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Exploring the contribution of case study research to the evidence base for occupational therapy: a scoping review

Leona mcquaid.

Glasgow Caledonian University, Glasgow, UK

Katie Thomson

Katrina bannigan, associated data.

The datasets generated and analysed during the current study are available in the UK Data Service ReShare repository, [10.5255/UKDA-SN-855706].

Case study research is generating interest to evaluate complex interventions. However, it is not clear how this is being utilized by occupational therapists or how feasible it is to contribute to the evidence base. This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base.

Opinion, text and empirical studies within an occupational therapy practice context were included. A three-step extensive search following Joanna Briggs Institute methodology was conducted in June 2020 and updated in July 2021 across ten databases, websites, peer-reviewed and grey literature from 2016 onwards. Study selection was completed by two independent reviewers. A data extraction table was developed and piloted and data charted to align with research questions. Data extraction was completed by one reviewer and a 10% sample cross checked by another.

Eighty-eight studies were included in the review consisting of ( n  = 84) empirical case study and ( n  = 4) non-empirical papers. Case study research has been conducted globally, with a range of populations across different settings. The majority were conducted in a community setting ( n = 48/84; 57%) with populations experiencing neurodevelopmental disorder ( n = 32/84; 38%), stroke ( n = 14/84;17%) and non-diagnosis specific ( n = 13/84; 15%). Methodologies adopted quantitative ( n = 42/84; 50%), mixed methods ( n = 22/84; 26%) and qualitative designs ( n = 20/84; 24%). However, identifying the methodology and ‘case’ was a challenge due to methodological inconsistencies.

Conclusions

Case study research is useful when large-scale inquiry is not appropriate; for cases of complexity, early intervention efficacy, theory testing or when small participant numbers are available. It appears a viable methodology to contribute to the evidence base for occupation and health as it has been used to evaluate interventions across a breadth of occupational therapy practice contexts. Viability could be enhanced through consistent conduct and reporting to allow pooling of case data. A conceptual model and description of case study research in occupational therapy is proposed to support this.

Systematic review registration

Open Science Framework 10.17605/OSF.IO/PCFJ6.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-023-02292-4.

Developing evidence informed occupational therapy practice is a priority across international practice standards and research agendas [ 1 , 2 ]. The challenge in achieving this, however, is multifaceted. Occupational therapists report a lack of research knowledge, time, resources and organizational support as barriers in the conduct of research [ 3 – 5 ]. Implementing findings from a research environment to the reality of clinical practice also presents a challenge despite knowledge translation and implementation strategies [ 6 ]. In practice, therapists use reasoning, experience and the client’s perspectives in addition to research [ 7 , 8 ]. This holistic approach to service provision can be difficult to capture, but the need to demonstrate impact and quality outcomes remains.

Arguably, the challenge in evidencing the value of occupational therapy reflects the complexity of practice where the ‘the active ingredient’ is difficult to stipulate [ 9 ]. This is comparable to the ‘complexity turn’ of wider health and social care which acknowledges that interventions are not always linear processes with predictable outcomes [ 10 ]. In recognition of this, debate exists in occupational therapy about how best to develop the evidence base [ 11 ]. Whilst the need for large-scale inquiry and randomized controlled trials is evident, there is also a growing perception that this may not be appropriate to answer the full spectrum of practice-based questions [ 10 ]. Instead, the research method adopted should respond appropriately to the question being asked and often a range of methods may be necessary. In particular for occupational therapy, researchers should consider designs carefully, particularly when testing interventions, so the holistic nature of practice is not compromised [ 11 ]. A shift to a pluralistic approach which best serves the decision-making needs of practitioners may be more appropriate [ 12 , 13 ].

Case study methodology—an in-depth analysis of a phenomenon within its real-world context [ 14 ]—has become increasingly popular in social sciences and is beginning to generate greater interest in occupational therapy [ 11 , 15 ]. Focus on a single case in context presents a familiar and therefore potentially feasible approach to research for practitioners. As a methodology, it relies on the collection of multiple sources of data to gain an in-depth understanding of the case [ 14 ], resembling multiple sources of evidence informing decision making in practice [ 11 ]. Flyvberg [ 16 ] argues this detailed contextual knowledge is necessary for understanding human behaviours when there can be no absolutes. It therefore provides an alternative methodology where large-scale inquiry is not appropriate or feasible [ 14 ].

Confusion surrounds case study methodology in terms of how it is conducted, reported and consequently identified in the literature. Previous reviews have noted inconsistencies between methodology and design, mislabeling of case study research and a lack of clarity defining the case and context boundaries [ 15 , 17 ]. It is often associated with qualitative origins, evolving from the natural and social sciences where disciplines such as anthropology, sociology and psychology demonstrate early application of the methodology and have since used it to grow their evidence base [ 18 , 19 ]. However, case study research can be shaped by paradigm, study design and selection of methods, either qualitative, quantitative or mixed. Its flexibility as a methodology and variation in approach by seminal authors may add to the confusion. For instance, Stake [ 20 ] and Merriam [ 21 ] align to a qualitative approach whereas Yin [ 14 ] adopts more of a positivist approach with a priori design to examine causality. The language around case studies can also be synonymous with ‘non-research’ case reports, anecdotes about practice or educational case studies which do not include data collection or analysis [ 22 ]. However, case study methodology is research involving systematic processes of data collection with the ability to draw rigourous conclusions [ 17 ]. Hence, there is a need to better understand this methodology and bring clarity in defining it for research use in occupational therapy practice.

There are misconceptions that case study research can provide only descriptive or exploratory data and it is regarded as poorer evidence in the effectiveness evidence hierarchy [ 10 ]. However, in a meta-narrative review of case study approaches to evaluate complex interventions, Paparini et al. [ 15 ] noted diversity in epistemological and methodological approaches from narrative inquiry to the more quasi-experimental. As such, case study research offers flexibility to answer a range of questions aiding a pluralistic approach to research. Yin [ 14 ] suggests three purposes of case study research; (i) descriptive; describes a phenomenon such as an intervention; (ii) explorative; explores situations where there is no single outcome, and (iii) explanatory; seeks to explain casual relationships. Stake [ 20 ] on the other hand describes case study research as (i) intrinsic; to understand a single case, (ii) instrumental; where the case is of secondary interest to facilitate understanding to another context and (iii) collective; when multiple cases are studied around a similar concept. Whilst it has been criticized for lack of rigour and external validity [ 22 ], one case can be sufficient to make causal claims, similar to a single experiment [ 15 ]. A particular case can disprove a theory and prompt further investigation or testing [ 16 ]. Furthermore, Yin [ 14 ] reasons the accumulation of case studies may offer greater rigour, reliability and external validity of findings as a larger dataset is created. Through case replication and organized accessible storage, there is potential for data to be mined to conduct rigourous practice-based research [ 11 , 23 ].

Some contention exists around the classification of single-case designs, including N-of-1 observational and experimental designs. Rice, Stein and Tomlin [ 24 ] argue the single-case experimental design (SCED) is not the same as a case study; however, Paparini [ 10 ] maintains this is coterminous with Yin’s explanatory case study aims. The International Collaborative Network of N-of-1 Trials and Single-Case Designs (ICN) articulates these designs broadly as the study of a single participant in a real-world clinical application [ 25 ]. This singular and contextual focus makes these designs appropriate to consider under the umbrella term case study research for the purposes of this review and exploring how N-of-1 may be a viable means to develop the occupational therapy evidence base.

