Occupational Therapists’ Experiences of working in Irish Schools

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Occupational Therapists’ Experiences of

working in Irish Schools

Arbetsterapeuters erfarenhet av att arbeta i Irländska skolor

Emil Heitz

Ida Jansson

Occupational Therapy, bachelor's level 2020

Luleå University of Technology Department of Health Sciences

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Heitz, E. & Jansson, I.

Occupational Therapists’ Experiences of working in Irish Schools. _{Examensarbete i}

arbetsterapi 15 hp, Luleå tekniska universitet, Institutionen för Hälsovetenskap, Avdelningen för hälsa och rehabilitering, 2020.

Abstract

Purpose. _{The purpose of the study was to describe Occupational Therapists’ experiences of}

working in Irish schools.

Method. _{Convenience sampling was used to recruit the eight participants in the study. A}

semi-structured interview was used to gain data about their experiences. The data was analysed through latent and manifest content analysis inspired by Olsson and Sörensen (2011) and meaning units were identified, condensed and labelled with codes.

Result. _{The analysis resulted in three categories: “Resources impact the delivery of service”}

which shows how resources, within and outside of the participants control, impact the delivery of service and the challenges that might lead to. _{“Importance of communication and}

understanding”_{describes the dynamic between the participants’, school-staff and parents.}

”_{Comparing school-based and clinic-based occupational therapy” where the participants share}

their experiences and opinions of school-based and clinic-based Occupational Therapy.

Conclusion. _{Resources and communication have a beneficial effect on Occupational Therapy in}

schools.Many factors add to the complexity of delivering the service. A preference of

school-based Occupational Therapy is seen, however, Occupational Therapy today is generally more clinic-based. More research on the topic is needed.

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INTRODUCTION

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

1. BACKGROUND

1.1 Occupational Therapy

Taylor _{(2017) shows how Occupational Therapy is largely based on a person's roles, habituation,} volition, performance capacity and the environment in which the person is.

Activity or occupation has been used as a method of therapy for a long time, however it was not until the late 19th century that Occupational Therapy started taking form. _{The Association of} Occupational Therapists of Ireland (AOTI, 2020) defines Occupational Therapy as a _{“healthcare} profession offering support to people with physical, psychological and social problems to enable them to live life to the fullest. Occupational therapists help people to do the everyday activities that they want to do and need to do when faced with illness, injury, and disability or challenging life events.”

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Both _{AOTI’s (2020) and Taylor’s (2017) descriptions of Occupational Therapy are easy to put in} a school context. A child’s volition and motivation to attend in school; the performance capacity in requirements of a curriculum; habituation in seeing the school as a Monday to Friday

occupation; the environment of being in a school setting and the role of being a student in school; and in all this being able to live life to fullest.

1.2 Occupational Therapy in schools

The school situation is challenging for all children in many ways as pointed out by Missiuna et al. (2017). It is not only about academic achievements and learning, it is also very much about social interaction, cultural understanding, cognitive skills, and much more. The interplay

between school and home is different from child to child and the same goes for the support from the parents. An OT has a holistic take (Taylor, 2017; Nicola-Richmond, Pépin & Larkin, 2016) on the situation and could contribute with strategies and interventions for managing the whole situation around school. Even though there are many possible interventions to help children, according to Rodrigues and Francine (2018) there are often a lack of resources and of treatment space in school settings. They go on to describe a lack of understanding from parents and school staff about school-based and clinic-based therapy and how Occupational Therapy can be best utilised to be a supporting factor for the curriculum.

Within the school environment it is important to understand the dynamic between the professions as explained by _{Tracy-Bronson, Causton, and MacLeod (2019). Their participants (OTs,}

Physical Therapists and Speech and Language Pathologists) describe the situation with

distinctive roles, for example the teacher is the expert when it comes to the curriculum and the other professions are experts at providing therapy support. They go on to describe the importance of knowing your role to be able to ensure the best possible guidance considering your experience and background.

