Australian Occupational Therapy Journal (2014) 61, 148–158
doi: 10.1111/1440-1630.12093
Research Article
Investigating the experiences in a school-based occupational therapy program to inform community-based paediatric occupational therapy practice Lezahn Rens1 and Annette Joosten2 1 School of Occupational Therapy and Social Work, Curtin University, and 2School of Occupational Therapy and Social Work, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
Background/aim: A collaborative approach with teachers is required when providing community-based occupational therapy to educationally at risk children. Collaborators share common goals and interact and support each other but challenges arise in providing collaborative occupational therapy in settings outside the school environment. The aim of this study was to capture experiences of teachers and occupational therapists working within a schoolbased occupational therapy program to determine if their experiences could inform collaborative practice. Method: In this pilot study, participant responses to questionnaires (n = 32) about their experiences formed the basis for focus groups and individual interviews. Two focus group were conducted, one with teachers (n = 11) and one with occupational therapy participants (n = 6). Individual interviews were conducted with the supervising occupational therapist, school principal and two leading teachers. Descriptive statistics were used to analyse the data from closed questions, and thematic analysis using a constant comparison approach was used to analyse open ended questions, focus groups and interviews. Results: Three main themes emerged: (i) the need for occupational therapists to spend time in the school, to explain their role, build relationships, understand classroom routines and the teacher role; (ii) occupational therapists need to not see themselves as the expert but develop equal partnerships to set collaborative goals and (iii) occupational therapists advocating for all parties to be informed throughout the occupational therapy process. Lezahn Rens BSc (Hons); Occupational Therapist. Annette Joosten PhD; Senior Lecturer. Correspondence: Annette Joosten, School of Occupational Therapy and Social Work, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia. Email: [email protected] Accepted for publication 7 October 2013. © 2013 Occupational Therapy Australia
Conclusion: The pilot study findings identified teacher and therapist experiences within the school setting that could inform improved collaborative practice with teachers and community-based occupational therapists and these findings warrant further investigation. KEY WORDS children, collaboration, community based, occupational therapists, school based, teachers.
Introduction Participation in school requires children to be a student, classmate, self-maintainer, player and friend in the dynamic environments of the classroom and playground (Case-Smith & Holland, 2009). Ideally, intervention to support performance and participation in these roles is best provided in the school setting to ensure best intervention outcomes. However, limitations in funding and in the availability of occupational therapy often result in these services being provided in community settings and private practice (Rodger, Brown & Brown, 2005). Best practice occupational therapy with school aged children is dependent on both the quality of direct intervention with the child, and the indirect strategies implemented to ensure that any progress that occurs in direct intervention is successfully transferred to the child’s occupational roles in everyday settings (Case-Smith & Holland; Spencer, Turkett, Vaughan & Koenig, 2006). Given teachers are the key adults in the child’s school it is vital that occupational therapists collaborate to ensure transfer and generalisation of new skills occur (Barnes & Turner, 2001; Kemmis & Dunn, 1996; Nochajski, 2001). Several definitions of collaboration exist and they vary between professions. However, common features of collaborative practice are that it involves two equal parties adopting a style based on respect and trust, and voluntarily sharing responsibility and accountability and working to build community (Cook & Friend, 2010). Villeneuve (2009) in a Canadian study proposed
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two main requirements necessary for collaboration between occupational therapists and teachers. First, it was suggested teachers needed to understand the occupational therapy role and in turn, occupational therapists needed to understand the educational system and school policies to ensure therapy was relevant and educationally focused. Secondly, both parties required the opportunity and time for formal and informal meetings to discuss individualised interventions. Very few studies have investigated collaboration in the school context in Australia (Kennedy & Stewart, 2011). Bose and Hinojosa (2008) agreed with the need for meetings but highlighted that meetings only enhanced collaboration when there was good communication and an ability and willingness to resolve conflicts. They further added that collaboration was threatened when occupational therapists were perceived as thinking they were the experts or did not personally seek to be collaborative. Kennedy and Stewart (2012) reported that therapists agreed about requirements for good collaboration but noted that this did not make it happen, and that therapists were not necessarily concerned or dissatisfied with lesser degrees of collaboration. The variation in school settings, children’s needs and the availability of funding and resources has resulted in the development of many different models for providing therapy services to school age children in the Australian context rather than there being an identifiable best practice model. The Australian government recognises the importance of occupational therapy by providing funding and school services for some groups of children, particularly those with diagnosed disabilities (Department of Families, Housing, Community Services and Indigenous Affairs, 2009). However, the current funding allocations and program policies, result in very few occupational therapists being employed in Australian schools (Western Australian Department of Education, 2007). When children are educationally at risk and require assistance to reach educational and extracurricular goals for reasons that may be complex, vague, or unexplained but do not meet disability diagnostic criteria, they are usually ineligible for funding (Chen, Hughes, Liew & Kwok, 2010; Gardynik & McDonald, 2005; Luo, Hughes, Liew & Kwok, 2009; Zubrick, 2000). As a consequence they often see occupational therapists in community settings, disconnected from the school environment (Rodger et al., 2005). Often without direct contact with teachers, community based occupational therapists rely on their written reports to convey information about the child’s progress, and provide recommendations to ensure skills are transferred to the child’s school environment (Barnes & Turner, 2001; McWilliam, 1995). An Australian study by Vincent, Stewart and Harrison (2008) highlighted difficulties with this process as teachers reported that occupational therapy reports were of limited value without further contact with occupational
therapists. Available literature is largely based on international contexts and indicates that collaborative practice, while reportedly desired was not always implemented or there were limitations in its implementation (Barnes & Turner; Dule, Korner, Williams & Carter, 1999; Villeneuve, 2009). The study by Kennedy and Stewart (2012) published after the current study commenced confirmed the inconsistencies in implementation in the Australian context and the need for further research. To gain information about collaboration within the Australian context this study investigated the perspectives of teachers, an occupational therapist and final year occupational therapy students in a school based occupational therapy program in Western Australia. This occupational therapy program provided all educationally at risk students (who did not have funding or individualised education plans) the opportunity to receive occupational therapy in the school setting. This study aimed to determine whether the experiences of a school based occupational therapy program, could inform the practices of community based occupational therapists within an Australian context. The following objectives were set: What were the possible barriers and enablers to successful collaboration between occupational therapists and teachers regarding effective occupational therapy intervention in the school environment? From the perspectives of the occupational therapist, final year occupational therapy students and teachers: What communication methods were most effective or ineffective in transferring information between occupational therapists and teachers regarding the progress of a child? What experiences best informed participants’ perceptions of each other’s roles? What learnt facts regarding each other’s roles, were most helpful to collaborative practice?
Methods Design This study utilised a mixed methodology approach of sequential quantitative-qualitative methods, with a questionnaire in phase one, and focus groups and interviews in phase two (Driscoll, Appiah-Yeboah, Salib & Rupert, 2007; Kelle, 2006). This methodology allowed the collection of opinion from a larger group prior to gaining more in-depth opinions from a smaller sample of participants. This particular study design was used to help identify the questions which would be further © 2013 Occupational Therapy Australia
150 investigated using qualitative data collection and analysis, and to ensure that the focus of the qualitative component was appropriate (Kelle). In addition to the rating scale responses, open questions on the questionnaire ensured that participants had the opportunity to raise any other areas they thought were important to collaboration. A search of the literature to find any existing questionnaires, revealed a survey by Dule et al. (1999) and although it was in an Australian context, it did not meet the aim of this study as it was designed to evaluate service delivery by therapists coming in to the school to see funded children with high needs rather than being based in the school and available to all educationally at risk children. Only a small number of items related to collaboration and sought only the therapists’ perspectives about an established therapy program for each child. A further questionnaire developed for the American context (Barnes & Turner, 2001) was also mainly evaluation based and only sought the teacher perspective. Therefore, a questionnaire was developed for this study which was based on relevant information from these and other studies (Bose & Hinojosa, 2008; Nochajski, 2001; Spencer et al., 2006; Villeneuve, 2009) to improve content validity. The purposes of the questionnaire were to obtain a broader picture of the whole school perspective, to confirm if the issues discussed in the literature, which was mainly internationally based, were relevant to this therapy context and to ensure relevant issues were discussed in the focus groups. Ethics approval was obtained from the Curtin University Human Research Ethics Committee (using Form A), and the Department of Education (Western Australia) prior to commencement of data collection.
Phase one: Questionnaire Participants and procedure The school provided school based occupational therapy services through a rare arrangement with an occupational therapist working in the school, providing supervision to final year occupational therapy students on fieldwork placement, from Curtin University in Western Australia. Final year occupational therapy students complete four 7-week fieldwork placements, during which they are required to demonstrate graduate entry occupational therapy competencies, including collaborative practice (Curtin University School of Occupational Therapy and Social Work, 2011). With four fieldwork rotations yearly, school leaders and teachers were repeatedly exposed to education about occupational therapy and varying styles of collaborative practice. Invitations with information packs were mailed to eligible occupational therapy participants (n = 13) including the supervising occupational therapist, and occupational therapy students who completed final year fieldwork placements at the school in 2010–2011. The © 2013 Occupational Therapy Australia
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occupational therapy students will be referred to as occupational therapists in this study as they were registered occupational therapists at the time of data collection, responding retrospectively to their experience as part of the occupational therapy team at the school. Ten occupational therapists (eight women; two men), including the therapist with 20 years of experience in paediatric occupational therapy in community and schoolbased services, and seven occupational therapists with 6–18 months experience as registered occupational therapists, provided consent and completed the occupational therapy questionnaire. Following a presentation about the study, information packs were placed in the pigeon holes of all 38 teachers teaching at the school. Teachers who provided consent and completed the teacher questionnaire (n = 22; 21 women; 1 men), participated in the study. Nineteen of the teachers had taught at the school since at least 2010 with 17.36 mean years of teaching experience. Individual participant identification codes were used on all questionnaires to ensure anonymity was maintained.
