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Collaborative Action for Effective Integration of Therapy Support Services at School

Successful Learning Conference, 2016

Feature Presentation

Dr. Michelle Villeneuve

Centre for Disability Research & Policy,

Faculty of Health Sciences

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As an occupational therapist working in schools…

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Outline

¤  Reflect on complexity of collaborative care in education settings

¤  Recognize the importance of activity theory framework for identifying dilemmas in collaborative practice using those dilemmas as a basis for program improvement

¤  Cross-case examples from one component of my research on SBOT collaborative consultation in Ontario, Canada

¤  Continuing the conversation: what resonates for you?

Service Delivery Approaches (see Bundy, 1995)

Service Delivery Methods

Goal/Outcome What Intervention Looks Like

Direct

Intervention

Change in student’s ability (develop student’s skills) to to meet expectations of the school program

•  provide “hands on” treatment •  pull out or push in

Indirect

Intervention

Support student with skill refinement or maintenance of function in school context

•  teach procedure to educators or educational assistants who in turn administer procedure with the student

Consultation

Identify strategies that will enable students to succeed at school despite limitations imposed by their disabilities (compensate; accommodate; modify; adapt)

•  support changes to human and non-human environment (e.g., helping behaviours of adults; adapting classroom/routines, learning materials, school facilities)

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Traditional Service Delivery Model

Consultation:

An approach to service provision in which the consultant, a specialist, assists another person in a problem-solving process with regards to a third individual, the client

Erchul & Martens, 2002; Kampwirth, 2006

child

Allied Health Professional (e.g., OT, SP, PT)

Educator

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child

Allied Health Provider Educators

•  Special education teachers •  Regular education teachers •  School-based education

administrators (e.g., VP; Principal) •  Education Assistants (SLSO)

and their family

Funder/Gatekeeper

Employer

child

OT

Educators

Special education teachers Regular education teachers School-based education administrators (e.g., VP; Principal) Education Assistants

and their family

Health funder

Employer

School Board

(e.g., Special Education Administrators, Coordinators of Special Education Services; Technicians; SLP; Clinical Psychology)

Other health care providers Providers (e.g., nursing, PT, SLP)

Other health care services (e.g., specialists; ACS, seating, feeding clinics)

Social service agencies (e.g., FACS)

Child care/Preschool providers

Other: private clinicians; advocates

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Service Integration and Coordination

https://blogs.ca.com/2015/03/30/hey-it-your-big-data-infrastructure-cant-sit-in-a-silo-anymore-2/

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Collaborative Consultation

An interactive problem-solving process that enables people with diverse expertise to generate creative solutions to mutually defined problems.

Idol, Nevin, & Paolucci-Whitcomb, 2000

Relationship between collaboration and outcomes

Villeneuve & Shulha

Canadian Journal of Occupational Therapy December 2012 79(5) 295

historical work practices that have shaped how work is orga-nized and shared (Cole & Engeström, 1993; Engeström, 2008) and use this new, shared understanding to expand work prac-tices to improve congruence within the activity system.

The role of the researcher in DWR is to enable a con-structive approach to workplace inquiry and support mean-ingful visioning for future action. In DWR, the researcher draws on real workplace episodes as a basis for shared learning. The researcher collects “mirror data” through extended obser-vation and interaction with participants in the work setting. Mirror data can include videotaped workplace episodes, sto-ries, and interviews with workers (Engeström, 2000). Follow-ing the ethnographic phase, the researcher uses mirror data to represent and examine teamwork practices through group discussion with key stakeholders (Engeström, 2000; Leadbet-ter, 2008). Over a series of focused discussion sessions, the researcher facilitates a multiple perspective examination of the complex interconnections among work activities and workers.