Case study research has previously been advocated for in occupational therapy. Ottenbacher [ 26 ] originally described the small ‘N’ study as a tool for practitioners to address their responsibilities of documenting service provision effectiveness. Others have provided support for case study methodology to demonstrate clinical impact, overcome challenges of investigating complex phenomena and develop the occupational therapy evidence base [ 27 – 29 ]. It is presented as a good ‘fit’ for occupational therapy with untapped potential for contributing to the evidence base [ 11 , 30 ]. Whilst these studies offer a justification for the use of case study research in occupational therapy and call for greater uptake of the method, no extensive review of empirical case study methodology in occupational therapy practice has been conducted. It therefore remains unclear if, and how, the methodology is being utilized, or how feasible it is to contribute to the evidence base. A scoping review was deemed the most appropriate methodology for this review as it has recognized value for researching broader topics [ 31 ]. It will identify all available, eligible evidence and chart key information from the literature to answer the research questions and identify any gaps in the knowledge base.

A preliminary search of PROSPERO, MEDLINE, the Open Science Framework and JBI Evidence Synthesis was conducted. A similar scoping review was published in 2020 but focused solely on the use of qualitative case studies in occupational therapy, therefore providing a restricted view of case study methodologies [ 32 ]. Equally, the literature search was conducted in 2017 and interest in this methodology has grown since; hence, there may have been a change in the use of qualitative case study research methods within occupational therapy in recent years.

This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. By reviewing case study research within the field, it will be possible to assess the viability of case study research for contributing to the evidence base for occupation and health. The enriched understanding of case study research within occupational therapy could identify areas for future research and strategies to improve evidence-based clinical outcomes for those accessing services.

Review questions

This review aims to understand how case study research methodologies are used to contribute to the evidence base for occupational therapy practice. Specifically, it will identify and chart data to address the following sub-questions:

  • How is ‘case study’ defined as a research methodology in occupational therapy literature?
  • What are the methodological characteristics of case study research used in occupational therapy practice?
  • What are the contexts and recorded implications of case study research undertaken in occupational therapy practice?

This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [ 33 ] and, in line with best practice, used the updated Preferred Reporting Items Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR)  (See Additional File 1 for PRISMA-ScR checklist) [ 34 – 36 ]. It was conducted in accordance with an a priori protocol [ 37 ], and any deviations from this are reported and justified.

Inclusion criteria

Participants.

This review considered studies where occupational therapy input is provided as the object of study or the ‘case’ within the case study; therefore, the inclusion criteria was not limited by participant characteristics. It is possible that included studies may not involve participants given the nature of case study research and non-empirical study types are also eligible for inclusion. This allowed the potential for a representative picture of who and what occupational therapists have studied using case study methodology.

Empirical studies using case study research methodology were included. Literature reviews, text or opinion pieces which discuss the value of case study research within occupational therapy practice were also included to ascertain how others have used or conceptualized the use of case study research to achieve evidence-based practice. Papers were excluded where a case study research design was not explicit, for example, a descriptive case report without data collection and analysis.

Any area of occupational therapy practice was considered which spans health and social care, criminal justice, education and other diverse areas [ 38 ]. An a priori decision was made to exclude studies where the occupational therapy context could not be clearly defined, for example, multidisciplinary input or where practice was not the focus of the study, for example, describing an occupation only. All geographical locations were considered; however, as only articles written in English language were included, this may have created a geographical restriction through language limitations.

Types of sources

This scoping review included studies, as well as thesis and book chapters, if they involved empirical quantitative, qualitative and mixed method case study designs. Opinion, text or other articles which discuss the use of case study research in an occupational therapy practice context were also included. Case studies that are descriptive with no data collection and analysis were excluded. This was identified through reviewing the methods undertaken rather than how a study self-identified.

Search strategy

The search strategy aimed to locate both published and unpublished primary studies, reviews and text and opinion papers. To support the development and accuracy of the search strategy, a health systems librarian and occupational therapy profession specialist librarian were consulted in the early development stages. As per the JBI recommended three-step approach, an initial limited search of MEDLINE (EBSCO) and CINAHL (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy. The scoping review process is iterative [ 33 ] so it was noted in the protocol that the search strategy may need to be adapted as the review evolved. As a result of the preliminary searches, a change was required through the addition of the search term ‘occupational science’. Without its inclusion, a valuable review on the use of case study research in occupational science which also included occupational therapy practice was missed [ 39 ]. Therefore, the addition of this term ensured a thorough search, recognizing the influence of occupational science on occupational therapy practice.

The search strategy, including all identified keywords and index terms, was adapted for each included information source and a second search was undertaken in June 2020 and updated on 7th July 2021. The full search strategies are provided in Additional file 2 . The reference lists of articles included in the review were screened for additional papers plus a key author search to ensure all relevant studies were identified [ 33 ]. Studies published in English were included as the resources for translation were not available within the scope of this review.

The databases searched included MEDLINE (EBSCO), CINAHL (EBSCO), AMED (EBSCO), EMBASE (Ovid), PsychINFO (ProQuest) and Web Of Science. Sources of unpublished studies and grey literature searched included OpenGrey, Google and Google Scholar, OTDBASE, EthOS and OADT. To identify occupational therapy-specific literature, the content pages of practice publications Occupational Therapy News (UK), Occupational Therapy Now (Canada) and Occupational Therapy Practice (USA) were also screened from 2016.

Despite running preparatory searches, an unmanageable amount of papers were returned and on inspection many were dated in their approach to practice and language. For example, Pinkney [ 40 ] referred to ‘senile dementia’ and Pomeroy [ 41 ] referred to ‘handicap goals’. Therefore, to keep the review feasible as well as contemporary, a decision was made by the team to limit date parameters to 2016 onwards. This also meant that the OTSeeker database was omitted as a change from a priori as it has not remained comprehensive from this date due to lack of funding.

Study/source of evidence selection

Following the search, all identified records were collated and uploaded into Mendeley V1.19.4 (Mendeley Ltd., Elsevier, Netherlands) and duplicates removed. A decision was made not to use the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Adelaide, Australia) as JBI SUMARI does not offer modifiable data extraction templates which was needed for this review [ 33 ]. Instead, studies were transferred to Rayyan QCRI (Qatar Computing Research Institute [Data Analytics], Doha, Qatar), a systematic review web application to manage the independent relevance checking process [ 42 ].

A screening tool was developed and piloted on a sample of studies by all three reviewers (LMQ; KT; KB) and adjusted until consensus reached to enhance clarity before continuing the full screening process. The screening tool served as a memory aid to ensure reviewers were being consistent in how the inclusion criteria was applied and all decisions were recorded on Rayyan QCRI. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria (LMQ; KT and KB reviewed half each). Due to the broad nature of the question and a lack of clarity in reporting case study research methodology in the title or abstract, where there was doubt, articles were included for full-text review to be as inclusive as possible. Potentially relevant papers were retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers (LMQ; KT and KB reviewed half each). Full-text studies that did not meet the inclusion criteria were excluded, and reasons for their exclusion recorded. Any disagreements that arose between reviewers were resolved through discussion or with a third reviewer. Where required, the screening tool was refined following these discussions to create an audit trail and further enhance consistency in how inclusion criteria was applied in the screening process. Studies were not quality assessed, as per scoping review guidance [ 33 ], as the purpose of this scoping review was to map available existing evidence rather than consider methodological quality.