Questionnaire format The questionnaires were based on information from current literature on collaboration, with the majority of the studies being set in the USA context. Primarily, closed ended questions were used in both questionnaires, with all closed ended questions being phrased the same way, ‘to what extent do you agree ‘or ‘to what extent does this situation happen to you’ and a 5-point Likert scale was used.
Analysis Descriptive statistics were used to analyse the frequency and variability of occupational therapist and teacher responses for each closed ended question (Portney & Watkins, 2009). The purpose of this analysis was to understand the pattern of responses so that questions with high consistency (at either end of the scale) and questions with variable responses could be identified and explored further in the next phase. Results to each question were treated as a continuous scale of agreement from 1 to 5 on the Likert scale of responses, with mean scores close to 1 indicating disagreement, and closer to 5 indicating agreement. Analysis beyond descriptive statistics was not completed, and would have been inappropriate when considering the small sample size, difference between sample size and that reliability and validity had not been tested for the questionnaire used.
Results Phase one: Questionnaire Teacher questionnaire Some of the close ended question responses specific to the teacher questionnaire are presented in Table 1.
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Open ended questionnaire responses relating to teachers’ understanding of occupational therapy identified the importance of professional development opportunities, observation of the occupational therapist/ students in action, seeing occupational therapy benefits, having an effective referral form and short and easy strategies. Teachers reported that occupational therapists gained an understanding of the teacher role by: occupational therapists seeking information about the classroom structure, timetable, and school expectations, year level academic expectations; and visiting the classroom at different times. Answers to questions about maximising collaboration included: occupational therapist and teacher exchanging contact information; key stakeholders all getting the same information; and regular therapy plan reviews.
Occupational therapy questionnaire Some of the closed ended question responses specific to the occupational therapy questionnaire are presented in Table 2. Open ended question responses about increasing teachers’ understanding of occupational therapy included: providing information about the role of occupational therapy, communicating an occupational focus and explaining clinical reasoning. On increasing occupational therapists’ understanding of the teacher role they focused on: the importance of seeking information TABLE 1: Some of the close ended question results of teacher participants (n = 22) regarding role understanding Understanding the occupational therapy role To what extent have you become aware of the role of occupational therapy in the school from The occupational therapist directly (M = 4.55, SD = 0.96) Written material from the occupational therapist (M = 3.5, SD = 1.19) Occupational therapy student (s) directly (M = 3.5, SD = 1.50) Written material from occupational therapy student (s) (M = 1.55, SD = 0.91) Parent/caregiver (M = 2.17, SD = 1.64) Understanding of the teacher role To what extent do you think occupational therapists understand the role of the teacher in terms of Time constraints to implement intervention strategies (M = 4.31, SD = 0.75) Resources available (M = 4.23, SD = 0.83) Opportunities to meet with the occupational therapist/ students (M = 4.23, SD = 0.83) Opportunities to meet with the child’s parents (M = 4, SD = 0.60) M, mean scores; SD, standard deviations.
TABLE 2: Some of the close ended questionnaire results of occupational therapy participants (n = 10) regarding role understanding Understanding of the occupational therapy role To what extent did you find the following communication methods used effective to communicate your role Formal Meetings (M = 3.50, SD = 1.18) Informal meetings (M = 4.70, SD = 0.48) Written material (M = 3.60, SD = 0.52) Understanding of the teacher role To what extent do you feel your perception of the role of a teacher has changed throughout your experience at this school? (M = 3.30, SD = 1.52) To what extent do you feel your experience at this school has informed your future practice of working within a team? (M = 3.90, SD = 0.57) To what extent do you feel your experience of working within a school-based program may be beneficial to other occupational therapists working with school-aged children? (M = 4.8, SD = 0.42) M, mean scores; SD, standard deviations.
regarding teacher responsibilities, school and department priorities and time restrictions; importance of increasing time spent at the school and initiating discussions with teachers about roles. Questions about maximising collaboration included: having mutual goals, increasing personal development opportunities on role understanding and the importance of building rapport with teachers. Some of the teacher and occupational therapy responses to close ended questions featured in both questionnaires are presented in Table 3.
Informing phase two Closed ended question results indicating a strong agreement or disagreement from participants as well as responses from open ended questions, informed study phase two. Phase one questions with strong responses in either direction, or with variable response patterns, were included in the focus group and interviews to further explore the pattern or variability in response but were presented in a manner designed to reduce bias in the focus group discussion. Examples of how the responses were used to develop the focus group questions are presented in Table 4.
Methods Phase two: Focus groups and interviews Participants All phase one participants were invited to participate in phase two. One focus group was conducted for occupa© 2013 Occupational Therapy Australia
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TABLE 3: Some of the closed ended questionnaire results regarding collaborative practice of occupational therapy participants (n = 10) and teacher participants (n = 15) who had children in their classroom receiving school based occupational therapy Collaborative practice
Occupational therapist/students
To what extent have you provided/been provided with M = 3.60, information regarding referrals? To what extent were the following communication methods used between students: Formal meetings M = 2.67, Informal meetings M = 4.47, Email M = 1.33, Written reports or documents M = 3.71, To what extent were the communication methods M = 4.56, used effective? To what extent was the teacher involved in Goal setting for interventions M = 3.67, Planning for intervention implementation M = 3.33, Implementing intervention strategies M = 4.00, To what extent do you believe the relationship was Mutual M = 4.56, Respectful M = 4.67,
SD = 1.27
Teachers M = 4.24, SD = 1.26
you and the teacher/occupational therapist/ SD SD SD SD SD
= = = = =
1.00 0.44 0.50 1.38 0.53
M M M M M
= = = = =
2.75, 4.50, 1.67, 3.71, 4.58,
SD SD SD SD SD
= = = = =
1.40 0.52 1.23 1.38 0.67
SD = 0.50 SD = 0.71 SD = 0.50
M = 3.54, SD = 1.39 M = 3.38, SD = 1.12 M = 3.71, SD = 1.38
SD = 0.53 SD = 0.50
M = 4.93, SD = 0.27 M = 4.93, SD = 0.27
M, mean scores; SD, standard deviations.
tional therapists (n = 6), with four women, and an age range > 25 to < 35. One focus group was conducted for teachers (n = 11), with 10 women with an age range 26 to < 35. To reduce potential influence of relationship, the occupational therapist who was a previous supervisor of other participants, the school principal and two school leaders were interviewed separately rather than being included in focus groups.
Procedure Email invitations were sent to potential focus group participants. Questions were prepared prior to conducting the focus groups and the interviews. However, to facilitate the natural flow of the conversation and keeping to topic, there was flexibility in the order of questioning (Krueger & Casey, 2000). All interviews were audio recorded, with participant informed consent, and a scribe taking notes, with pseudonyms used to uphold confidentiality.
Analysis The interview audio recordings were transcribed verbatim by the researcher and analysed using a constant comparison approach in which codes were assigned to relevant statements across all interviews and focus groups, codes were categorised and finally main themes determined (Onwuegbuzie, Dickinson, Leech & Zoran, 2009). A qualitative software analysis program, NVivo 9.2, was used as a tool throughout data analysis (QSR International, 2010). Trustworthiness of data collected was achieved through reflective journaling (Shenton, 2004) and with © 2013 Occupational Therapy Australia
the research supervisor independently analysing both focus group transcripts, to confirm credibility of thematic analysis process. Emerging themes were discussed, and transcripts were re-read by the principal researcher and the research supervisor for additional themes or alterations until consensus was reached for final themes. Stakeholder checking was employed to enhance the study’s credibility with participants responding to an email of the theme summary, to ensure accurate theme interpretation and description (Lysack, Luborksy & Dillaway, 2006). Triangulation, by employing two methods of data collection and recording field notes increased the dependability of the study (Lysack et al.).
Results Phase two: Focus groups and interviews From all interviews and focus groups three main themes were identified, with the first theme having four subthemes. The first main theme included the need for occupational therapists to increase time spent in the school with subthemes including (i) to explain the occupational therapy role more effectively; (ii) to build relationships; (iii) for the occupational therapist to better understand the child in their occupational contex; and (iv) make more realistic recommendations by considering the teacher role and responsibilities. The second theme included for the occupational therapists to not see themselves as the expert and the third theme
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TABLE 4: Example of phase one question results informing phase two focus group and interview questions Teacher question examples
Occupational therapy question examples
Informed by close ended question results in a particular direction and themes from open ended question results
The majority indicated that the professional development in 2010 by [Occupational therapist] was a valuable experience to learn more about occupational therapy. The question asked was: What were some things that you learnt from the professional development by the occupational therapist? The majority indicated that observing an occupational therapist/student working with a child was most valuable. The question asked was: Can you discuss how observing an occupational therapist/ student working with a child was valuable?
Informed by inconsistent close ended question results
Can you provide more information about what things helped or prevented you from being part of the occupational therapy process?