In this study, appreciative inquiry (AI) (Cooperrider et al., 2008) was employed as an overarching framework to deepen collective understanding of work practices within and between agencies that support interprofessional collabora-tion for the delivery of SBOT services. While acknowledging constraints on practice, AI embraces a philosophy of engag-ing program stakeholders to recognize successes and draw on strengths as the basis for program improvement (Preskill & Catsambas, 2006). This study emphasized the first three stages of the AI process: (a) identifying organizational practices that work well, (b) envisioning the processes that would work well in the future, and (c) prioritizing areas for program improve-ment (Coghlan, Preskill, & Catsambas, 2003). Planning and implementing new ways of working, the final phase of AI, was

MethodsMethodological ApproachDevelopmental Work Research (DWR) (Engeström, 2000) is an interventionist methodology used to promote shared learning among workers for the purpose of developing future practice. DWR has been used to examine health care, social service, and education practices that rely on interagency coop-eration and team collaboration (Engeström, 2008; Leadbet-ter, 2004, 2008; Martin, 2008). The aim of DWR is to support stakeholders in developing “expansive learning” in workplace settings. Drawing on group-learning theory, expansive learn-ing occurs when team members are more disposed to use each other’s knowledge to improve practice (Engeström, 2008). In DWR, sociocultural activity theory is used to support concep-tual analysis by representing work practices within an activity system (Daniels, 2008; Engeström, 2000).

Based on the work of Vygotsky, sociocultural activity the-ory enables the study of collaboration by examining teamwork from multiple stakeholder perspectives (Cole & Engeström, 1993, 2000). Engeström (2000) expanded Vygotsky’s basic activ-ity system to include social and contextual factors that shape teamwork. Sociocultural activity theory provides a framework to support understanding of collaborative practice by consider-ing six elements of the activity system: (a) the desired goals or outcomes; (b) what is being worked on in relation to the goal; (c) the tools, methods, or approaches used; (d) the community of others who are involved; (e) the rules, routines, and profes-sional conduct that support or constrain practice; and (f) the way in which work is divided (Leadbetter, 2008; Martin, 2008) (see Figure 1). In DWR, incongruence between elements in the activity system is used as a catalyst for reflection and shared meaning making. Participants consider the social, cultural, and

Figure 1. Sociocultural activity theory conceptual framework. Adapted from Leadbetter, 2008

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Gaps in Research

¤  Relationship between educator-OT collaboration and outcomes for students? (Barnes & Turner, 2001)

¤  Impact of collaboration for teachers? (Reid et al., 2006)

¤  Tension: pressure to adopt collaborative consultation as best practice vs. evidence that OT continue to employ direct intervention (Bayona et al., 2006; Fairbarin & Davidson, 1993; Niehues, 1991; Spencer, 2006)

¤  Factors that facilitate collaborative interactions? (Villeneuve, 2009)

¤  Limited description of health-educator collaborative consultation

Expansive Transitions toward Collaborative Working

Engestrom, 2008

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Quality inclusion results from optimising joint effort among adults.

http://www.cea-ace.ca/education-canada/article/school-inclusion

Connor (focal participant) & Connorʼ’s mom

- Occupational Therapist (OT) - Case Manager (CM)

- Special Education Teacher (SET) - Education Assistant (EA) - Grade 1 Teacher - Vice Principal (VP)

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Alisha (focal participant) & Alishaʼ’s parents

- Occupational Therapist (OT) - Case Manager (CM)

– Special Education Teacher (SET) – Education Assistant (EA) – Senior Kindergarten Teacher – Vice Principal (VP)

Key Findings

¤ Focus for Educational Programming

¤ Communication Practices

¤ Leadership & Accountability Practices of Educators

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Focus for educational programming: Alisha

activities for Alisha’s EA and used her knowledge of motor develop-ment “to challenge Alisha to do different things with her hands.”

COOPERATION

Cooperative working involves modes of interaction that move participantsbeyond their scripted roles. When team members focus on a sharedproblem and contribute their knowledge to find mutually acceptable waysof understanding and solving it, their interactions can be characterized ascooperative. According to Engestrom, practitioners each contribute theirprofessional knowledge to re-conceptualize a shared problem but withoutexplicitly re-conceptualizing their roles and responsibilities.

Transitions from service coordination to cooperative working occurredduring informal interactions between the occupational therapist and each ofAlisha’s educators (Case Example 2). Consistent with Engestrom’s charac-terization of cooperation, participants shared knowledge to re-conceptualize

Help EAunderstandAlisha’s self-care needs

Alisha’smom

Ensure thatAlisha iscared for atschool

Communication is ahuge part of Alisha’sprogram

A lot of her programcomes from therapyrecommendations

Spec Ed.Teacher

SKTeacher

Comprehensionat story time

EA

Mobility isthe mainfocus

OT

ChallengeAlisha’s use ofher hands

Program for Alisha in Spec Ed. class; write Alisha’s IEP

Program for SK class

Schedule forAlisha andimplementprogram

Give EA activity suggestions; recommend equipment to supportAlisha’s participation

Communicationbook with EA;Educate EA ontube feeding

Therapysuggestions;computer &switch; toysin Spec Edclassroom

Daily story time at carpet

Sit – stand; personal care routines; resources in SK class

Pull-out sessionswith Alisha andEA; resourcesbrought fromoffice; equipmentrecommendations

Tools

Fig. 2. Professional Roles Drive Programming for Alisha.