Data extraction

Data were extracted from papers using a data extraction tool developed by the reviewers into a Microsoft Excel spreadsheet (Redmond, Washington, USA). The tool was piloted by two independent reviewers initially on fourteen papers, an increase from the suggestion at protocol stage given the high number of included studies, and subsequently modified and revised. This clarified that only study designs stated, rather than conjected, would be extracted to reflect how authors self-categorize and define case study methodology. Additionally, it presented the need for a separate data extraction tool for non-empirical papers as some of the detail in the original tool was not relevant to review or discursive paper designs. The new tool captured details on reported strengths, limitations and explanations of data collection/analysis for the use of this methodology in occupational therapy practice. The updated data extraction tools are presented in Additional files 3 and 4 .

Data extraction was completed by the first author and a 10% sample checked by a second reviewer. As recommended in the data extraction process [ 34 ], multiple reports from the same study were linked. The data extracted for empirical studies included specific details about the definitions, justification and citations of case study research, the methodological characteristics, the context in terms of practice setting and population and key findings and implications relevant to the review question [ 37 ]. Authors of papers were contacted to request missing or additional data, where required.

Data presentation

As specified in the protocol and recommended in the JBI scoping review guidance, the extracted data is presented in diagrammatic and tabular form. A narrative summary accompanies the charted results and describes how the results relate to the scoping review questions. A mapping approach to analysis was adopted as the objective of this scoping review was to collate the range of existing evidence and describe the methodological characteristics of case study research, rather than synthesis or appraise the evidence.

In total, database and secondary searching returned 8382 studies (Fig.  1 ). After duplicates were removed, 5280 underwent title and abstract screening with 4080 articles excluded at this stage. Full-text screening and application of the updated 2016 date parameters led to a further 1108 articles excluded. This left 92 articles eligible for inclusion. This included seven reports linked to three studies which were subsequently combined [ 43 ] and four non-empirical papers consisting of a discussion piece and three literature reviews. Three of these reviewed the use of case study research in occupational therapy and/or occupational science prior to 2016, further justifying the decision to provide a more contemporary review. A final total of 88 records were included in the review; 84 empirical studies, and four non-empirical papers. The characteristics of included studies are presented in Additional files 5 and 6 . The majority of studies were excluded due to not having an occupational therapy practice focus, for example, multidisciplinary or a description of the meaning of an occupation rather than in a practice context (see Additional File 7 for more detail).

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Search results and study selection and inclusion process [ 34 ]

After an initial dip from 2016, publication of empirical case study research shows a consistent trend from 2017 onwards; the lower number in 2021 is attributed to the search stopping mid-way through the year (July 2021) (Table ​ (Table1). 1 ). Across the 88 included studies, there is greater representation of the Global North with the USA ( n  = 24/88; 27%), Canada ( n  =12/88; 14%) and UK ( n  = 11/88; 13%) publishing the most case study research. Case study research has been adopted to address exploratory and explanatory aims, and as such, it has been used to understand the outcomes of interventions, to explore elements of practice such as theoretical models, and to understand occupation and occupational science concepts to inform practice. Empirical case study research was identified in journal articles ( n  = 77/88; 87%), predominantly in occupational therapy-specific journals ( n  = 56/88; 63%), theses ( n  = 6/88; 7%), abstracts ( n  = 4/88; 5%) and a book chapter ( n  = 1/88; 1%). The majority of case study research adopted a multiple case design ( n  = 64/84; 76%); however, single-case designs were also published ( n  = 19/84; 23%). Included studies have used multiple data collection methods including interviews, observation and outcome data and have been used in a range of practice settings across the life span. The empirical studies will now be mapped to answer each question of this review followed by mapping of the non-empirical studies.

Summary of included studies

Mapping of empirical studies

There did not appear to be a consistent approach adopted across studies to define case study methodology. Figure  2 captures the various ways studies self-reported their methodological design (the more prominent the text, the more a word or phrase was featured in the data). Of the 84 empirical studies, 57% ( n  = 48/84) provided a definition or justification for the chosen case study research methodology. The most common cited explanations for adopting case study methodology were as follows: (i) to gain a deep understanding of the case ( n  = 28/84; 33%); (ii) to achieve this using multiple data sources, perspectives or baseline measures ( n  = 21/84; 25%) and (iii) to study the case in the real-world environment or context ( n  = 17/84; 20%). A need for comprehensive understanding was linked to the complexity of the case, such as a social interaction or human behaviour, e.g. Carrol [ 44 ] and Soeker & Pape [ 45 ]. Case study methodology was also justified as more suitable or practical when the phenomena was too complex or too little was already known for other data collection approaches, such as experiments or surveys to be used, e.g. Nilsson et al. [ 46 ] and Stickley & Hall [ 47 ]. Consequently, 10 studies specifically justified case study research as appropriate for early efficacy and feasibility studies, e.g. Peters et al. [ 48 ]. Case study methodology was described as a form of empirical enquiry or research by a small number of studies ( n  = 13/84; 15%), and in some instances, this was justified as being closely aligned to the principles of occupational therapy practice or a way to provide clinically relevant information, e.g. Kearns Murphy & Sheil [ 49 ] and Verikios et al. [ 50 ]. To a lesser extent ( n  = 6/84; 7%), case study methodology was described as a way to test theory.

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Phrase cloud illustration of study design as self-identified in included empirical studies. Size of the word illustrates frequency of use

Less than half of studies ( n  = 41/84; 48%) referred to seminal authors or included relevant case study methodological citations. Table ​ Table2 2 provides a summary of cited author explanation of case study research. Yin’s work was most commonly cited followed by Stake and Merriam whom were more associated, but not limited to, qualitative case studies. Dibsdall [ 51 ] and Hurst [ 52 ] justified their choice of Yin’s approach to case study methodology because it provided a clearer structure to follow.

  • a Study design.

Summary of cited author explanation of case study research

Congruence between description of study design and the methods undertaken was not always consistent, and reporting of ethical approval to distinguish case study research from case reports was not always reliable. For example, two studies classified as case reports by the American Journal of Occupational Therapy [ 56 , 57 ] include a methods section with data collection and analysis and have received ethical approval which would be more consistent with case study research methodology rather than a descriptive, non-research case report [ 14 ]. In contrast, Longpre et al. [ 58 ] documented that, after seeking guidance from three university review boards, ethics was not required for a case study approach despite including interview and document review data collection and an appropriate research citation.

  • b Methods of data collection

Quantitative data collection methods accounted for the majority of methods ( n  = 42/84; 50%), but mixed methods ( n  = 22/84; 26%) and qualitative ( n  = 20/84; 24%) approaches were also used. As such, studies appeared to represent different research paradigms, although the authors positioning is only stated in two studies; critical realism [ 52 ] and constructivism [ 59 ]. Data collection methods varied dependent on practice setting with quantitative methods dominant in inpatient and outpatient settings whereas third sector only used qualitative methods (Fig.  3 ). Community settings used a mixture of quantitative, qualitative and mixed methods.