The majority indicated that observing teachers and classroom activity was most valuable. The question asked was: Can you discuss how observing teachers and classroom activity was valuable? Many indicated informal meetings as the most effective method of communication The question asked was: Can you provide more insight into the value of informal meetings as an effective method of communication? What are some things that were good or not so good about using written reports to communicate a child’s progress to a teacher?
included the occupational therapist needing to take on the role of ensuring all parties are included.
The need for occupational therapists to increase time spent at the school To explain the occupational therapy role more effectively Several teachers discussed their limited knowledge about the role of occupational therapy prior to the school based occupational therapy program. This was reflected in comments such as, ‘I had no idea they did anything with school kids …’ (Kelsey, teacher) and ‘I thought, children don’t have an occupation… they don’t work…. Why do they need an occupational therapist?’ (Celine, teacher). Two teachers commented that throughout their teaching careers they had not previously had contact with an occupational therapist, ‘I’ve been doing this for 30 years and I’ve never seen an occupational therapist before coming to this school’ (Gerald, teacher). Other participants reported some contact with community occupational therapists, but they had not provided the teachers with much education about the occupational therapy role. This was reflected in phrases such as, ‘And really I don’t know what they’ve done, they’ve just said, ‘we need a room, we need to be on our own in private’’ (Liz, teacher interview). Several teachers reported increased knowledge about occupational therapy due to the school based program
because of the increased consistency of contact and opportunity for therapists to explain their role. Karen commented that, ‘It’s only in this environment where I’ve found out more about what’s available in terms of occupational therapy’ (teacher interview). Both groups reported that the occupational therapy role was best understood through the provision of practical handson personal development sessions run by the occupational therapist, by teachers observing occupational therapy in action, and seeing the benefits of occupational therapy recommendations and resources being provided. Several teachers commented that knowing more about the role of occupational therapy made them feel more confident in referring a child, and in explaining the importance and purpose of occupational therapy support to the child’s parent. Occupational therapists reported teachers being less defensive and more enthusiastic about their input, making more appropriate occupational therapy referrals, and being more receptive to incorporating recommendations into the curriculum.
To build relationships Several teachers commented that they had not built relationships with community occupational therapists who also worked with children in the school because of inconsistent contact, absence of school visits and the occupational therapists assuming an expert role. This was described by Lauren ‘You know I might have Joe Blogs this year, his undergoing, you know…works with © 2013 Occupational Therapy Australia
154 [therapy services], and so occupational therapist (a) and speech therapist (a) come in and see me, but then next year I’ve got student, you know, Fred who’s seeing [therapy services], and occupational therapist (b) comes in with speechie (c), so there’s no relationships able to be built up’ (teacher). In contrast with experiences with community occupational therapists, teachers discussed the benefits of consistent contact to relationship building with school based occupational therapists. Bree commented, ‘And we have had that positive experience with the occupational therapy students, because they are in a lot’ (teacher). This was supported by the occupational therapists with previous community experience who spoke of the importance of being available to teachers to enable consistency and facilitate relationship building. Both groups reported a major benefit of relationship building being that teachers were more receptive to occupational therapy. Liz commented ‘I do wonder whether I would have been as receptive if I hadn’t had the relationship with Beth [occupational therapist]’ (teacher interview). Both groups raised a further benefit that teachers felt more comfortable seeking information from a familiar occupational therapist, which added to their understanding and fostered collaboration. This was reflected in comments such as ‘…and the result of that is that, you know, people will ask me about stuff’ (Beth, occupational therapist interview), and ‘…we feel more comfortable going to her’ (Lauren, teacher).
For the occupational therapist to better understand the child in their occupational context Many teachers discussed the need for occupational therapists to understand how a classroom can vary at different times. Several teachers made comments about their frustration when occupational therapists visit for a short timeframe on one day, and generalise this to what the classroom is like every day, with Janice commenting, ‘…there’s no such thing as a normal day…’ (teacher). Occupational therapists supported this, reporting on the influence of teaching styles, environmental preferences, timetables and the way a particular cohort of children may interact. Both occupational therapists and teachers reported on likely differences in a child’s behaviour in a clinic with minimal distractions compared to within the classroom. The occupational therapists discussed the importance of knowing more about the child’s occupational context providing examples of where this information was crucial to the intervention plan. ‘But like even one teacher was really softly spoken, and you don’t know that unless you’re there in the classroom…’ (Renee, occupational therapist), ‘And the physical nature, like he could never find his work, and you’d open up his big drawer, and you’re just like, ‘whoa!’’ (Aden, occupational therapist). Many occupational therapists made comments © 2013 Occupational Therapy Australia
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about the risk of not achieving occupational therapy goals if the occupational environment was not considered ‘…but as soon as you put a child into their true occupational environment, which is where they have to perform, and they can’t do it, you’ve wasted your time’ (Beth, occupational therapy interview).
Considering the teacher role and responsibilities to make more realistic recommendations Teachers discussed that the recommendations made by occupational therapists were at times, ‘brilliant ideas on paper’ (Celine, teacher), but often impractical in terms of the teacher’s responsibilities and the realities of the classroom environment, school and Education Department expectations. Lauren commented, ‘But without that school experience…these people don’t know …’ (teacher). Teachers’ frustrations with impractical recommendations were evident in comments such as, ‘If you’ve referred 5 or 6 students in your class, and that’s 10 minutes for each, there’s a big gap out of the session’ (Wilma, teacher) and ‘You just can’t find that 10 minutes…’ (Lauren, teacher). Similar comments were made by occupational therapists with Beth commenting ‘Well 10 minutes out of a day when you’ve got a class of 30 odd kids, is a lot of time’ (occupational therapist interview). Both participant groups reported that the reality was that impractical recommendations were least likely to be implemented. All participants reported that whole class strategies were easier to integrate into the daily classroom routine. Lauren commented, ‘I can pick that up and the whole class can do it, and you’ve got a lot more chance of me doing that than doing a one on one program’ (Teacher). Developing strategies that enabled the child to take responsibility for implementation was seen as being particularly beneficial, ‘That was something that he could do and it didn’t necessarily need the teacher for that’ (Helen, occupational therapist). Both reported that therapy recommendations in the reports needed to be, ‘…brief, clear, to the point’ (Alan, occupational therapist), and ‘If you are recommending that kids need like lists of things, or if they need it in an order, provide them with an example to go off, because they don’t have time to make one’ (Kate, occupational therapist). Teachers also added that therapists then need to make themselves available if teachers needed to clarify information.
Not seeing themselves as an expert Several teachers discussed the frustration experienced with community occupational therapists often clearly assuming the expert role in the relationship, without acknowledging the teacher’s perspective. Comments included phrases such as, ‘I felt quite disempowered cause you’re always having an expert telling you and you’re just the person in the middle of the pie and you’re getting told this and that’ (Bree, teacher), and
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‘Please don’t come in and tell me what’s going on because I’ve only been doing this for 18 years so I’m starting to get a bit of a handle on it’ (Lauren, teacher). Their experience working in the school had helped the occupational therapists realise that taking on the expert role was not effective in achieving successful occupational therapy outcomes in the classroom setting. Kate commented that, ‘…and not going in there as a ‘super hero’, trying to fix everything, because you can’t’ (occupational therapist). Both groups commented that a supportive and equal approach was more effective in fostering collaboration to optimise outcomes. Alan commented, ‘…You work together, they’re involved in it, and you’re not just going there and telling them what you are going to be doing, but asking them’ (occupational therapist focus group). Teacher comments reflected a similar view on the effectiveness of a more equal relationship, ‘It’s always felt very much like a support…and it’s been very much a collaborative thing’ (Bree, teacher). Teachers and occupational therapists discussed the importance of setting goals together, so that the occupational therapy goals related to the teacher’s goals for the child. Yvette commented, ‘So that the occupational therapist knows what we’re aiming for and we know what they’re aiming for…’ (teacher). Occupational therapists also highlighted the importance of providing their clinical reasoning for how recommendations could link with the teacher’s goals as this increased the chance teachers would implement the recommendations as they better understood how it could assist the child or support their teaching. Kate commented, ‘…if you could link it back, and show them the bigger picture …’ (occupational therapist).
Taking a role of ensuring all parties are included Teachers discussed their experiences of often being excluded from the therapy process when it occurred outside the school setting, often because the parent did not inform the teacher they were seeking these services and the community occupational therapists did not make contact with the teacher either. Teachers reflected with comments such as, ‘…unless the parent tells you, you don’t even know if they’re going’ (Melissa, teacher), and ‘There can only really be communication if the parent lets you know’ (Celine, teacher). This exclusion left them feeling responsible if the child was not progressing, as the parent had expected change because of the occupational therapist’s recommendations, even though they were made without teacher consultation. Lauren commented ‘…these occupational therapists then go to the parents, ‘Okay so your teacher’s now got this so you should see the results happening in class in the next couple of weeks’, and you go gee thanks for selling me out, because now I’m going to appear like a really crap teacher’ (teacher). Teachers also commented on the
frustration of receiving occupational therapy reports with recommendations that teachers were already implementing in the classroom. Kelsey commented, ‘… and I think well gosh, what was the point in all that?’ (teacher). An important long-term benefit of all parties being included/collaborating in the therapy process was the gradual increased understanding of each other’s roles. Several participants commented that after working closely together for a period of time, they were able to view the child from both an occupational therapy and education perspective, instead of just focussing solely on their particular area. Liz commented, ‘I just look at children so differently. I think I look at it a bit through education eyes and a little bit through occupational therapy eyes now…’ (teacher interview). Both groups commented that they thought it was the occupational therapist who was often in the position to advocate for all parties to work together so that all parties felt empowered and confident to consistently implement recommended strategies.
