakeholders’ perspectives increases the possibility of understanding the phenomena under study (Patton, 2002). Credibility was further sought by means of ongoing open dialogue and brainstorming between Michal Waisman-Nitzan and Yonat Ivzori and verification with Dana Anaby’s input, to achieve agreement with the way data were labeled and sorted and to avoid researcher bias during data analysis (Graneheim & Lundman, 2004). KT programs detailed in the supplemental material facilitated study transferability.
Results
The analysis revealed both common and distinct themes across the two units of analysis (i.e., focus groups and questionnaires) and across the micro, meso, and macro ecological levels of the P-KT framework (see Figure 1).
Common and distinct themes across units of analysis and across the micro, meso, and macro ecological levels.
Micro-Level Themes
Micro-level themes addressed perceptions related to knowledge, attitudes, skills, and practice behaviors, common to both managers and therapists, that emerged in the form of three themes: (1) setting participation-focused goals, (2) expanding partnerships, and (3) PREP’s contribution to redefining occupational therapists’ role in the school. First, managers emphasized that PREP encourages therapists to set functional goals that are relevant to and meaningful for the child and parents: “It’s a great opportunity to work on functional goals that are based on the child’s and their family’s own desire and initiation” (TA, manager). Concurrently, therapists further emphasized specific elements to consider when measuring a participation goal: “[One element is to] measure the child’s enjoyment, satisfaction—outcomes which we may have overlooked during the intervention. Now I ask [the child]: ‘How much fun was it for you to play during recess?’ [to] consider the fun, the enjoyment, the involvement” (S, therapist).
The second theme revealed perceptions about partnerships in the therapy process. The managers related to PREP’s contribution in establishing a genuine rapport with parents: “Another advantage [of PREP] is actively engaging the child’s parents in the intervention program in order to achieve the goals—something that is less seen in the education context” (ZA, manager). The therapists also expanded the multidisciplinary team beyond the parents to realize a participation goal, including relevant team members (i.e., peers and classmates). A therapist working with a student with a participation goal of playing with friends during recess illustrated this: What really motivated me was to create a participation team coming from [the child’s] own environment . . . a team that includes others, rather than just me or her personal aid/support worker. . . . So I engaged two of her girlfriends. I think that this was the key to success in achieving the goal, and it made a huge difference. (S, therapist)
The third theme encompassed perceptions regarding occupational therapists’ role in school settings and how PREP can contribute to redefining this role. Some managers refocused on occupation as the core of SB occupational therapy interventions: “Now [in light of the PREP] the essence of the word ‘occupational therapy’ has a meaning for the patient[;] it is exactly the essence of our profession” (AF, manager). The therapists related to their role in applying new terminology during discourse with parents and other team members, representing a shift toward an environment-based therapy approach: I think the change should come from us—the language that we use with parents and staff, and speak about the meaning of therapy, what is therapy about? It is not me and the child being together in the therapy room. (O, therapist)
Two additional micro-level themes emerged from the therapists only: (1) expanding children’s activities to different settings and contexts and (2) shifting from body functions to participation. First, the therapists recognized that, through PREP, they addressed a broader range of occupations and settings and contexts beyond the school, to include home and community settings (e.g., baking, shopping). They also stressed the need to focus the intervention on meaningful activities that are important to the child: I asked [the child] if there was anything he wanted to be able to do. . . . His eyes lit up and immediately he knew. He asked to play catch with two friends . . . make pancakes with Mom and go shopping with Dad. (Y, therapist)
Therapists also stressed a change in their approach, shifting from a focus on “fixing” the child’s impairments to a participation-focused intervention in which participation serves as both an outcome and a means for intervention: A significant change is shifting from “fixing the child” and working on skills to being convinced that if you will focus on function then you will also achieve (better) skills along the way. I witness first-hand that some skills have improved as a result of working on function. (O, therapist)
Meso-Level Themes
The meso-level analysis addressed the organizational aspects of implementing PREP in schools. Participants in both groups addressed (1) school–PREP fit and (2) organizational barriers to PREP’s application in school. The first theme encompassed organizational characteristics corresponding to the PREP approach. For example, one therapist related to her ability to maximize the productivity of occupational therapy service in the school because of the inherent presence of partners in an educational system. This included educators and professional teachers who were consistently present and who worked together regularly: Due to the characteristics of the school setting, we are able to optimize our intervention. . . . We have many partners who exchange information with one another, whether it is the core teacher, specialized teacher (music, physical education), the complementary teacher, the personal aide, and even the school principal. (Y, therapist)
Participants also commented on new opportunities for occupational therapy interventions through targeting different aspects of the school’s environment: “The different environment factors: physical, social, attitudinal [that we learned] . . . resulted in a much broader sphere to act on and apply the intervention in” (Y, therapist). They stressed that PREP refined their ability to accurately analyze environmental factors and assisted in shifting from an intervention held in the therapy room to real-world contexts of school life, such as during recess and class. Moreover, therapists highlighted the linkage between the disciplines of education and health, which are inherently embedded in occupational therapy intervention in schools, and emphasized that a change may be required, especially in educators’ attitudes regarding the practice of SB occupational therapy: “[PREP is] a comprehensive intervention that provides an opportunity to involve the nonclinical domains such as educational domains, in addition to the therapeutic work. This requires explaining and educating the school staff [about the approach]” (S, therapist). Managers reflected on the fit between schools’ procedures and aspects of PREP, such as an alignment between the goal-setting step in the PREP protocol and individualized education programs (IEPs): “PREP goals are linked to the [IEP]” (AC, manager).