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Number of studies per practice setting and data collection approach

Quantitative data was used to evaluate effectiveness with testing pre and post intervention, and as such, they adopted explanatory, N-of-1, single-case experimental or observational designs. In contrast, qualitative designs were used in studies with an exploratory or descriptive purpose. Here, qualitative data added further understanding of the effects or acceptability of an intervention from a variety of perspectives. Data collection methods across qualitative studies included the use of semi-structured interviews, observation, document review, field diaries and focus groups. Observation was also evident in quantitative methods but for the purpose of gathering performance data and applying objective measures rather than descriptive or thematic purposes. Mixed methods case study research included a range of designs such as the single-case experimental design [ 60 ], multiple case study [ 61 ] and descriptive case study [ 62 ].

  • iii Outcome measures.

None of the included quantitative studies used exactly the same measures. However, the Canadian Occupational Performance Measure (COPM) was the most commonly used occupation-based outcome measure ( n  = 20/84; 23%) and to a lesser extent, the Assessment of Motor and Process Skills (AMPS) was used ( n  = 3/84; 4%). The Goal Attainment Scale (GAS) was also used ( n  = 5/84; 6%) and Kearns Murphy and Sheil [ 50 ] in particular advocated for its use in occupational therapy case study research, particularly in mental health settings. Non-occupation-specific measures of function were also used such as Range of Movement, Fugl-Meyer assessment, Sensory profiles and other condition-specific measures, e.g. Hospital Anxiety Depression Scale [ 63 ], Stroke Impact Scale [ 64 ] and Modified Checklist for Autism in Toddlers [ 65 ].

  • iv Methods of analysis.

Descriptive analysis and visual analysis to compare data graphed over time was used in quantitative experimental designs. Statistical analysis in the form of Rasch and frequency analysis was also employed in some instances [ 66 – 68 ] but this was largely in conjunction with visual analysis. Both Gustaffson et al. [ 69 ] and Gimeno et al. [ 70 ] suggested in their studies that visual analysis is preferable for single-case designs rather than statistical hypothesis testing due to the small number of participants. Thematic and content analyses were commonly used in qualitative studies in addition to descriptive statistics. For multiple case designs, within and cross case analysis was described [ 59 , 64 , 71 – 74 ]. Specifically, Yin’s approach to pattern matching [ 51 , 73 , 75 , 76 ], explanation building [ 45 ] and matrix coding [ 77 ] was used. Two studies referred specifically to Stake’s approach to data analysis [ 59 , 78 ].

  • e The case.

Few studies ( n  = 10/84; 11%) made the case explicit in terms of description, selection or boundaries. In particular, quantitative case study designs appeared not to define the case; therefore, the participant receiving occupational therapy was assumed to be the case. In these studies, the inclusion criteria, time and location of intervention appear to be the boundary. Alternatively, the provision of occupational therapy input as a process could be the case of interest. Fields [ 78 ] and Pretorious [ 79 ] exemplify a clearly defined case as an individual and both were bounded by the context of time and location. Haines et al. [ 78 ] and Hyett et al. [ 59 ] demonstrate a defined case as a process, occupational therapy provision and a social network respectively. Across the studies, the case, either stated or conjected, was predominately an individual ( n  = 72/84; 85%). Groups, namely families ( n  = 5/84; 6%) and organizations were also identified as the case ( n  = 4; 5%). The case was stated as a process in a small number of studies ( n  = 3/84; 4%); however, without a clear description of the case and boundary, it is challenging to accurately identify this within the included studies.

  • a Practice contexts

Occupational therapy case study research were conducted with various client groups across a range of practice settings (Additional files 8 and 9 ). The majority were based in the community ( n  = 48/84; 57%); however, the practice context or setting where the research was carried out was not always clearly reported ( n  = 11/84; 13%). Interventions adopting therapeutic use of occupation and activity were apparent, such as feeding [ 80 ], gaming [ 81 , 82 ], gardening [ 83 ] and play [ 84 – 86 ]. This was more prevalent in outpatient or community settings with inpatient settings adopting more of a compensatory approach [ 87 ] to facilitate engagement in occupations as an end, rather than the therapeutic use of occupation itself as a means. Across all practice settings, the most common occupational therapy interventions were sensory-based interventions ( n  = 10/84; 12%) for example Giencke Kimball et al. [ 88 ], Go & Lee [ 89 ] Hejazi-Shirmard et al. [ 90 ], and provision of assistive equipment ( n  = 9/88; 11%) for example Cruz et al. [ 91 ], Golisz et al. [ 92 ] and Teixeira & Alves [ 93 ]. In other instances ( n  = 4/84; 5%), provision of occupational therapy was described as the intervention, subsequently involving a range of input rather than a single defined intervention, for example Kearns Murphy & Sheil [ 49 ], Haines et al. [ 78 ] and Pretorius [ 79 ].

Although all studies had a practice focus, not all were intervention specific but investigated a broader aspect of practice and so did not always include participants ( n  = 11/84; 13%). For example, Carey et al. [ 94 ] conducted an instrumental case study on the case of occupational therapy practice in the broad context of mental health services in Saskatchewan, Canada. This involved reviewing documentation and records from practice rather than including a population group or specific intervention. Others focused on particular assessments used in practice [ 95 , 96 ] using conceptual frameworks in practice [ 52 , 59 ] and practice at the organization or community level [ 47 , 71 , 97 , 98 ].

For studies that included a population group, case study methodology was used across the life span; adults ( n  = 27/84; 32%) children ( n = 24/84; 29%) and to a lesser extent, older adults ( n  = 6/84; 7%). It was also used with mixed age populations ( n  = 21/84; 25%) for instance, with families. Across all age groups, case study research was conducted largely with populations experiencing neurodevelopmental disorder ( n  = 32/84; 38%), stroke ( n  = 14/84; 17%) and ill mental health ( n  = 9/84; 11%) but was not always diagnosis specific ( n  = 13/84; 15%) (Additional file  9 ). For example, in Dibsdall’s [ 51 ] case study of a reablement service, occupational therapists provided a service to individuals with a range of diagnoses. Similarly, Fischl et al. [ 72 ] supported older adults with digital technology-mediated occupations irrelevant to a particular diagnosis.

  • b Recorded implications for practice.

As the majority of studies had an intervention focus ( n  = 73/84; 87%), they were able to draw conclusions in terms of how and why an intervention works. However, implications for practice in terms of intervention efficacy were often presented as preliminary or pilot with recommendations for further research including larger sample size studies. Through multiple data collection methods, some studies incorporated participant, family or therapist views to triangulate data and draw conclusions about the acceptability of an intervention [ 50 , 62 , 99 ]. As an example, Peny-Dahlstand et al. [ 99 ] includes a clear diagram illustrating how multiple data sources are collected from the patient, the therapist and the organizational perspective to analyse feasibility in terms of acceptability, efficacy, adaptation and expansion. Details of the Cognitive Orientation to daily Occupational Performance intervention are aligned to a protocol giving the reader a sense of how this can be implemented in practice. Similarly, a detailed description of the intervention, case and/or context can aid transferability [ 14 ] as in Carlsedt et al.’s [ 64 ] overview of the BUS TRIPS intervention.

The remaining studies ( n  = 11/84; 13%) added to the understanding of non-intervention aspects of practice such as the use of models, frameworks and assessment tools within the practice context or recommended policy changes. For example, Soeker and Pape [ 45 ] explored the experiences of individuals with a brain injury of the Model of Self-Efficacy (MOOSE) as it was used by occupational therapists to support their return to work journey. Using an exploratory multiple case design, the authors were able to conclude that the MOOSE is a useful model in this area of practice as well as increasing understanding of how and why it supported work retraining.