Discussion The study purpose was to investigate the perspectives of an occupational therapist, occupational therapists who were final year students at the time of their participation in the school program and teachers working together in an Australian school, to be able to inform community occupational therapists of collaboration in action. The perspectives from this study have supported the need for occupational therapists to not give up on collaboration, as it was found to be vital to teachers implementing occupational therapy recommendations in the school. Several important messages for occupational therapists seeking to provide occupational therapy that enables a child to increase performance and participation at school emerged from this study. The findings revealed that occupational therapists needed to spend more time at the school, but as reported by Friend (2000) and Bose and Hinojosa (2008) simply going to the school did not equate to collaboration. The experiences of both groups in this study clearly highlighted that collaborative practice was enhanced when the occupational therapist spent more time in school explaining their role, and building rapport and forming an equal relationship which resulted in increasing the teachers’ responsiveness to their recommendations. Understanding of each other’s role was further enhanced by seeing how each other worked in the school environment. Presence in the school environment further encouraged collaboration as it provided the therapist with key information about the demands and routines of the classroom which enabled more realistic expectations to be set by the therapist. This study supported Hinder and Ashburner’s (2010) statement that essential infor© 2013 Occupational Therapy Australia
156 mation about enablers and barriers to the child’s occupational performance could only be identified by seeing the child in the classroom context and without that, recommendations were often inappropriate (Vincent et al., 2008). Being in the school environment also provided the therapist with opportunities to seek the teacher’s expertise, resulting in less perception by the teacher that the therapist was assuming an expert role. These findings highlighted that realistic recommendations were not just about seeing the child in the school environment but that occupational therapists have an obligation to understand the teacher’s role, the role of the school and as Villeneuve (2009) noted, it was vital to understand the curriculum, policies and classroom practices if the recommendations were to be educationally relevant. As reported, the occupational therapist being present was not enough on its own to overcome barriers to collaboration. Kennedy and Stewart (2012) reported that community occupational therapists did not view themselves as taking on an expert role. However, this was in stark contrast with the views of the teachers in the current study who reported strong feelings of frustration and inequality when community occupational therapists did visit the school, and when they only communicated with them indirectly through reports or only through the child’s parent. The lack of collaboration was most evident in teachers reporting that they often were not informed that a child in their classroom was receiving occupational therapy in the community. Teachers reported that parents were often resistant to even providing this verbal information, and speculated a sense of parent ownership over the occupational therapy services as it was funded privately. While parents have a right to determine how they share information about their child, given that parents and therapists then expect the teacher to act on the therapist’s recommendations it seems that therapists may be missing an opportunity early on in building their relationship with the parent, to advocate for teacher, parent and therapist collaboration to foster successful therapy outcomes. Importantly, the occupational therapists in the school also reported that it was very easy to forget to include the absent party, in their case, the parent. While occupational therapists might not view themselves as the experts, and while care needs to be taken in generalising the findings from this pilot study, occupational therapists perhaps do need to reflect on how their lack of contact with schools, and what they do if they do visit the school, and their reliance on written reports might be interpreted by teachers. From the teacher perspective, limited or no contact meant that teacher expertise, experience, knowledge of the child, and perspectives were not being taken into account resulting in a further barrier to collaboration, which supported findings by Bose and Hinojosa (2008). © 2013 Occupational Therapy Australia
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The study provided support for the findings by Spencer et al. (2006) that occupational therapists who worked collaboratively with teachers were more likely to set goals that supported the child’s participation rather than being component focused. However, providing clinical reasoning and making the benefits clear, further increased the likelihood that teachers would implement recommendations. Further to this, teachers and therapists in this study reported a responsibility to write reports and make recommendations that were brief, practical, and used appropriate terminology and to develop mutually agreed goals and, where possible, whole class strategies were seen as most easily implemented. To best share information about the child’s progress and to set goals, having an effective referral form, having formal or informal meetings, and regular review of goals, recommendations and strategies, and encouraging all parties to communicate were seen as being important. Failure to meet this responsibility was regarded as a significant barrier to collaboration as it resulted in teachers not implementing occupational therapy recommendations, confirming findings of earlier studies (Bose & Hinojosa, 2008; Vincent et al., 2008). From this study’s findings it appeared that the occupational therapists might be in the best position to advocate for improved collaboration but they perhaps do not see the lack of collaboration as a major concern which was a finding in the study by Kennedy and Stewart (2012). Further to this it was also suggested that service providers who employ a number of community occupational therapists, should make an effort to have the same therapists assigned to work with children from the same school, so that over time they foster relationships to enable more cost effective communication methods and improved child outcomes.
Limitations and future research Further research is required to add to the limited Australian research base and to employ methods to increase the generalisation of the preliminary findings of this study. Descriptive statistics were deemed appropriate for analysis of phase one study findings due to meeting the study purpose; however, it would be beneficial for future studies to test the newly constructed questionnaire for reliability and validity and to aim for a larger sample size to complete analysis beyond descriptive statistics. A limitation of this research was that the majority of occupational therapy participants were final year occupational therapy students at the time of their experience and were reporting retrospectively after graduating as occupational therapists. However, one significant advantage of using this research context was that the rotational placement of final year occupational therapy students in the school throughout the research period provided teachers with repeated exposure to explanations of the role of occupational therapy and various styles of collaborative practice. A key competency
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requirement for the students was to demonstrate collaborative practice (Curtin University School of Occupational Therapy and Social Work, 2011). Future research involving a larger sample size and all participants reporting on current practice contexts would better support generalisability as participants in this study mainly reported retrospectively on their experiences, although it is important to note that the majority of study participants including the teachers and supervising occupational therapist were still working in the practice setting explored.
Conclusion This study described the perspectives of school based occupational therapists and teachers within a unique environment, to find out more about collaborative practice with the aim of informing community practice. This study highlighted that a greater effort was needed by Australian occupational therapists to increase the implementation of collaborative practice by spending more time in the school, working with parents to involve all parties in the therapy process, communicating and reporting in clear language with recommendations relevant to the school context. These strategies along with working to understand the role of the teachers and the demands of the environment, building relationships based on recognition of mutual expertise are likely to further enhance collaborative practice. Findings from this study provided a basis for future research into occupational therapists actively implementing strategies to increase collaboration to enable all Australian children at educational risk to achieve optimal outcomes in performance and participation in their school roles. Importantly, this study provides clinicians and undergraduates with the approaches very necessary for collaborative practice.
Acknowledgements We would like to thank the school principal, teachers and occupational therapists for the time they have taken to participate in this study questionnaire, focus group and interviews, and checking themes for accuracy.
References Barnes, K. J. & Turner, K. D. (2001). Team collaborative practices between teachers and occupational therapists. The American Journal of Occupational Therapy, 55 (1), 83– 89. Bose, P. & Hinojosa, J. (2008). Reported experiences from occupational therapists interacting with teachers in inclusive early childhood classrooms. The American Journal of Occupational Therapy, 62 (3), 289–297. Case-Smith, J. & Holland, T. (2009). Making decisions about service delivery in early childhood programs. Language, Speech and Hearing Services in Schools, 40 (4), 416–423.
157 Chen, Q., Hughes, J. N., Liew, J. & Kwok, O.-M. (2010). Joint contributions of peer acceptance and peer academic reputation to achievement in academically at-risk children: Mediating processes. Journal of Applied Developmental Psychology, 31 (6), 448–459. Cook, L. & Friend, M. (2010). The state of the art of collaboration on behalf of students with disabilities. Journal of Educational and Psychological Consultation, 20 (1), 1–8. Curtin University School of Occupational Therapy and Social Work. (2011). Occuational therapy fieldwork manual. Perth: Curtin University. Department of Families, Housing, Community Services and Indigenous Affairs (2009). Better start for children with disability (better start) initiative. Retrieved 7 October, 2011, from http://www.fahcsia.gov.au/sa/disability/progserv/ people/Pages/better_start_early_intervention.aspx Driscoll, D. L., Appiah-Yeboah, A., Salib, P. & Rupert, D. J. (2007). Merging qualitative and quantitative data in mixed methods research: How to and why not. Ecological and Environmental Anthropology, 3 (1), 19–28. Dule, K., Korner, H., Williams, J. & Carter, M. (1999). Delivering therapy services for students with high support needs: Perceptions of roles, priorities and best practice. Journal of Intellectual and Developmental Disability, 24, 243–263. Friend, M. (2000). Myths and misunderstandings about professional collaboration. Remedial and Special Education, 21 (3), 130–132. Gardynik, M. U. & McDonald, L. (2005). Implications of risk and resilience in the life of the individual who is gifted/learning disabled. Roeper Review, 27 (4), 206–214. Hinder, E. A. & Ashburner, J. (2010). Occupation-centred intervention in the school setting. In: S. Rodger (Ed.), Occupation-centred practice with children: A practical guide for occupational therapists (pp. 228–230). Oxford: Wiley-Blackwell. Kelle, U. (2006). Combining qualitative and quantitative methods in research practice: Purposes and advantages. Qualitative Research in Psychology, 3 (4), 293–311. Kemmis, B. L. & Dunn, W. (1996). Collaborative consultation: The efficacy of remedial and compensatory interventions in school contexts. The American Journal of Occupational Therapy, 50 (9), 709–717. Kennedy, S. & Stewart, H. (2011). Collaboration between occupational therapists and teachers: Definitions, implementation and efficacy. Australian Occupational Therapy Journal, 58 (3), 209–214. Kennedy, S. & Stewart, H. (2012). Collaboration with teachers: A survey of South Australian occupational therapists’ perceptions and experiences. Australian Occupational Therapy Journal, 59 (2), 147–155. Krueger, R. A. & Casey, M. A. (2000). Focus groups (3rd ed.). Thousand Oaks: Sage Publications. Luo, W., Hughes, J. N., Liew, J. & Kwok, O. (2009). Classifying academically at-risk first graders into engagement types: Association with long-term achievement trajectories. The Elementary School Journal, 109 (4), 380–405. Lysack, C., Luborksy, M. R. & Dillaway, H. (2006). Overview of qualitative research. In: G. Kielhofner (Ed.),
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158 Research in occupational therapy: Methods of inquiry for enhancing practice (pp. 341–357). Philedelphia: F. A. Davis. McWilliam, R. A. (1995). Integration of therapy and consultative special education: A continuum in early intervention. Infants and Young Children, 7 (4), 29–38. Nochajski, S. M. (2001). Collaboration between team members in inclusive educational settings. Occupational Therapy in Health Care, 15 (3–4), 101–112. Onwuegbuzie, A. J., Dickinson, W. B., Leech, N. L. & Zoran, A. G. (2009). A qualitative framework for collecting and analyzing data in focus group research. International Journal of Qualitative Methods, 8 (3), 5–6. Portney, L. G. & Watkins, M. P. (2009). Descriptive statistics. In: L. G. Portney & M. P. Watkins (Eds.), Foundations of clinical research: Applications to practice (3rd ed., pp. 285–403). Upper Saddle River: Pearson Prentice Hall. QSR International (2010). NVivo 9. Retrieved 10 September, 2012, from http://www.qsrinternational.com/products_ previous-products_nvivo9.aspx Rodger, S., Brown, G. T. & Brown, A. (2005). Profile of paediatric occupational therapy practice in Australia. Australian Occupational Therapy Journal, 52 (4), 311–325.