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

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“Pull-out”, “Push-in” and/or consultation._{Pull-out interventions refer to time with the child or a} group of children outside of the classroom environment. Therapists in the study often describe

Push-in_{interventions as sitting next to a child in the classroom and supporting the current class}

agenda or providing alternative activities to improve performance in the classroom. With

consultation _{the main focus is often in the form of support for the teacher about an individual}

child, where the OT discusses their abilities and difficulties followed by recommendations for the teacher to help with class performance for that child. It is frequently used in combination with pull-out interventions. In this study, Clough (2019) points out how OTs consider the

primary focus to be on helping children develop skills that can be transferred into the classroom. The focus is therefore mainly to work towards skill-based goals instead of using activity in a way to enhance personal growth.

According to Tracy-Bronson et al. (2019), when it comes to setting up goals, everyone involved in the child's school day, including parents, plays an important part. By having a shared focus, centered on the child, the result may lead to faster improvements in cognitive and social skills. It cannot be assumed that all children will adapt and be able to learn just by putting them in a school environment. Collaboration between everyone involved is key for educational results. They continue by describing that being engaged in the school system as an OT may lead to other positive impacts than intended. Providing supplemental support for one student can, in the long run, benefit the whole class and increase the overall _{participation and social interaction, not only} for those with disabilities, but for all children in the class_{. In 2017 a motion (Motion}

2017/18:2505) from the Swedish Parliament suggested that OTs would be included in Swedish school healthcare. The OT’s competence was described as suitable and even needed in the Swedish school healthcare. The motion was however rejected, which indicates a knowledge gap and that the Swedish Government does not consider Occupational Therapy to be a priority addition to the educational system.

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According to Campbell, Missiuna, Rivard, and Pollock (2012) it is shown that OTs working in classrooms develop a great understanding for which interventions are possible and useful in that environment. This leads to OTs being forced to re-evaluate their own methods and that their close work with teachers in the classrooms is eye-opening for them regarding which

recommendations are realistic and workable in an educational setting. This demonstrates the importance of different professions collaborating and sharing the same focus.

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

atmosphere focused instead on actual learning.

According to the reasoning above, Occupational Therapy has a clear role in schools in many countries. However, when we look at the origin of most scientific articles on the subject, there is a dearth of articles from a Swedish source. This, along with the motion being rejected by the Swedish Government indicates a knowledge gap. If we looked at another country, where

Occupational Therapy in school is more common, what would their experiences be? On the basis of the proximity principle we chose Ireland as a good place to look at and explore the

experiences of OTs working in schools.

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

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2. METHOD

This is a qualitative study using a semi-structured interview, as described by Kvale and

Brinkmann (2014), in order to explore _{Occupational Therapists’ Experiences of working in Irish} Schools. _{The interviews were analysed through content analysis as described by Olsson and} Sörensen (2011).

2.1 Procedure

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

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

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

2.2 Participants

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

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

2.3 Data collection

Five of the individual semi-structured interviews were conducted by both authors taking turns as the role of the interviewer and the other author as an active observer. Three of the interviews were conducted by only one of the authors. As an example, all the interviews contained the question _{“Could you tell us about a typical day at work?”. The questions touched on different} topics and required the authors to be responsive in the interview to encourage the participants to speak freely about their experiences. The interviews were conducted over digital communication platforms (Skype, Zoom) between February 2020 and April 2020 and lasted between 40 and 70 minutes. The semi-structured interview guide was used more as a support than as guidelines to follow. The interviews did not have a set time and ended when they reached data saturation and when the participant felt there was nothing else to add. Interviews were audio and video

recorded, in an attempt to keep the interpretations of the experience as close as possible to the original due to having body language and expressions included in the data. The participants were informed that participation was voluntary and could be aborted, for any reason, at any time.

2.4 Data analysis

The authors listened to the interviews in full. The interviews were then transcribed and the material was read several times. Participants' identities were anonymized by replacing their names with codes. The data was analysed through content analysis as explained by Olsson and Sörensen (2011). Meaning units were identified, condensed, and labeled with codes, as

exemplified in Table I. The codes were then categorised by looking at similar codes with similar condensed meaning units, in order to find experiences that could be linked together.