The second common theme at the meso level included barriers to implementing PREP in school settings. Examples included a lack of flexibility in school procedures and unsupportive attitudes on the part of other professionals and school staff: The lack of staff meetings and collaboration between different teams [in the school], lack of resources and equipment that may be necessary for the implementation of the program, and of course school principal and staff who do not believe in and support our work. (AH, manager)
Another meso-level theme, future steps needed to implement PREP in inclusive schools, was noted by managers only. They elaborated on ensuring sustainability, including continuing courses for occupational therapists at the regional and school levels and presenting PREP in future occupational therapy meetings held in the school.
Macro-Level Themes
The macro-level analysis emphasized a link between PREP implementation and current systemic policies. Two themes emerged from managers: (1) anchoring PREP to the existing agenda and policy of the IME and (2) leveraging successes to accelerate PREP implementation in the ministry. Participants suggested that PREP is congruent with the agenda and vision of the ministry with respect to special education and inclusion, emphasizing a client- and family-centered approach: “[It is an] ecological perception and child-centered approach underlining PREP corresponds with our work in the Ministry of Education” (AL, manager). Managers linked the PREP approach to the ministry’s policy regarding therapy resources in inclusive education in Israel, and they underlined PREP’s role in paving the way to expand occupational therapy practice in the ministry: “The approach is applicable as part the of current resources that children in inclusive education are entitled to, and at the same time can increase the presence of occupational therapists and occupational therapy positions at all educational settings” (XB, manager). Moreover, some managers believed that PREP can be done remotely, which is fitting with the current emphasis on telehealth rehabilitation.
Another theme revealed by the managers related to leveraging successes to accelerate PREP implementation in the ministry. They agreed that adopting PREP at the ministry level was a process rather than a one-time act and that it required a shift in thinking: “By building on successful experiences we can expand the application of PREP. Sharing successes with others will result in initiation of additional processes” (RD, manager).
Discussion
Guided by the ecological levels of the P-KT framework (Anaby et al., 2022), this study presents the perspectives of two stakeholder groups in inclusive educational settings regarding the application of participation-focused interventions by occupational therapists in inclusive schools after completing customized KT programs. As such, this study adds to the growing evidence for the unique role of occupational therapy in educational settings (Chen & Patten, 2021; Kaelin et al., 2019; Lamash & Fogel, 2021).
Five out of the 10 themes that we noted were common to therapists and managers within the micro and meso levels of the P-KT framework. At the micro level, the two themes of setting participation-focused goals and expanding partnerships, which emerged in both stakeholder groups, represent PREP’s core principles. Setting occupation-based meaningful goals, as required by PREP, corresponds with recommended practice (Laverdure & Beisbier, 2021). Thus, our findings contribute to minimizing an existing know–do gap (Kolehmainen et al., 2020). Consistent with previous research (Bexelius et al., 2018; Maciver et al., 2019), in this study we found that setting meaningful goals requires both the child’s and parents’ perspectives (especially children of a young age or those with complex disabilities), to improve child participation. Existing procedures, such as IEP meetings, along with the application of intervention protocols, (e.g., PREP), could further engage parents (who are not present in school) in setting goals with a special focus on participation.
Expanding partnerships during the application of an intervention, also revealed in this study, was facilitated by forming a participation team—a key element of PREP that is introduced in the KT programs. Partnerships, often established through collaborative relationships, are embedded in SB occupational therapy (Lamash & Fogel, 2021), yet they are difficult to achieve because of a lack of time and a limited understanding of occupational therapists’ role by school staff (Truong & Hodgetts, 2017). Similarly, our meso-level findings suggest that unsupportive attitudes on the part of other professionals and staff members in the school can hinder the adoption of participation-based innovation. Concurrently, as therapist participants applied PREP in their own setting, they were able to use it to facilitate collaborative relationships within their organization, to highlight their role in school, and to ignite change in others’ attitudes toward participation-focused SB occupational therapy services.
Another common theme that emerged in both stakeholder groups at the micro level illustrated PREP’s contribution to redefining occupational therapy’s role in school, especially by redirecting the focus on occupation and environment. This is particularly important given recent evidence suggesting that the physical environment is being addressed in occupational therapy practice, whereas limited attention is directed to other environmental aspects (Bonnard & Anaby, 2016; Chen & Patten, 2021). Moreover, a survey conducted in Switzerland (Kaelin et al., 2019) showed that a majority of therapists provided services in various school settings (classrooms, schoolyards, restrooms); however, therapists did not mention whether they focused on changes in environmental factors. KT programs that facilitate a broader environmental perspective as a means of intervention can address these gaps. Moreover, therapists in this study related to their responsibility for applying new terminology, during discourse with others, that focuses on both environment and occupation. Indeed, sharing knowledge with teachers was found to promote occupational therapy services in schools (Hutton, 2009). As such, expanding others’ knowledge in school about occupation- and environment-based approaches may not only assist in redefining occupational therapists’ roles but also influence students’ participation. This assumption requires further study.