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Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22 (2), 63–75. Spencer, K. C., Turkett, A., Vaughan, R. & Koenig, S. (2006). School-based practice patterns: A survey of occupational therapists in Colorado. The American Journal of Occupational Therapy, 60 (1), 81–91. Villeneuve, M. (2009). A critical examination of schoolbased occupational therapy collaborative consultation. The Canadian Journal of Occupational Therapy, 76, 206–218. Vincent, R., Stewart, H. & Harrison, J. (2008). South Australian school teachers’ perceptions of occupational therapy reports. Australian Occupational Therapy Journal, 55 (3), 163–171. Western Australian Department of Education (2007). Review of educational services for students with disabilities in government schools. Retrieved 6 October, 2011, from http://www.det.wa.edu.au/education/disrev/action plan.htm Zubrick, A. (2000). Students at educational risk. In: Department of Education, Training and Youth Affairs (Ed.), The impact of educational research (pp. 322–323). Canberra, ACT: Commonwealth of Australia.
doi: 10.1111/1440-1630.12093
Research Article
Investigating the experiences in a school-based occupational therapy program to inform community-based paediatric occupational therapy practice Lezahn Rens1 and Annette Joosten2 1 School of Occupational Therapy and Social Work, Curtin University, and 2School of Occupational Therapy and Social Work, Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
Background/aim: A collaborative approach with teachers is required when providing community-based occupational therapy to educationally at risk children. Collaborators share common goals and interact and support each other but challenges arise in providing collaborative occupational therapy in settings outside the school environment. The aim of this study was to capture experiences of teachers and occupational therapists working within a schoolbased occupational therapy program to determine if their experiences could inform collaborative practice. Method: In this pilot study, participant responses to questionnaires (n = 32) about their experiences formed the basis for focus groups and individual interviews. Two focus group were conducted, one with teachers (n = 11) and one with occupational therapy participants (n = 6). Individual interviews were conducted with the supervising occupational therapist, school principal and two leading teachers. Descriptive statistics were used to analyse the data from closed questions, and thematic analysis using a constant comparison approach was used to analyse open ended questions, focus groups and interviews. Results: Three main themes emerged: (i) the need for occupational therapists to spend time in the school, to explain their role, build relationships, understand classroom routines and the teacher role; (ii) occupational therapists need to not see themselves as the expert but develop equal partnerships to set collaborative goals and (iii) occupational therapists advocating for all parties to be informed throughout the occupational therapy process. Lezahn Rens BSc (Hons); Occupational Therapist. Annette Joosten PhD; Senior Lecturer. Correspondence: Annette Joosten, School of Occupational Therapy and Social Work, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia. Email: [email protected] Accepted for publication 7 October 2013. © 2013 Occupational Therapy Australia
Conclusion: The pilot study findings identified teacher and therapist experiences within the school setting that could inform improved collaborative practice with teachers and community-based occupational therapists and these findings warrant further investigation. KEY WORDS children, collaboration, community based, occupational therapists, school based, teachers.
Introduction Participation in school requires children to be a student, classmate, self-maintainer, player and friend in the dynamic environments of the classroom and playground (Case-Smith & Holland, 2009). Ideally, intervention to support performance and participation in these roles is best provided in the school setting to ensure best intervention outcomes. However, limitations in funding and in the availability of occupational therapy often result in these services being provided in community settings and private practice (Rodger, Brown & Brown, 2005). Best practice occupational therapy with school aged children is dependent on both the quality of direct intervention with the child, and the indirect strategies implemented to ensure that any progress that occurs in direct intervention is successfully transferred to the child’s occupational roles in everyday settings (Case-Smith & Holland; Spencer, Turkett, Vaughan & Koenig, 2006). Given teachers are the key adults in the child’s school it is vital that occupational therapists collaborate to ensure transfer and generalisation of new skills occur (Barnes & Turner, 2001; Kemmis & Dunn, 1996; Nochajski, 2001). Several definitions of collaboration exist and they vary between professions. However, common features of collaborative practice are that it involves two equal parties adopting a style based on respect and trust, and voluntarily sharing responsibility and accountability and working to build community (Cook & Friend, 2010). Villeneuve (2009) in a Canadian study proposed
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two main requirements necessary for collaboration between occupational therapists and teachers. First, it was suggested teachers needed to understand the occupational therapy role and in turn, occupational therapists needed to understand the educational system and school policies to ensure therapy was relevant and educationally focused. Secondly, both parties required the opportunity and time for formal and informal meetings to discuss individualised interventions. Very few studies have investigated collaboration in the school context in Australia (Kennedy & Stewart, 2011). Bose and Hinojosa (2008) agreed with the need for meetings but highlighted that meetings only enhanced collaboration when there was good communication and an ability and willingness to resolve conflicts. They further added that collaboration was threatened when occupational therapists were perceived as thinking they were the experts or did not personally seek to be collaborative. Kennedy and Stewart (2012) reported that therapists agreed about requirements for good collaboration but noted that this did not make it happen, and that therapists were not necessarily concerned or dissatisfied with lesser degrees of collaboration. The variation in school settings, children’s needs and the availability of funding and resources has resulted in the development of many different models for providing therapy services to school age children in the Australian context rather than there being an identifiable best practice model. The Australian government recognises the importance of occupational therapy by providing funding and school services for some groups of children, particularly those with diagnosed disabilities (Department of Families, Housing, Community Services and Indigenous Affairs, 2009). However, the current funding allocations and program policies, result in very few occupational therapists being employed in Australian schools (Western Australian Department of Education, 2007). When children are educationally at risk and require assistance to reach educational and extracurricular goals for reasons that may be complex, vague, or unexplained but do not meet disability diagnostic criteria, they are usually ineligible for funding (Chen, Hughes, Liew & Kwok, 2010; Gardynik & McDonald, 2005; Luo, Hughes, Liew & Kwok, 2009; Zubrick, 2000). As a consequence they often see occupational therapists in community settings, disconnected from the school environment (Rodger et al., 2005). Often without direct contact with teachers, community based occupational therapists rely on their written reports to convey information about the child’s progress, and provide recommendations to ensure skills are transferred to the child’s school environment (Barnes & Turner, 2001; McWilliam, 1995). An Australian study by Vincent, Stewart and Harrison (2008) highlighted difficulties with this process as teachers reported that occupational therapy reports were of limited value without further contact with occupational
therapists. Available literature is largely based on international contexts and indicates that collaborative practice, while reportedly desired was not always implemented or there were limitations in its implementation (Barnes & Turner; Dule, Korner, Williams & Carter, 1999; Villeneuve, 2009). The study by Kennedy and Stewart (2012) published after the current study commenced confirmed the inconsistencies in implementation in the Australian context and the need for further research. To gain information about collaboration within the Australian context this study investigated the perspectives of teachers, an occupational therapist and final year occupational therapy students in a school based occupational therapy program in Western Australia. This occupational therapy program provided all educationally at risk students (who did not have funding or individualised education plans) the opportunity to receive occupational therapy in the school setting. This study aimed to determine whether the experiences of a school based occupational therapy program, could inform the practices of community based occupational therapists within an Australian context. The following objectives were set: What were the possible barriers and enablers to successful collaboration between occupational therapists and teachers regarding effective occupational therapy intervention in the school environment? From the perspectives of the occupational therapist, final year occupational therapy students and teachers: What communication methods were most effective or ineffective in transferring information between occupational therapists and teachers regarding the progress of a child? What experiences best informed participants’ perceptions of each other’s roles? What learnt facts regarding each other’s roles, were most helpful to collaborative practice?