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

Meaning unit Condensed meaning unit

Code Category

The way that we work then is that we only go in for that particular child when they come on top of the waitlist, you have to be on the waitlist firstly, and then if there’s 6 kids in that class you might be seeing one and six months later you might be see a second child in that class

We go in for the child on top of the waitlist. Other children in that class will have to wait to be on top of the waitlist.

Waiting list Resources impact the

delivery of service

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

I was in the same school, I got to know the other professions and we developed teamwork. Professional relationships and teamwork Communication and understanding

There is so much OTs could be doing with children in school. It’s such a massive role and I do think sometimes if they were in schools either for a full day or a full week, the relationships would build up much better.

OTs have a massive role and a lot to offer. Relationships would improve if OT’s were in schools for longer periods.

OTs time spent in school Comparing school-based and clinic-based Occupational Therapy

2.5 Ethical aspects

In agreement with Olsson and Sörensen (2011), it is important to pay attention to the

participants' integrity and autonomy in a study. We informed all our participants in a missive, the purpose of the study, that the interview would be recorded and transcribed, that their

participation was totally voluntary, that they could interrupt the interview whenever they felt they needed to and that their personal information would be anonymised. This was in order to protect the integrity and autonomy of the participants.

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

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

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

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

3. RESULT

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

● Resources impact the delivery of service ● Communication and understanding

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3.1 Resources impact the delivery of service

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

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

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

The client’s family is described as an important resource in supporting the child in everyday life and in implementing interventions. The parents are often the persons that care the most for their child and are committed to that child being the best version of themselves. With a resource like that, the OT’s job is really just to guide them in the right direction. _{One example of this}

experience is a participant describing_{a child who showed very little interest in playing with toys.} The parents were of the impression that if you hand the child a toy, he would know what to do with it. The OT then started modelling how to play with toys and encouraged the parents to participate. The boy started to copy and interact more. It turned out to be enough with one single session and then a follow up six weeks later, since the parents could continue the training by

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

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

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

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

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

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

“Doing simple things like just changing where that child is in the classroom, their proximity to the teacher or their proximity to the

bathroom… They’re small things that can have a very fast and rapid effect and sometimes create the most functional change.”

The participants see competence as a vital resource. Continuing professional development [CPD] and continuous training is something that is valued. After receiving their degree in Occupational Therapy there was still an expressed need for continued training, in order to be able to work with children and especially children with Autism. Some expressed a piece missing when it comes to paediatrics in college, but there were also participants who had done more about paediatrics than others, even so they also felt a need for continuous training. Pedagogy was mentioned as a part missing from college, or something that could have been emphasised more, with the idea of pedagogy being of great use when it comes to influencing or impacting the developmental process. There is no set standard on specified training which means that it is up to each individual OT to decide what is needed in their practise of work. Among our participants,

understanding of sensory integration is commonly needed and is beneficial in practise. They also said that it would be difficult to work in a school without having had that additional training. It takes time to get experience and build up a bank of resources and strategies, however additional training can help getting a head start.

3.2 Communication and understanding

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

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

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

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

The participants imply that it is important for OTs to recognise and understand that the role of a parent is not to be a therapist, it is to be a parent. The responsibility of a parent involves

parenting firstly; cooking, cleaning, hanging out and even watching TV. When OTs demonstrate that they understand the family situation and communicate this to parents, it is helpful and

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

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

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3.3 Comparing school-based and clinic-based Occupational Therapy

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

The experience among the participants is that nowadays occupational therapy is more commonly clinic-based, than school-based. In clinic-based work with school age children, the norm is a family-centred focus where parents describe areas of problems and goals are set around those problems. Assessments are usually made in the clinic, while both observations and later interventions often take place in school or at home. The experience is that oftentimes

interventions and suggestions are welcomed by teachers. The participants who have experience of both clinic-based and school-based work with children, have a tendency to see advantages with the school-based way of working. Others appreciate being clinic-based and going out to different schools, although some express that by being clinic-based you can spend less time on travels between clients. However most of the participants express that more time in schools for the OT would be beneficial for the children. Conflict situations do occur when teachers do not have the time or when they feel that the intervention will not work. Sometimes OTs are expected by school staff to “fix” a situation without the school staff seeing their part in the process.