74 MICHELLE A. VILLENEUVE AND NANCY L. HUTCHINSON

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Special Education Teacher

SK Teacher EA VP

OT

Alishaʼ’s mom

Communication Practices: Alisha

IEP

Report cards

Therapy Notes

Documentation: Therapy Notes

Principal

Equipment Recommendations

Equipment Recommendations

Communication book

Reading Folder

IEP

Therapy Notes

Case Manager Therapy Plan

Mid-block report

Year-end report

Modeling Activity for EA

SK routines Amandaʼ’s Program

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Focus for educational programming: Connor

education program was implemented in practice, how her progress wasmeasured or gauged by each of her educators, and how recommendationsmade by the occupational therapist were used.

Systemic barriers to collaborative working, described in previousresearch, were evident in both Alisha’s and Connor’s cases. The therapistshad a limited number of visits at which to consult with educators, providecomprehensive support for the child, and document their visit, all within 60minutes. Both therapists had a large caseload and, on one day each month,visited all the children on their caseload who attended the same school.However, communication practices among collaborators in these two casesdiffered substantially. Joint planning was facilitated in Connor’s casethrough meaningful communication among the educators, therapist, and

Shared Focus: Foundation Skills for Learning

Connor’sMom OT SET EA Gr. 1

Shared Script: Successful Inclusion at School

Socialinteractionacceptanceby peers

Developfoundationalhand skills

Attend toothers/routines/directions; socialcommunication

Interact withothers usingverbal & non-verbalcommunication

Initiate &follow classroutines

In-classconsultation;meetingswitheducatorsand Connor’smom

IEP; Formal &informalassessment;special education team meetings

Structured interactionwith peers;Gr. 1routines;body breaks

Movement-basedactivities; Gr. 1curriculum

HelpteachersunderstandConnor

Make activitysuggestionsto addresslearning goals

Program forConnor;monitorprogresstoward goals

Implementprogram withConnor

Program forGr. 1 class

Tools

Transitionmeeting;agenda;hallwayconvers-ations

Fig. 3. Educational Goals Drive Programming for Connor.

79Incorporating Therapy into the Regular Curriculum

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Communication Practices: Connor

Special Education Team:

•  VP

•  Principal

•  Special Education Teachers

Special Education Teacher OT

CM

EA

Connorʼ’s mom

Gr. 1 Class

Teacher

Transition Supports:

•  IBI Therapist

•  Daycare Resource Teacher

EAs

Assessment

Mid-block report

Year-end report

Regular Formal Meetings

Transition Planning Formal Meeting

Connorʼ’s mom

Case conference

Intake Ax

OT documentation; IEP; Meetings

Observation in Gr. 1 Program

Pull-out

Formal Interview with S2C

Informal Interview with EA

Hallway

conversation

Co

mm

unity Visits

Regular Hallway conversations

Agenda

OT documentation

Regular Meetings

Connorʼ’s mom Agend

a

Gr.

1 Sc

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Expansive Transitions to Cooperative Working

•  On the spot trouble shooting •  Sustained interaction over duration of school year

Expansive Transitions to Collaborative Working

•  Shared focus on educational goals •  Making time up front •  Documentation to sustain shared focus for joint working •  Showing how and explaining why

•  in class context; •  using materials readily available at school

•  Leadership & accountability practices of special education team

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Implications

¤  Define expectations for occupational therapy involvement grounded in the studentʼ’s educational goals and classroom routines.

¤  Use formal meetings to support development of shared

goals; use informal meetings to support ongoing communication and relationships among collaborators.

¤  Collaborate in the classroom; use what is available at school. ¤  Leadership and responsibility of educators is critical to the

successful implementation of occupational therapy recommendations at school.