Methods Design This study utilised a mixed methodology approach of sequential quantitative-qualitative methods, with a questionnaire in phase one, and focus groups and interviews in phase two (Driscoll, Appiah-Yeboah, Salib & Rupert, 2007; Kelle, 2006). This methodology allowed the collection of opinion from a larger group prior to gaining more in-depth opinions from a smaller sample of participants. This particular study design was used to help identify the questions which would be further © 2013 Occupational Therapy Australia
150 investigated using qualitative data collection and analysis, and to ensure that the focus of the qualitative component was appropriate (Kelle). In addition to the rating scale responses, open questions on the questionnaire ensured that participants had the opportunity to raise any other areas they thought were important to collaboration. A search of the literature to find any existing questionnaires, revealed a survey by Dule et al. (1999) and although it was in an Australian context, it did not meet the aim of this study as it was designed to evaluate service delivery by therapists coming in to the school to see funded children with high needs rather than being based in the school and available to all educationally at risk children. Only a small number of items related to collaboration and sought only the therapists’ perspectives about an established therapy program for each child. A further questionnaire developed for the American context (Barnes & Turner, 2001) was also mainly evaluation based and only sought the teacher perspective. Therefore, a questionnaire was developed for this study which was based on relevant information from these and other studies (Bose & Hinojosa, 2008; Nochajski, 2001; Spencer et al., 2006; Villeneuve, 2009) to improve content validity. The purposes of the questionnaire were to obtain a broader picture of the whole school perspective, to confirm if the issues discussed in the literature, which was mainly internationally based, were relevant to this therapy context and to ensure relevant issues were discussed in the focus groups. Ethics approval was obtained from the Curtin University Human Research Ethics Committee (using Form A), and the Department of Education (Western Australia) prior to commencement of data collection.
Phase one: Questionnaire Participants and procedure The school provided school based occupational therapy services through a rare arrangement with an occupational therapist working in the school, providing supervision to final year occupational therapy students on fieldwork placement, from Curtin University in Western Australia. Final year occupational therapy students complete four 7-week fieldwork placements, during which they are required to demonstrate graduate entry occupational therapy competencies, including collaborative practice (Curtin University School of Occupational Therapy and Social Work, 2011). With four fieldwork rotations yearly, school leaders and teachers were repeatedly exposed to education about occupational therapy and varying styles of collaborative practice. Invitations with information packs were mailed to eligible occupational therapy participants (n = 13) including the supervising occupational therapist, and occupational therapy students who completed final year fieldwork placements at the school in 2010–2011. The © 2013 Occupational Therapy Australia
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occupational therapy students will be referred to as occupational therapists in this study as they were registered occupational therapists at the time of data collection, responding retrospectively to their experience as part of the occupational therapy team at the school. Ten occupational therapists (eight women; two men), including the therapist with 20 years of experience in paediatric occupational therapy in community and schoolbased services, and seven occupational therapists with 6–18 months experience as registered occupational therapists, provided consent and completed the occupational therapy questionnaire. Following a presentation about the study, information packs were placed in the pigeon holes of all 38 teachers teaching at the school. Teachers who provided consent and completed the teacher questionnaire (n = 22; 21 women; 1 men), participated in the study. Nineteen of the teachers had taught at the school since at least 2010 with 17.36 mean years of teaching experience. Individual participant identification codes were used on all questionnaires to ensure anonymity was maintained.
Questionnaire format The questionnaires were based on information from current literature on collaboration, with the majority of the studies being set in the USA context. Primarily, closed ended questions were used in both questionnaires, with all closed ended questions being phrased the same way, ‘to what extent do you agree ‘or ‘to what extent does this situation happen to you’ and a 5-point Likert scale was used.
Analysis Descriptive statistics were used to analyse the frequency and variability of occupational therapist and teacher responses for each closed ended question (Portney & Watkins, 2009). The purpose of this analysis was to understand the pattern of responses so that questions with high consistency (at either end of the scale) and questions with variable responses could be identified and explored further in the next phase. Results to each question were treated as a continuous scale of agreement from 1 to 5 on the Likert scale of responses, with mean scores close to 1 indicating disagreement, and closer to 5 indicating agreement. Analysis beyond descriptive statistics was not completed, and would have been inappropriate when considering the small sample size, difference between sample size and that reliability and validity had not been tested for the questionnaire used.
Results Phase one: Questionnaire Teacher questionnaire Some of the close ended question responses specific to the teacher questionnaire are presented in Table 1.
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Open ended questionnaire responses relating to teachers’ understanding of occupational therapy identified the importance of professional development opportunities, observation of the occupational therapist/ students in action, seeing occupational therapy benefits, having an effective referral form and short and easy strategies. Teachers reported that occupational therapists gained an understanding of the teacher role by: occupational therapists seeking information about the classroom structure, timetable, and school expectations, year level academic expectations; and visiting the classroom at different times. Answers to questions about maximising collaboration included: occupational therapist and teacher exchanging contact information; key stakeholders all getting the same information; and regular therapy plan reviews.
Occupational therapy questionnaire Some of the closed ended question responses specific to the occupational therapy questionnaire are presented in Table 2. Open ended question responses about increasing teachers’ understanding of occupational therapy included: providing information about the role of occupational therapy, communicating an occupational focus and explaining clinical reasoning. On increasing occupational therapists’ understanding of the teacher role they focused on: the importance of seeking information TABLE 1: Some of the close ended question results of teacher participants (n = 22) regarding role understanding Understanding the occupational therapy role To what extent have you become aware of the role of occupational therapy in the school from The occupational therapist directly (M = 4.55, SD = 0.96) Written material from the occupational therapist (M = 3.5, SD = 1.19) Occupational therapy student (s) directly (M = 3.5, SD = 1.50) Written material from occupational therapy student (s) (M = 1.55, SD = 0.91) Parent/caregiver (M = 2.17, SD = 1.64) Understanding of the teacher role To what extent do you think occupational therapists understand the role of the teacher in terms of Time constraints to implement intervention strategies (M = 4.31, SD = 0.75) Resources available (M = 4.23, SD = 0.83) Opportunities to meet with the occupational therapist/ students (M = 4.23, SD = 0.83) Opportunities to meet with the child’s parents (M = 4, SD = 0.60) M, mean scores; SD, standard deviations.
TABLE 2: Some of the close ended questionnaire results of occupational therapy participants (n = 10) regarding role understanding Understanding of the occupational therapy role To what extent did you find the following communication methods used effective to communicate your role Formal Meetings (M = 3.50, SD = 1.18) Informal meetings (M = 4.70, SD = 0.48) Written material (M = 3.60, SD = 0.52) Understanding of the teacher role To what extent do you feel your perception of the role of a teacher has changed throughout your experience at this school? (M = 3.30, SD = 1.52) To what extent do you feel your experience at this school has informed your future practice of working within a team? (M = 3.90, SD = 0.57) To what extent do you feel your experience of working within a school-based program may be beneficial to other occupational therapists working with school-aged children? (M = 4.8, SD = 0.42) M, mean scores; SD, standard deviations.
regarding teacher responsibilities, school and department priorities and time restrictions; importance of increasing time spent at the school and initiating discussions with teachers about roles. Questions about maximising collaboration included: having mutual goals, increasing personal development opportunities on role understanding and the importance of building rapport with teachers. Some of the teacher and occupational therapy responses to close ended questions featured in both questionnaires are presented in Table 3.
Informing phase two Closed ended question results indicating a strong agreement or disagreement from participants as well as responses from open ended questions, informed study phase two. Phase one questions with strong responses in either direction, or with variable response patterns, were included in the focus group and interviews to further explore the pattern or variability in response but were presented in a manner designed to reduce bias in the focus group discussion. Examples of how the responses were used to develop the focus group questions are presented in Table 4.
Methods Phase two: Focus groups and interviews Participants All phase one participants were invited to participate in phase two. One focus group was conducted for occupa© 2013 Occupational Therapy Australia
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TABLE 3: Some of the closed ended questionnaire results regarding collaborative practice of occupational therapy participants (n = 10) and teacher participants (n = 15) who had children in their classroom receiving school based occupational therapy Collaborative practice
Occupational therapist/students
To what extent have you provided/been provided with M = 3.60, information regarding referrals? To what extent were the following communication methods used between students: Formal meetings M = 2.67, Informal meetings M = 4.47, Email M = 1.33, Written reports or documents M = 3.71, To what extent were the communication methods M = 4.56, used effective? To what extent was the teacher involved in Goal setting for interventions M = 3.67, Planning for intervention implementation M = 3.33, Implementing intervention strategies M = 4.00, To what extent do you believe the relationship was Mutual M = 4.56, Respectful M = 4.67,
SD = 1.27
Teachers M = 4.24, SD = 1.26
you and the teacher/occupational therapist/ SD SD SD SD SD
= = = = =
1.00 0.44 0.50 1.38 0.53
M M M M M
= = = = =
2.75, 4.50, 1.67, 3.71, 4.58,
SD SD SD SD SD
= = = = =
1.40 0.52 1.23 1.38 0.67
SD = 0.50 SD = 0.71 SD = 0.50
M = 3.54, SD = 1.39 M = 3.38, SD = 1.12 M = 3.71, SD = 1.38
SD = 0.53 SD = 0.50
M = 4.93, SD = 0.27 M = 4.93, SD = 0.27
M, mean scores; SD, standard deviations.
tional therapists (n = 6), with four women, and an age range > 25 to < 35. One focus group was conducted for teachers (n = 11), with 10 women with an age range 26 to < 35. To reduce potential influence of relationship, the occupational therapist who was a previous supervisor of other participants, the school principal and two school leaders were interviewed separately rather than being included in focus groups.