Mapping of non-empirical papers

Four non-empirical papers that reviewed the use of case study research related to occupational therapy were included in this review. These were integrative reviews of case study research in occupational therapy [ 100 ], occupational science [ 39 ] and a scoping review of qualitative case study research [ 32 ] together with a discussion of the applicability of single-case experimental designs to occupational therapy [ 101 ]. The literature review searches were conducted in either 2016 or 2017 and identified 32 [ 100 ], 27 [ 32 ] and 18 studies [ 39 ]. Results reflect the findings of the empirical studies in the current review, suggesting a global uptake of case study research in occupational therapy across a diversity of practice settings used to understand interventions as well as broader concepts related to practice.

Together, the reviews present the defining features of case study methodology as investigating a phenomenon (i) in depth, (ii) in its real-life natural context, and (iii) using multiple sources of data for triangulation. Jonasdittor et al. [ 39 ] and Carey [ 100 ] both suggest case study methodology can cross research paradigms and therefore can be qualitative, quantitative or mixed methods in nature. Lane [ 101 ] somewhat contradicts this stating that case studies are a form of descriptive qualitative inquiry and therefore described the quantitative single-case experimental design (SCED) as distinct and separate from case study research. However, Lane [ 101 ] also acknowledged that multiple sources of data may be used including narrative records but this should be considered secondary to observing trends in data because the primary focus is to determine the effect of the intervention. In the SCED, multiple data collection points are used for in-depth understanding to measure change and make appropriate intervention responses. Hercegovac et al. [ 32 ] did not make a distinction about data collection methods but sought only qualitative case study research. Reflective of this, the majority of studies identified by Jonasdottir et al.’s [ 39 ] and Hercegovac et al.’s [ 32 ] reviews were qualitative but in Carey’s review [ 100 ] they were mixed methods. Quantitative studies were less common.

All four papers comment that generalizations cannot be made from a single case. Instead, providing a thick description of characteristics and information about the case was deemed necessary to help the reader understand the context and determine transferability of the case. Collecting and comparing across cases was also noted to provide greater validity [ 101 ]. Despite this, Hercegovac et al. [ 32 ] identified only 18% of studies that had adequately defined the case. All review and discussion papers conclude that case study or single-case experimental designs are appropriate in the study of occupation and health. They support the wider adoption of this methodology to advance the occupational therapy evidence base because it offers a rigourous but flexible approach to study complexity in the real-world practice environment. It is presented as a ‘familiar, appropriate tool’ ([ 100 ]; p.1293) to develop evidence informed practice.

The findings of this review, in conjunction with the wider literature knowledge base, are integrated in Fig.  4 as a proposed conceptual model to illustrate how case study research can be applied in occupational therapy practice. It highlights the three important elements of the methodology as the ‘Case’ of interest, the rationale for the ‘Study’ design and that it is a ‘Research’ method. Central to the application of this methodology is the aim to achieve an in-depth understanding of a phenomenon within the occupational therapy practice context. To compliment Fig.  4 , a description of case study research within occupational therapy is proposed as;

‘a flexible methodology that can cross research paradigms where the focus is to gain an in-depth understanding of a case in the real-life practice context. The case and context can reflect any aspect of occupational therapy, but must be clearly defined and described within a given boundary. A comprehensive understanding of the case or cases should be gained through triangulation of data collection either through multiple data sources or multiple time points.’

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Proposed conceptual model describing case study research in occupational therapy practice

This scoping review explored the use of case study research within the occupational therapy evidence base from 2016 to 2021. A large number of studies ( N  = 88) were identified across a variety of practice settings and following a dip after 2016, publication trends appeared consistent over this period. This suggests that case study research has potential viability for contributing to the evidence base of occupation and health. However, the findings of this review identified inconsistencies in how case study research was defined and variation in the methodologies adopted. Therefore, to maximize its potential as an evidence building tool, further clarity on case study methodology is needed. It is hoped that this review, in particular the proposed definition and conceptual model, will help achieve this.

A key issue highlighted was the lack of consistent or easily identifiable terms used to describe the methodology. Some studies defined the design by number of cases (e.g. single/multiple), by purpose (e.g. exploratory, descriptive, experimental) or by data collection (e.g. quantitative, qualitative, mixed). Other terms were also used such as ‘almost experimental’, ‘case series’, ‘changing criterion’ and ‘case report’. Hyett [ 17 ] suggested case study, as a research approach, has been confused with the non-research-based case report and this is supported by the findings of the current review. Self-identified ‘case studies’ were excluded, in line with the inclusion criteria, if they did not report data collection or analysis. In addition, journal classification of study type was at times incongruent with the methodology taken, e.g. Proffitt et al. [ 57 ]. Alpi & Evans [ 102 ] highlight this lack of distinction not only in journal classification but also in database indexing. They propose that case study is a rigourous qualitative research methodology and case report is a patient or event description. Based on this, the Journal of Medical Library Association updated classification of descriptive manuscripts previously known as case studies to case reports and case studies as a research methodology are now identified as original investigations. Despite this effort at clarification, there is still room for debate. Where Alpi & Evans [ 102 ] suggest N-of-1 single subject studies fit the case report label, Paparini et al. [ 10 ] aligns this to the explanatory case study. Therefore, this review adopted Yin’s [ 14 ] term ‘case study research’ as a common language that can be used by occupational therapists in the conduct and reporting of this methodology. It is suggested this will make the distinction clear from case report or non-research.

The issues highlighted in this review reflect current debate about case study research methodology. A key issue identified with empirical case study research was the inadequate description of the case and boundary so that it could be easily identified by the reader. Other reviews of case study research in occupational therapy included in this review [ 32 , 39 , 100 ] also identified this as a concern pre-2016 and Hyett [ 17 ] identified this more broadly in the literature, but particularly a concern for health and social science case studies. A clearly identifiable case, with detailed description including the boundary and context, is necessary for practitioners to understand how it may translate to their own practice. A case is not synonymous with participant and, whilst it can be an individual of interest, it can also take a more intangible form of a process such as intervention delivery, practice networks or other practice areas of interest such as theory.

As a form of inquiry, case study research provides context-specific, practice-based evidence, so the practice context must be understood. This in-depth, contextual understanding provides an alternative to studies seeking breadth of knowledge or generalizations and is thus the unique characteristic of case study research [ 11 ]. For this reason, ‘in-depth’ inquiry and ‘occupational therapy practice context’ are positioned at the core of the proposed descriptive model, encapsulated by the ‘case and context boundary’ as essential elements to case study research methodology (Fig.  4 ).