School Leadership for Collaborative Action

¤  School leadership (agency-based service integration)

¤  Fostering collaborative care (child/family-based service coordination)

¤  Families as experts in their child’s capabilities,

¤  Educator’s as experts in the curriculum and instruction,

¤  Special Educators as “knotworkers,”

¤  Therapists as experts in functional performance & participation in everyday activities.

¤  Inform policy health-education service coordination (system/cross-sector-based service integration)

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Does any of this resonate with your experiences?

Jot down a key idea that resonates with your experience

or twitter.com/ResearchC4I

WHAT DO YOU HAVE?

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Acknowledgements

¤  Dr. Nancy Hutchinson & Dr. Lyn Shulha, Faculty of Education, Queenʼ’s University

¤  Social Sciences and Humanities Research Council of Canada, Grant 752-2007-0270

¤  Participants

References ¤  Cole, M., & Engeström, Y. (1993). A cultural-historical approach to distributed cognition. In G. Salomon (Ed.), Distributed cognitions (pp. 1 - 46).

Cambridge: Cambridge University Press.

¤  King, G., Meyer, K. (2006) Service integration and coordination: A framework of approaches for the delivery of coordinated care to children with disabilities and their families. Child: Care, Health, & Development, 32, 4, 477 – 492. doi:10.1111/j.1365-2214.2006.00610.x

¤  Engeström, Y. (2000). Activity theory as a framework for analyzing and redesigning work. Ergonomics, 43(7), 960-960.  

¤  Engeström, Y. (2001). Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of Education & Work, 14(1), 133-156.

¤  Engeström, Y. (2008). From teams to knots: Activity-theoretical studies of collaboration and learning at work. Cambridge; New York: Cambridge University Press.

¤  Erchul, W. P., & Martens, B. K. (2002). School consultation (2nd ed.). New York: Kluwer Academic/Plenum.

¤  Giangreco, M. F. (1997). Key Lessons Learned About Inclusive Education: summary of the 1996 Schonell Memorial Lecture, International Journal of Disability, Development and Education, 44:3, 193-206, DOI: 10.1080/0156655970440302

¤  Idol, L., Nevin, A., & Paolucci-Whitcomb, P. (2000). Collaborative consultation (3rd ed.). Austin, TX: Pro-Ed.

¤  Kampwirth, T. J. (2006). Collaborative consultation in the schools: Effective practices for students with learning and behavior problems (3rd ed.). Upper Saddle River, N.J.: Pearson/Merrill/Prentice Hall.

¤  Leadbetter, J. (2008). Learning in and for interagency working: Making links between practice development and structured reflection. Learning in Health & Social Care, 7(4), 198-208.

¤  Martin, D. (2008). A new paradigm to inform inter-professional learning for integrating speech and language provision into secondary schools: A socio-cultural activity theory approach. Child Language Teaching & Therapy, 24(2), 173-192.

¤  Villeneuve, M.A., Hutchinson, N.L. (2015). Chapter 4 - Incorporating therapy into the regular curriculum: Working together with occupational therapists. In Chambers, D. (Ed). Working with teaching assistants and other support staff for inclusive education. Emerald Insight. http://www.emeraldinsight.com/doi/pdfplus/10.1108/S1479-363620150000004004 Role: lead author of invited book chapter.

¤  Villeneuve, M., Shulha, L. (2012). Learning together for effective collaboration in school-based occupational therapy practice. Canadian Journal of Occupational Therapy, 79, 211-224. Doi: 10.2182/cjot.2012.79.5.6.

¤  Villeneuve, M., Hutchinson, N.L. (2012). Enabling outcomes for students with developmental disabilities through collaborative consultation. The Qualitative Report, 17(Art.97), 1-29. Retrieved from http://www.nova.edu/sss/QR/QR17/villeneuve.pdf / http://www.nova.edu/ssss/QR/

¤  Villeneuve, M. (2009). A critical examination of school-based occupational therapy collaborative consultation. Canadian Journal of Occupational Therapy, 76 (Influencing Policy Special Issue), 206-218.

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MICHELLE VILLENEUVE PhD, MSc, BSc OT  Co-stream Leader, Disability Inclusive Development | Centre for Disability Research and Policy  Senior Lecturer | Occupational Therapy Discipline  Faculty of Health Sciences      THE UNIVERSITY OF SYDNEY

michelle.villeneuve@sydney.edu.au http://sydney.edu.au twitter.com/ResearchC4I