Procedure Email invitations were sent to potential focus group participants. Questions were prepared prior to conducting the focus groups and the interviews. However, to facilitate the natural flow of the conversation and keeping to topic, there was flexibility in the order of questioning (Krueger & Casey, 2000). All interviews were audio recorded, with participant informed consent, and a scribe taking notes, with pseudonyms used to uphold confidentiality.
Analysis The interview audio recordings were transcribed verbatim by the researcher and analysed using a constant comparison approach in which codes were assigned to relevant statements across all interviews and focus groups, codes were categorised and finally main themes determined (Onwuegbuzie, Dickinson, Leech & Zoran, 2009). A qualitative software analysis program, NVivo 9.2, was used as a tool throughout data analysis (QSR International, 2010). Trustworthiness of data collected was achieved through reflective journaling (Shenton, 2004) and with © 2013 Occupational Therapy Australia
the research supervisor independently analysing both focus group transcripts, to confirm credibility of thematic analysis process. Emerging themes were discussed, and transcripts were re-read by the principal researcher and the research supervisor for additional themes or alterations until consensus was reached for final themes. Stakeholder checking was employed to enhance the study’s credibility with participants responding to an email of the theme summary, to ensure accurate theme interpretation and description (Lysack, Luborksy & Dillaway, 2006). Triangulation, by employing two methods of data collection and recording field notes increased the dependability of the study (Lysack et al.).
Results Phase two: Focus groups and interviews From all interviews and focus groups three main themes were identified, with the first theme having four subthemes. The first main theme included the need for occupational therapists to increase time spent in the school with subthemes including (i) to explain the occupational therapy role more effectively; (ii) to build relationships; (iii) for the occupational therapist to better understand the child in their occupational contex; and (iv) make more realistic recommendations by considering the teacher role and responsibilities. The second theme included for the occupational therapists to not see themselves as the expert and the third theme
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TABLE 4: Example of phase one question results informing phase two focus group and interview questions Teacher question examples
Occupational therapy question examples
Informed by close ended question results in a particular direction and themes from open ended question results
The majority indicated that the professional development in 2010 by [Occupational therapist] was a valuable experience to learn more about occupational therapy. The question asked was: What were some things that you learnt from the professional development by the occupational therapist? The majority indicated that observing an occupational therapist/student working with a child was most valuable. The question asked was: Can you discuss how observing an occupational therapist/ student working with a child was valuable?
Informed by inconsistent close ended question results
Can you provide more information about what things helped or prevented you from being part of the occupational therapy process?
The majority indicated that observing teachers and classroom activity was most valuable. The question asked was: Can you discuss how observing teachers and classroom activity was valuable? Many indicated informal meetings as the most effective method of communication The question asked was: Can you provide more insight into the value of informal meetings as an effective method of communication? What are some things that were good or not so good about using written reports to communicate a child’s progress to a teacher?
included the occupational therapist needing to take on the role of ensuring all parties are included.
The need for occupational therapists to increase time spent at the school To explain the occupational therapy role more effectively Several teachers discussed their limited knowledge about the role of occupational therapy prior to the school based occupational therapy program. This was reflected in comments such as, ‘I had no idea they did anything with school kids …’ (Kelsey, teacher) and ‘I thought, children don’t have an occupation… they don’t work…. Why do they need an occupational therapist?’ (Celine, teacher). Two teachers commented that throughout their teaching careers they had not previously had contact with an occupational therapist, ‘I’ve been doing this for 30 years and I’ve never seen an occupational therapist before coming to this school’ (Gerald, teacher). Other participants reported some contact with community occupational therapists, but they had not provided the teachers with much education about the occupational therapy role. This was reflected in phrases such as, ‘And really I don’t know what they’ve done, they’ve just said, ‘we need a room, we need to be on our own in private’’ (Liz, teacher interview). Several teachers reported increased knowledge about occupational therapy due to the school based program
because of the increased consistency of contact and opportunity for therapists to explain their role. Karen commented that, ‘It’s only in this environment where I’ve found out more about what’s available in terms of occupational therapy’ (teacher interview). Both groups reported that the occupational therapy role was best understood through the provision of practical handson personal development sessions run by the occupational therapist, by teachers observing occupational therapy in action, and seeing the benefits of occupational therapy recommendations and resources being provided. Several teachers commented that knowing more about the role of occupational therapy made them feel more confident in referring a child, and in explaining the importance and purpose of occupational therapy support to the child’s parent. Occupational therapists reported teachers being less defensive and more enthusiastic about their input, making more appropriate occupational therapy referrals, and being more receptive to incorporating recommendations into the curriculum.
To build relationships Several teachers commented that they had not built relationships with community occupational therapists who also worked with children in the school because of inconsistent contact, absence of school visits and the occupational therapists assuming an expert role. This was described by Lauren ‘You know I might have Joe Blogs this year, his undergoing, you know…works with © 2013 Occupational Therapy Australia
154 [therapy services], and so occupational therapist (a) and speech therapist (a) come in and see me, but then next year I’ve got student, you know, Fred who’s seeing [therapy services], and occupational therapist (b) comes in with speechie (c), so there’s no relationships able to be built up’ (teacher). In contrast with experiences with community occupational therapists, teachers discussed the benefits of consistent contact to relationship building with school based occupational therapists. Bree commented, ‘And we have had that positive experience with the occupational therapy students, because they are in a lot’ (teacher). This was supported by the occupational therapists with previous community experience who spoke of the importance of being available to teachers to enable consistency and facilitate relationship building. Both groups reported a major benefit of relationship building being that teachers were more receptive to occupational therapy. Liz commented ‘I do wonder whether I would have been as receptive if I hadn’t had the relationship with Beth [occupational therapist]’ (teacher interview). Both groups raised a further benefit that teachers felt more comfortable seeking information from a familiar occupational therapist, which added to their understanding and fostered collaboration. This was reflected in comments such as ‘…and the result of that is that, you know, people will ask me about stuff’ (Beth, occupational therapist interview), and ‘…we feel more comfortable going to her’ (Lauren, teacher).
For the occupational therapist to better understand the child in their occupational context Many teachers discussed the need for occupational therapists to understand how a classroom can vary at different times. Several teachers made comments about their frustration when occupational therapists visit for a short timeframe on one day, and generalise this to what the classroom is like every day, with Janice commenting, ‘…there’s no such thing as a normal day…’ (teacher). Occupational therapists supported this, reporting on the influence of teaching styles, environmental preferences, timetables and the way a particular cohort of children may interact. Both occupational therapists and teachers reported on likely differences in a child’s behaviour in a clinic with minimal distractions compared to within the classroom. The occupational therapists discussed the importance of knowing more about the child’s occupational context providing examples of where this information was crucial to the intervention plan. ‘But like even one teacher was really softly spoken, and you don’t know that unless you’re there in the classroom…’ (Renee, occupational therapist), ‘And the physical nature, like he could never find his work, and you’d open up his big drawer, and you’re just like, ‘whoa!’’ (Aden, occupational therapist). Many occupational therapists made comments © 2013 Occupational Therapy Australia
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about the risk of not achieving occupational therapy goals if the occupational environment was not considered ‘…but as soon as you put a child into their true occupational environment, which is where they have to perform, and they can’t do it, you’ve wasted your time’ (Beth, occupational therapy interview).
Considering the teacher role and responsibilities to make more realistic recommendations Teachers discussed that the recommendations made by occupational therapists were at times, ‘brilliant ideas on paper’ (Celine, teacher), but often impractical in terms of the teacher’s responsibilities and the realities of the classroom environment, school and Education Department expectations. Lauren commented, ‘But without that school experience…these people don’t know …’ (teacher). Teachers’ frustrations with impractical recommendations were evident in comments such as, ‘If you’ve referred 5 or 6 students in your class, and that’s 10 minutes for each, there’s a big gap out of the session’ (Wilma, teacher) and ‘You just can’t find that 10 minutes…’ (Lauren, teacher). Similar comments were made by occupational therapists with Beth commenting ‘Well 10 minutes out of a day when you’ve got a class of 30 odd kids, is a lot of time’ (occupational therapist interview). Both participant groups reported that the reality was that impractical recommendations were least likely to be implemented. All participants reported that whole class strategies were easier to integrate into the daily classroom routine. Lauren commented, ‘I can pick that up and the whole class can do it, and you’ve got a lot more chance of me doing that than doing a one on one program’ (Teacher). Developing strategies that enabled the child to take responsibility for implementation was seen as being particularly beneficial, ‘That was something that he could do and it didn’t necessarily need the teacher for that’ (Helen, occupational therapist). Both reported that therapy recommendations in the reports needed to be, ‘…brief, clear, to the point’ (Alan, occupational therapist), and ‘If you are recommending that kids need like lists of things, or if they need it in an order, provide them with an example to go off, because they don’t have time to make one’ (Kate, occupational therapist). Teachers also added that therapists then need to make themselves available if teachers needed to clarify information.