Case study research has been shown to be a flexible methodology both in design and purpose. Of particular interest to evidence building is its use to explore the efficacy and feasibility of an intervention in the real-life practice context. These findings support the assertions of previous authors who have suggested that case study research can be used to demonstrate clinical impact of interventions and to investigate complex multifactorial phenomena [ 11 , 27 – 29 ]. Particularly in areas of innovative or emerging practice, case study research can provide a way to capture impact when participant numbers or resources are not available to conduct larger-scale inquiry. Stickley and Hall [ 47 ], for instance, specifically state that their study is the first known investigation into social enterprise in occupational therapy. As a first step to building evidence, a descriptive or single-case account can therefore provide an important grounding on which to build upon. The need for timely evidence during the Covid-19 pandemic demonstrated an acute awareness of this but it has also been recognized as a process of cumulative evidence building in occupational science [ 103 ] and more broadly across other disciplines [ 104 ]. Of note however is Flyvbjerg’s [ 16 ] argument that the case study holds value beyond pilot or preliminary data. Whilst it may be difficult to generalize from a case study, particularly in terms of process, the outcomes can contribute to knowledge when used to test a theory or data pooled across cases.

By mapping the findings of this review, case study research appears to mirror the broad and varying nature of occupational therapy. It reflects occupational therapy as a direct service provided to individuals or groups, but also to others on a client’s behalf [ 105 ]. Organization, population and system-level practice is also recognized as an important aspect of occupational therapy practice [ 38 ] and was reflected in the included cases [ 71 , 97 ]. Case study research therefore not only has the potential to evidence impact through intervention outcomes, but also has wider health and well-being impact potential by exploring and advocating for occupational therapy across the full spectrum of practice including diverse areas.

Occupational therapy was provided in a range of settings including hospital, community and industry sectors. Interventions adopted illustrate the global variation in occupational therapy practice. For instance, compression bandaging [ 69 , 106 ] and electrical stimulation [ 107 , 108 ] are not aspects of standard practice in the UK but reflect other international practice standards [ 109 , 110 ]. Interventions were wide ranging and reflective of those described in the American Occupational Therapy Process and Domain Framework [ 38 ]. This included therapeutic use of occupation [ 83 ], interventions to support occupation [ 111 ], education and training-based [ 112 ], advocacy-based [ 76 ], group-based [ 113 ] and virtual interventions [ 114 ]. Narrowing the intervention to a single entity was not always possible or appropriate reflecting the complexity of occupational therapy practice and several authors, for example Kearns Murphy & Sheil [ 49 ] and Pretorious [ 79 ] instead reported occupational therapy as the intervention involving a range of activities and approaches that were meaningful and goal directed for the client.

A suggested strength of case study research identified by the findings is the similarity between the research process and clinical practice. Fleming [ 115 ] had suggested that practitioners generate hypothesis in clinical practice to test theory and problem solve elements of the therapy process for example, why an intervention may not be working as expected. Similarly, case study research has been used to test theory in evaluative or explanatory designs. Methods of data collection (e.g. observation, outcome measurement, document review, interview, client feedback) and analysis (e.g. descriptive, visual, pattern-matching outcomes) bear resemblance to how evidence is collected in practice to inform the intervention process [ 116 ]. The term ‘pattern matching’ is an analytic strategy adopted by Yin [ 14 ] in case study research to compare patterns in collected data to theory. However, pattern matching is also evident in occupational therapy clinical reasoning literature, particularly in relation to how practitioners utilize tacit knowledge to inform decision making [ 117 , 118 ]. This insight into case study research supports the perspective that it may be a more familiar and therefore achievable approach to evidence building for practitioners.

The challenge of capturing the complexity of practice has previously been cited as a barrier to research engagement and evidence-based practice in occupational therapy [ 11 ]. In contrast to this, case study research was largely justified as the chosen methodology because it allowed for individual tailoring of the intervention to the case and context [ 72 , 74 , 75 ]. The ability to provide a narrative description of the case, context, intervention and how it was implemented or adapted was seen across case study research, including single-case experimental designs (SCED). This idea of ‘individualization’ of treatment is also noted by Fleming [ 119 ] to differentiate occupational therapy clinical reasoning from medical procedural reasoning. The effectiveness of occupational therapy is not solely based on a prescriptive treatment, but is also influenced by the interactions between the therapist and service user and the particulars of that context. Therefore, if thinking on clinical reasoning has evolved to capture the important nuances of interactive reasoning [ 115 ] and furthermore embodied practice [ 118 ] then it would seem appropriate that the research approach to building evidence should also. A pluralistic approach whereby there is a valued position for both case study research and larger-scale inquiry to capture both the depth and breadth of practice would seem fitting. Collecting and pooling case study research data from practice can capture these important elements and allow for pattern matching or synthesis. In this way, case study research can hold value for evidence building, just as the randomized controlled trial, or other larger-scale inquiry, does for generalizability with the potential to inform policy and practice.

Based on the findings from this review, collecting case studies from practice to develop an evidence base is potentially viable given its uptake across practice areas and relatively consistent publication. In psychotherapy, Fishman [ 23 ] advocated for a database of cases which follow a systematic structure so they can be easily understood, recognized and data compared. Journals dedicated to publishing case data using a methodical format have since evolved in psychotherapy [ 120 ]. In occupational therapy, the Japanese Association of Occupational Therapists [ 121 ] collects practical case reports from members using dedicated computer software to host a collective description of occupational therapy practice. There is potential then to adopt this even on an international basis, where occupational therapy practice can be shared and measured. The challenge however is in achieving a systematic approach to how case study research data is collected and recorded to allow for meaningful comparisons and conclusions to be drawn.

In this review, quantitative and mixed method designs used a range of different outcome measures which is not conducive to pooling cross case data. Goal Attainment Scaling (GAS) is an outcome measure that defines individualized goals and relative outcomes to determine therapeutic effectiveness [ 122 ]. It is a measure advocated for its applicability across areas of practice but also for research, both large-scale inquiry and case study research [ 123 ]. In this review, it was used across age groups, in the community, outpatient settings and schools and in the areas of neurodevelopmental disorder, stroke, brain injury and ill mental health.

Kearns-Murphy & Sheil [ 49 , 123 , 124 ] adopted Goal Attainment Scaling in their longitudinal case study and explored the different methods of analysis of the measure. They concluded that charting GAS scores at multiple timepoints is beneficial to case study research as it adds to the ‘in-depth’ analysis providing insight into the fluctuations of therapy and outcomes in the real-life context. Visual analysis of charted scores is then an appropriate analytic technique for intervention-based case study research. Two time points, before and after, are more suited to large-scale inquiry for generalization but in the case study, only the performance of an individual on a particular day is highlighted which may be influenced by several contextual factors. Given these assertions, adopting a consistent outcome measure across practice such as GAS, would allow for in-depth, case and context-specific understanding that could also be comparable and pooled across cases.

Strengths and limitations of the scoping review

This review searched published and grey literature using a variety of terms that have been used interchangeably with case study research with the aim of conducting a comprehensive overview. It followed a peer-reviewed protocol with systematic and transparent processes. JBI methodology for the conduct of scoping reviews was followed and bibliographic software (Mendeley) and systematic review software (Rayyan) was used to manage citations and the screening process. Additionally, an updated search was completed in July 2021 to enhance the timeliness and relevance of findings.

Ten databases were searched and no further relevant articles were identified through websites or citation searching, affirming that a thorough search had been conducted. However, to balance a comprehensive search with the practicality of resources, some decisions were made which may impact the inclusivity of the review. Western dominant databases and English language limits were applied because of translation resource availability within the research team. The search algorithm was developed and tested with an academic health librarian at the protocol stage; however, as case study methodology was not always clear from the title and abstract, an unmanageable amount of data was presented at full-text stage. To manage the number of records, inclusion criteria was changed to provide a contemporary overview from 2016 rather than 1990. This may introduce some bias to the review, where relevant articles pre-2016 or in other languages were omitted. However, the narrower focus allowed for in-depth data mapping to maximize the value of findings for informing future practice and research. Without taking this step, the output would likely have been more superficial. As a large number of 88 studies were still included in total, it was felt an appropriate balance had been achieved.