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

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

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

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

4. DISCUSSION

4.1 Result discussion

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

4.1.1 Resources impact the delivery of service

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

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

As the result describes, it is always important to have the individual child in focus. The Model of Human Occupation (Taylor, 2017) emphasises the use of a client-centred approach, where the focus is on the needs of the individual. On the other hand, the result showed a family-centred focus in relation to goal setting. Hanna and Rodger (2002) point out the importance of building relationships with parents in a family-centred approach and the gains of learning from the

expertise that the parents bring to the situation. Even though the needs of the child are in focus, it is necessary to remember that the context of the child is the family. To be able to achieve what is best for the child, the goals need to be suitable for the entire family. The result shows that a client-centered approach is somewhat of a theoretical standard. In praxis, the family-centered approach appears to be the most used.

The result stresses the importance of continuous training even after receiving the Occupational Therapy degree. The occupation is broad which means it is impossible to prepare Occupational Therapy students during their degree studies for everything they encounter in practise.

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

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

4.1.2 Communication and understanding

Rodrigues and Francine (2018) point out how communication and planning between OTs and school staff can be difficult. The respondents in their study felt that they had to explain and educate parents and staff about the role of an OT. This is also seen in the result of this study. The result also indicates that miscommunication between parents and school may push the OT into a role of a mediator, which according to Berryhill and Vennum (2015), is a role that a therapist should take, although they are referring to a school-based family therapist. This indicates though that in the communication between school and the parents, a school-based therapist can ease the communication just by being a neutral third party.

The best possible service is achieved when all concerned professions have clear roles and a close collaboration (Campbell et al., 2012; Tracy-Bronson, et al., 2019), but as mentioned earlier interprofessional communication can be difficult. The result shows how interventions issued by clinic-based OTs sometimes do not get implemented by the school staff. In these situations, the child may not get access to the recommended intervention due to miscommunication between OTs and teachers. The absence of follow-ups and lack of understanding are seen as the main cause. On the other hand, the result also shows that inventive strategies are being used to avoid this happening. For instance explaining to and informing the teacher about the needs of a child, about the intervention and in what way those match, which can increase compliance. This is supported by Vincent, Stewart and Harrison (2008).

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

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

4.1.3 Comparing school-based and clinic-based Occupational Therapy

By OTs and school staff having a shared focus, centered on the child, faster improvements can be seen (Tracy-Bronson et al., 2019). The result reinforces this by highlighting the opposite; poor relationships between OTs and school staff can _{have a negative effect on children. In}

clinic-based practise inaccurate interventions in school sometimes continue for a long time, other times the children do not even get access to the delegated interventions. The understanding of the competence and the role of an OT is, according to the result, wider and the relationships function better, when school-based. The lack of understanding from parents and school staff about how Occupational Therapy can be a supporting element, is described by Rodrigues and Francine (2018). The result indicates that this is less of a factor when OTs are school-based, but stands out more when they are clinic-based.

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

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

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

4.2 Method discussion

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

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

over-representation in participants with experience in autism related work. This may have impacted the transferability of the result.

The anonymity of the participants was ensured by using coded names during the process. Occupational therapy is a female dominated profession, therefore to further respect the

anonymity and prevent from traceability, we chose not to reveal the number of male and female participants. There is a possibility that the reliability is affected by this. Our goal is that both

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male and female readers can relate to and learn from the participants' experiences and that parallels can be seen to related situations.

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

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

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

5. CONCLUSION

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

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

ACKNOWLEDGEMENT

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

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Occupational Therapists’ Experiences of working in Irish Schools