Not seeing themselves as an expert Several teachers discussed the frustration experienced with community occupational therapists often clearly assuming the expert role in the relationship, without acknowledging the teacher’s perspective. Comments included phrases such as, ‘I felt quite disempowered cause you’re always having an expert telling you and you’re just the person in the middle of the pie and you’re getting told this and that’ (Bree, teacher), and
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‘Please don’t come in and tell me what’s going on because I’ve only been doing this for 18 years so I’m starting to get a bit of a handle on it’ (Lauren, teacher). Their experience working in the school had helped the occupational therapists realise that taking on the expert role was not effective in achieving successful occupational therapy outcomes in the classroom setting. Kate commented that, ‘…and not going in there as a ‘super hero’, trying to fix everything, because you can’t’ (occupational therapist). Both groups commented that a supportive and equal approach was more effective in fostering collaboration to optimise outcomes. Alan commented, ‘…You work together, they’re involved in it, and you’re not just going there and telling them what you are going to be doing, but asking them’ (occupational therapist focus group). Teacher comments reflected a similar view on the effectiveness of a more equal relationship, ‘It’s always felt very much like a support…and it’s been very much a collaborative thing’ (Bree, teacher). Teachers and occupational therapists discussed the importance of setting goals together, so that the occupational therapy goals related to the teacher’s goals for the child. Yvette commented, ‘So that the occupational therapist knows what we’re aiming for and we know what they’re aiming for…’ (teacher). Occupational therapists also highlighted the importance of providing their clinical reasoning for how recommendations could link with the teacher’s goals as this increased the chance teachers would implement the recommendations as they better understood how it could assist the child or support their teaching. Kate commented, ‘…if you could link it back, and show them the bigger picture …’ (occupational therapist).
Taking a role of ensuring all parties are included Teachers discussed their experiences of often being excluded from the therapy process when it occurred outside the school setting, often because the parent did not inform the teacher they were seeking these services and the community occupational therapists did not make contact with the teacher either. Teachers reflected with comments such as, ‘…unless the parent tells you, you don’t even know if they’re going’ (Melissa, teacher), and ‘There can only really be communication if the parent lets you know’ (Celine, teacher). This exclusion left them feeling responsible if the child was not progressing, as the parent had expected change because of the occupational therapist’s recommendations, even though they were made without teacher consultation. Lauren commented ‘…these occupational therapists then go to the parents, ‘Okay so your teacher’s now got this so you should see the results happening in class in the next couple of weeks’, and you go gee thanks for selling me out, because now I’m going to appear like a really crap teacher’ (teacher). Teachers also commented on the
frustration of receiving occupational therapy reports with recommendations that teachers were already implementing in the classroom. Kelsey commented, ‘… and I think well gosh, what was the point in all that?’ (teacher). An important long-term benefit of all parties being included/collaborating in the therapy process was the gradual increased understanding of each other’s roles. Several participants commented that after working closely together for a period of time, they were able to view the child from both an occupational therapy and education perspective, instead of just focussing solely on their particular area. Liz commented, ‘I just look at children so differently. I think I look at it a bit through education eyes and a little bit through occupational therapy eyes now…’ (teacher interview). Both groups commented that they thought it was the occupational therapist who was often in the position to advocate for all parties to work together so that all parties felt empowered and confident to consistently implement recommended strategies.
Discussion The study purpose was to investigate the perspectives of an occupational therapist, occupational therapists who were final year students at the time of their participation in the school program and teachers working together in an Australian school, to be able to inform community occupational therapists of collaboration in action. The perspectives from this study have supported the need for occupational therapists to not give up on collaboration, as it was found to be vital to teachers implementing occupational therapy recommendations in the school. Several important messages for occupational therapists seeking to provide occupational therapy that enables a child to increase performance and participation at school emerged from this study. The findings revealed that occupational therapists needed to spend more time at the school, but as reported by Friend (2000) and Bose and Hinojosa (2008) simply going to the school did not equate to collaboration. The experiences of both groups in this study clearly highlighted that collaborative practice was enhanced when the occupational therapist spent more time in school explaining their role, and building rapport and forming an equal relationship which resulted in increasing the teachers’ responsiveness to their recommendations. Understanding of each other’s role was further enhanced by seeing how each other worked in the school environment. Presence in the school environment further encouraged collaboration as it provided the therapist with key information about the demands and routines of the classroom which enabled more realistic expectations to be set by the therapist. This study supported Hinder and Ashburner’s (2010) statement that essential infor© 2013 Occupational Therapy Australia
156 mation about enablers and barriers to the child’s occupational performance could only be identified by seeing the child in the classroom context and without that, recommendations were often inappropriate (Vincent et al., 2008). Being in the school environment also provided the therapist with opportunities to seek the teacher’s expertise, resulting in less perception by the teacher that the therapist was assuming an expert role. These findings highlighted that realistic recommendations were not just about seeing the child in the school environment but that occupational therapists have an obligation to understand the teacher’s role, the role of the school and as Villeneuve (2009) noted, it was vital to understand the curriculum, policies and classroom practices if the recommendations were to be educationally relevant. As reported, the occupational therapist being present was not enough on its own to overcome barriers to collaboration. Kennedy and Stewart (2012) reported that community occupational therapists did not view themselves as taking on an expert role. However, this was in stark contrast with the views of the teachers in the current study who reported strong feelings of frustration and inequality when community occupational therapists did visit the school, and when they only communicated with them indirectly through reports or only through the child’s parent. The lack of collaboration was most evident in teachers reporting that they often were not informed that a child in their classroom was receiving occupational therapy in the community. Teachers reported that parents were often resistant to even providing this verbal information, and speculated a sense of parent ownership over the occupational therapy services as it was funded privately. While parents have a right to determine how they share information about their child, given that parents and therapists then expect the teacher to act on the therapist’s recommendations it seems that therapists may be missing an opportunity early on in building their relationship with the parent, to advocate for teacher, parent and therapist collaboration to foster successful therapy outcomes. Importantly, the occupational therapists in the school also reported that it was very easy to forget to include the absent party, in their case, the parent. While occupational therapists might not view themselves as the experts, and while care needs to be taken in generalising the findings from this pilot study, occupational therapists perhaps do need to reflect on how their lack of contact with schools, and what they do if they do visit the school, and their reliance on written reports might be interpreted by teachers. From the teacher perspective, limited or no contact meant that teacher expertise, experience, knowledge of the child, and perspectives were not being taken into account resulting in a further barrier to collaboration, which supported findings by Bose and Hinojosa (2008). © 2013 Occupational Therapy Australia
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The study provided support for the findings by Spencer et al. (2006) that occupational therapists who worked collaboratively with teachers were more likely to set goals that supported the child’s participation rather than being component focused. However, providing clinical reasoning and making the benefits clear, further increased the likelihood that teachers would implement recommendations. Further to this, teachers and therapists in this study reported a responsibility to write reports and make recommendations that were brief, practical, and used appropriate terminology and to develop mutually agreed goals and, where possible, whole class strategies were seen as most easily implemented. To best share information about the child’s progress and to set goals, having an effective referral form, having formal or informal meetings, and regular review of goals, recommendations and strategies, and encouraging all parties to communicate were seen as being important. Failure to meet this responsibility was regarded as a significant barrier to collaboration as it resulted in teachers not implementing occupational therapy recommendations, confirming findings of earlier studies (Bose & Hinojosa, 2008; Vincent et al., 2008). From this study’s findings it appeared that the occupational therapists might be in the best position to advocate for improved collaboration but they perhaps do not see the lack of collaboration as a major concern which was a finding in the study by Kennedy and Stewart (2012). Further to this it was also suggested that service providers who employ a number of community occupational therapists, should make an effort to have the same therapists assigned to work with children from the same school, so that over time they foster relationships to enable more cost effective communication methods and improved child outcomes.
Limitations and future research Further research is required to add to the limited Australian research base and to employ methods to increase the generalisation of the preliminary findings of this study. Descriptive statistics were deemed appropriate for analysis of phase one study findings due to meeting the study purpose; however, it would be beneficial for future studies to test the newly constructed questionnaire for reliability and validity and to aim for a larger sample size to complete analysis beyond descriptive statistics. A limitation of this research was that the majority of occupational therapy participants were final year occupational therapy students at the time of their experience and were reporting retrospectively after graduating as occupational therapists. However, one significant advantage of using this research context was that the rotational placement of final year occupational therapy students in the school throughout the research period provided teachers with repeated exposure to explanations of the role of occupational therapy and various styles of collaborative practice. A key competency
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requirement for the students was to demonstrate collaborative practice (Curtin University School of Occupational Therapy and Social Work, 2011). Future research involving a larger sample size and all participants reporting on current practice contexts would better support generalisability as participants in this study mainly reported retrospectively on their experiences, although it is important to note that the majority of study participants including the teachers and supervising occupational therapist were still working in the practice setting explored.
Conclusion This study described the perspectives of school based occupational therapists and teachers within a unique environment, to find out more about collaborative practice with the aim of informing community practice. This study highlighted that a greater effort was needed by Australian occupational therapists to increase the implementation of collaborative practice by spending more time in the school, working with parents to involve all parties in the therapy process, communicating and reporting in clear language with recommendations relevant to the school context. These strategies along with working to understand the role of the teachers and the demands of the environment, building relationships based on recognition of mutual expertise are likely to further enhance collaborative practice. Findings from this study provided a basis for future research into occupational therapists actively implementing strategies to increase collaboration to enable all Australian children at educational risk to achieve optimal outcomes in performance and participation in their school roles. Importantly, this study provides clinicians and undergraduates with the approaches very necessary for collaborative practice.
Acknowledgements We would like to thank the school principal, teachers and occupational therapists for the time they have taken to participate in this study questionnaire, focus group and interviews, and checking themes for accuracy.
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