Findings suggest that case study research is a viable methodology to contribute to the evidence base for occupation and health as it has been used to evaluate interventions across a range of occupational therapy practice contexts. It has been used for cases of complexity, early intervention efficacy and feasibility, theory testing or when small participant numbers are available, in other words, when large-scale inquiry is not appropriate.

Inconsistencies were identified that mirror findings of case study research methodology in other disciplines. In particular, case study design and description of the case and boundary were poorly reported. Therefore, this review proposes that a common language is used—case study research—to define this flexible methodology. A description and conceptual model are proposed to assist in clarifying how case study research can be applied and reported in occupational therapy. Consistent reporting as a research form of inquiry improved description of the case and boundary and reference to seminal authors would help differentiate research from non-research cases and enhance viability for pooling cases together through more consistent, systematic conduct and reporting.

Implications for research and practice

There is a need to distinguish case study as a research method, separate from the illustrative case report and from purely qualitative inquiry, for it to be identifiable in the literature to reduce confusion and capability concerns. Therefore, the term ‘case study research’ is proposed when referring to the research methodology specifically. Citation of seminal authors alongside this description of study design would aid visibility of case study research as distinct from non-research and could also support appropriate journal classification. Greater clarity in reporting case description, including a narrative summary of the case, context and boundary of study is also an area for development. The development of a systematic template for the collection and reporting of case study data, ideally mirrored internationally, would likely be an ideal solution. This would potentially build capability for the conduct of rigourous case study research, help make it more identifiable in the literature and support pooling data across studies for synthesis and generalization, thereby overcoming the criticisms of case study research. Through accurate and detailed description of case context and boundary, practitioners would more easily be able to identify if the information is relevant to their own practice context.

Case study research has been shown to be appropriate for use across settings and populations, therefore pooling data could enable services to benchmark. Practitioners seeking to explore research within their practice are encouraged to consider the case study approach for its flexible nature and suitability to the person-centred values of occupational therapy. Use of a consistent outcome measure would support pooling of data and, as GAS is specific to the individual rather than practice setting, services may want to explore it as a measure suitable for intervention-based case study research.

Acknowledgements

Acknowledgements and thanks are extended to the Elizabeth Casson Trust for individual funding awarded to the corresponding author and to the Case Study International Think Tank for their professional support.

Abbreviation

Authors’ contributions.

All authors (LMQ; KT; KB) were involved in the conceptualization of the idea for this review. LMQ developed the search strategy and conducted database searching. All authors contributed to the screening and selection of studies and piloted the data extraction tool. LMQ completed data extraction and KT cross checked a 10% sample of these. LMQ charted the results and completed the first draft of the paper with input from the other authors. LMQ critically revised the draft paper and all authors read and approved the final draft before submission.

No grant funding has been provided for this review.

Availability of data and materials

Declarations.

Not applicable.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

  • Research article
  • Open access
  • Published: 16 May 2013

The integration of occupational therapy into primary care: a multiple case study design

  • Catherine Donnelly 1 , 2 ,
  • Christie Brenchley 3 ,
  • Candace Crawford 4 &
  • Lori Letts 5  

BMC Family Practice volume  14 , Article number:  60 ( 2013 ) Cite this article

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For over two decades occupational therapists have been encouraged to enhance their roles within primary care and focus on health promotion and prevention activities. While there is a clear fit between occupational therapy and primary care, there have been few practice examples, despite a growing body of evidence to support the role. In 2010, the province of Ontario, Canada provided funding to include occupational therapists as members of Family Health Teams, an interprofessional model of primary care. The integration of occupational therapists into this model of primary care is one of the first large scale initiatives of its kind in North America. The objective of the study was to examine how occupational therapy services are being integrated into primary care teams and understand the structures supporting the integration.

A multiple case study design was used to provide an in-depth description of the integration of occupational therapy. Four Family Health Teams with occupational therapists as part of the team were identified. Data collection included in-depth interviews, document analyses, and questionnaires.

Each Family Health Team had a unique organizational structure that contributed to the integration of occupational therapy. Communication, trust and understanding of occupational therapy were key elements in the integration of occupational therapy into Family Health Teams, and were supported by a number of strategies including co-location, electronic medical records and team meetings. An understanding of occupational therapy was critical for integration into the team and physicians were less likely to understand the occupational therapy role than other health providers.

With an increased emphasis on interprofessional primary care, new professions will be integrated into primary healthcare teams. The study found that explicit strategies and structures are required to facilitate the integration of a new professional group. An understanding of professional roles, trust and communication are foundations for interprofessional collaborative practice.

Peer Review reports

There is a clear fit between occupational therapy (OT) and primary care. Both view health in a holistic manner and seek to support individuals and communities in achieving and maintaining a healthy lifestyle [ 1 , 2 ]. While there is evidence to support the role of occupational therapy in health promotion and prevention, there have been few practice examples of occupational therapy within primary care settings [ 3 , 4 ].

The lack of an occupational therapy presence in primary care can be attributed to a number of factors [ 5 ]. First and foremost, there has not been funding for occupational therapy in primary care, both in Canada and internationally [ 5 ]. Second, primary care has traditionally been delivered in solo practitioner models [ 6 ]. Finally, the occupational therapy profession has traditionally focused on the rehabilitation or remediation of function versus health promotion [ 7 ].

In 2003, the First Ministers of Canada committed to ensuring that half of Canadians would have access to multidisciplinary primary care teams by 2011 [ 8 ]. While this has not yet been achieved, the province of Ontario’s commitment to health reform has resulted in the establishment of Family Health Teams, an innovative model of interprofessional primary care [ 9 ]. There are currently 200 teams that serve approximately 25% of the province’s population.

Each Family Health Team is interprofessional in nature; however there is considerable variability in structure, size and organizational dimensions. A Family Health Team may consist of a single site or may be comprised of multiple offices that have common programs or structures such as an electronic medical record (EMR), programs and management. The complement of interdisciplinary health professionals also varies according to the specific needs of the community.

While the initial list of funded interdisciplinary health providers did not include occupational therapists, in March 2009 the Ontario government committed funds to include occupational therapy services in Family Health Teams [ 10 ]. At the initiation of the study, 20 teams had occupational therapists within their team complement. Ontario’s initiative is one of the first examples of large-scale integration of occupational therapy into primary care teams in North America.

A growing number of national and international studies have documented the structures and processes to support interprofessional primary care teams [ 11 , 12 ]. However, few of these studies have included occupational therapy within the team complement and no study has exclusively examined the implementation of occupational therapy into a new or existing primary care team.

A handful of articles have examined the integration of other professionals into primary care teams [ 13 – 15 ]. While these findings might provide insights for occupational therapy, each profession entering primary care will have unique features and support the team through unique roles. Occupational therapists have a long history in working in team- based environments and therefore the implementation of occupational therapy services may be experienced differently than professions that have been primarily consultative.