With respect to the notion of occupation, participants described a variety of occupations they focused on when applying PREP, expanding children’s activities to different settings and contexts. This coincides with previous research highlighting the need to expand beyond core academics, in particular to address social participation (e.g., playing with friends during recess, joining school committees and clubs), to improve students’ outcomes (Bonnard & Anaby, 2016; Chen & Patten, 2021; Kaelin et al., 2019).
Two common meso-level themes included school–PREP fit and organizational barriers to applying PREP in a school setting. This study emphasizes the unique school characteristics, stemming from existing structures and organizations (e.g., consistent presence of partners), and their role in supporting PREP application. Well-planned structures and organizations are required to facilitate participation opportunities (Maciver et al., 2019). Our study revealed organizational barriers to PREP application in the school setting (e.g., inflexible procedures, attitudes of others in school and their lack of knowledge regarding participation) that coincide with SB participation constraints in the literature (Chen & Patten, 2021; Maciver et al., 2019). This suggests targeting future KT interventions at meso-level barriers while highlighting existing unique supports in the school setting.
Five of the 10 revealed themes were addressed by either therapists or managers. Our findings emphasize the importance of a multilevel perspective, as proposed by the P-KT framework (Anaby et al., 2022). Whereas the therapists focused on the micro level, describing the shift in their practice from body functions toward participation and expanding children’s activities to different contexts, the managers contributed a more comprehensive perspective, referring to meso-level steps required for further implementing PREP in educational contexts and to macro-level issues, such as linking PREP to an existing ministry’s policy. For example, our findings show that supportive legislation and policies, especially those that promote therapy as a part of the school’s curriculum (meso- and macro-level factors) are still required, despite emerging evidence for the effectiveness of interventions held in the child’s natural environment (i.e., the school setting; Kaelin et al., 2019; Waisman-Nitzan et al., 2022) and therapists’ supportive attitudes toward implementing such practices (micro-level factors). Given that school policies and procedures for expanding children’s participation tend to be overlooked in current practice (Chen & Patten, 2021), PREP may help in identifying challenges and opportunities to addressing these environmental factors.
Limitations
A relatively small subsample of therapists was included in the focus groups (∼20% of those who participated in the Part 1 study); however, their characteristics varied, allowing for diverse perspectives whereby similar ideas raised in the first focus group emerged in the second group. Having another focus group, or more members in each group, would have further supported data saturation. Although managers represented 50% of all managers in the IME, the perspectives of higher-level directors and policymakers in the ministry were not elicited, limiting our understating of macro-level issues. Further research could identify and address macro-level factors affecting participation-focused practices.
Future Directions
Given that this study focused on inclusive education, further KT initiatives targeting other educational contexts (e.g., special education, preschools and high schools), as well as engaging other stakeholders, such as parents, are required. Moreover, follow-ups on KT outcomes are warranted, to ensure the sustainability of knowledge use.
Implications for Occupational Therapy Practice
Fostering change toward participation-focused SB intervention may consider the micro, meso, and macro levels of the educational context, by doing one or more of the following through a research–stakeholder partnership: ▪ tailoring a participation-focused KT program for occupational therapists that includes real-life applications of the intervention, such as PREP, while providing ongoing feedback on actions; ▪ advocating for increased knowledge of other stakeholders in the school about participation and participation-focused interventions; and ▪ initiating participation-focused KT programs for distinct groups of stakeholders in the organization, representing its meso and macro levels.
Conclusions
This study illustrates the importance of tailoring KT interventions to different stakeholders when facilitating the uptake of participation-focused approaches in inclusive schools. Our findings emphasize the need for comprehensive multilevel approaches, including micro-, meso-, and macro-level factors, as suggested by the P-KT framework, when initiating a change in the delivery and packaging of SB occupational therapy. In addition, applying therapy interventions such as PREP may foster collaborative practice, centered on participation goals, that is in line with current evidence, theory, and professional standards. This may also increase the understanding of occupational therapy services in school settings.
Supplemental Material
Supplementary material for Promoting Participation-Focused Practices in Inclusive Educational Settings: Stakeholders’ Perspectives Following a Knowledge Translation Initiative
Supplementary material, sj-pdf-1-aot-10.5014_ajot.2023.050262.pdf for Promoting Participation-Focused Practices in Inclusive Educational Settings: Stakeholders’ Perspectives Following a Knowledge Translation Initiative by Michal Waisman-Nitzan, Yonat Ivzori and Dana Anaby in The American Journal of Occupational Therapy
Footnotes
Acknowledgments
We thank the occupational therapists who competed the program and participated in the study. Special thanks are extended to the Israeli Ministry of Education for supporting this training.
References
Supplementary Material
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