Interprofessional teams are poised to play a greater role in the delivery of primary care in Canada and abroad [ 16 , 17 ]. It is anticipated that more disciplines will continue to enter primary care, making it critical to understand how professionals are being introduced into primary care teams. The purpose of the paper is to examine how occupational therapy is being integrated into primary care teams and understand the structures and processes supporting the integration.

The study aimed to explore the primary guiding question: What structures and processes support the integration of occupational therapy in Family Health Teams? A multiple case study design [ 18 ] was conducted that included four Family Health Team sites within the province of Ontario, Canada. Case study research seeks to investigate real life experiences within the context in which it occurs and involves the collection of detailed information using a variety of data collection methods [ 18 – 20 ]. As there are few documented examples of occupational therapists in primary care, a case study design enabled an in-depth exploration of how occupational therapy was being integrated into interprofessional primary care teams. As per case study methodology as outlined by Yin [ 18 ], each case provided an opportunity for the replication of the outlined questions and methods.

Site identification

Four cases (Family Health Teams) were identified from the approximately 20 that employed occupational therapists at the time of the study. The sites were chosen to reflect different dimensions of service provision that may influence the role and integration of occupational therapy. The literature on interprofessional collaborative practice has identified certain elements that support interprofessional collaborative care, including: (1) EMR, (2) team size, and (3) co-location of health professionals [ 6 , 13 ]. Each dimension was considered in the identification of the cases. Two further dimensions were considered in the case selection; academic versus community and rural versus urban. While there is little evidence examining the role of occupational therapist in primary care, the literature has described occupational therapy working with a wide range of client populations and conditions [ 4 ]. Therefore the nature and duration of clinical experience of occupational therapist as well as the full-time equivalency (FTE) were also thought to be important elements to consider in the identification of cases. Purposeful sampling of sites was used with the intent to sample breadth of communities, teams, and occupational therapists.

Participants

Information letters were sent to the Executive Director at each site describing the study and seeking approval for participation. All occupational therapists working at the Family Health Teams were asked to participate. The Executive Director and the lead physician were also invited due to their leadership and decision making roles on the team. In addition, any member of the team that provided collaborative patient care with the occupational therapist was also considered to be eligible for the study. The occupational therapist(s) at each Family Health Team acted as the main contact for liaising and coordinating interviews with the staff.

Ethics approval was provided by Queen’s University Health Sciences Research Ethics Board.

Data collection

Data collection drew on multiple forms of evidence including semi-structured interviews, document analyses and questionnaires. The principal investigator (CD) visited each Family Health Team to retrieve documents for analyses, distribute questionnaires and conduct interviews with key informants. See Table  1 for list of disciplines interviewed at each site. All interviews were conducted between the February-May 2012 using a semi-structured interview guide. Questions were developed by the research team and were informed by the literature on interprofessional collaborative primary care [ 11 , 12 ]. Questions fell under five broad categories including; roles (how would you describe your role, how did you establish your role), physical space (i.e. location of team members and primary care sites), community collaborations, collaborative practice (i.e. nature, processes and structures to support collaborative practice) and processes (i.e. nature and use of electronic medical record). Additional questions regarding funding for occupational therapy were included in the interview guide for the Executive Director and questions related to clinical practice were removed.

Program documents included job descriptions, occupational therapy assessments, team mission and vision. The web pages of each Family Health Team were viewed to obtain further information about team collaboration, and sites were contacted if further questions about the nature of occupational therapy services were identified. Two sites were contacted to clarify demographic information (number of sites and number of physicians) and the occupational therapist(s) at each site was contacted to provide further details on the referral process to occupational therapy. A Family Health Team Profile was completed by each Executive Director to obtain descriptive information about the Family Health Team demographics, including the type of electronic medical record system, number of rostered patients and health professional make-up. An Occupational Therapy Profile was completed by each occupational therapist to obtain information about their educational background and work experiences.

Data analyses

Both within-case and cross-case analyses were conducted [ 18 , 19 ]. Pattern matching was then used as the overall analytic strategy. This approach “compares an empirically based pattern with a predicted one” [18, p 106], where propositions are developed prior to data collection in order to identify a predicted pattern of variables. Propositions for this study were derived from the literature on interprofessional collaborative practice. A number of factors have been found to support interprofesional practice. One of these is the extent to which there is a shared understanding of team members’ roles and scopes of practice [ 12 ]. This was felt to be particularly relevant for the study as occupational therapists were new professionals within the teams. Studies have also identified the nature of team processes and organizational structures to be important influences on collaboration, and the nature of team processes was anticipated to influence the integration of occupational therapy [ 21 ]. The use of electronic medical records (EMR) have become standard in Family Health Teams in Ontario, Canada [ 22 ] and have already been found to support internal communication. Occupational therapists’ access and use of EMRs thus become an important element to consider [ 13 ]. Therefore, the two study propositions were:

Integration of occupational therapy into the Family Health Team will depend on the understanding of the occupational therapy role by team members, and structures to support interprofessional collaborative practice.

The EMR will be pivotal in supporting the integration of occupational therapy.

Each case was first analyzed individually, followed by cross-site analyses to determine common themes [ 19 ]. Data obtained from documents were extracted using apriori document analysis forms. Tables and matrixes were used to visually examine the data for each case and across cases. Qualitative interview data were digitally recorded and transcribed verbatim by a research assistant. Atlas ti, a qualitative data analysis and research software program, was used to code data and identify themes both within and across cases. All transcripts were read and re-read by the primary author and preliminary codes were established. A number of strategies were used to establish trustworthiness [ 23 , 24 ]. Four transcripts were read and independently coded by a second investigator (LL) using the preliminary coding structure. Transcripts were selected from four different health professions to ensure the coding structure could be applied across transcripts. Any discrepancies in coding were noted and discussed until consensus was reached. Two revisions to the coding structure were made; the first involved collapsing two codes into one code, the second revision involved renaming a code to better reflect the essence of the statements being captured.

A second strategy to establish trustworthiness involved member checking. Occupational therapists were provided with a preliminary summary of their site and asked to contact the primary author if any errors were noted, or if additional information should be included. None of the participants reported any errors or provided further information.

A third strategy involved triangulation of data methods, sources and investigators. The study included a number of data methods including interviews, questionnaires and document analyses. Each contributed to the understanding of how occupational therapists are integrated into primary care and structures to support the integration. Participants included members from a range of disciplines across four sites in order to provide different perspectives and experiences on the integration of occupational therapists. Finally, the investigation team was made up four occupational therapists; two academics (CD, LL), one administrative (CB) and one clinician working in primary care (CC). The diversity of the team brought unique perspectives to the design, implementation and analyses and grounded the study in both research and practice.

Table  2 provides a description of the four sites. Patient rosters ranged from 7,200 to 42,000 patients and sites were located in both rural and urban centres. Three sites were community sites and one was an academic site. The academic site had a dual mandate to provide both primary care services, and to educate medical students/residents and other health disciplines. Occupational therapists were all relatively new to their positions with a range of 3 to 18 months. Occupational therapists in two sites had less than five years experience, while two sites had occupational therapists with 15 and more years of experience. Each site had a unique complement of health providers, which included: chiropodists, psychologists, social workers, dieticians, physician assistants, pharmacists, patient educators, mental health workers, health promoters, respiratory therapists, case managers, nurses, nurse practitioners, and physicians.

Case 1: Very large rural community family health team

In case one the occupational therapists along with the interdisciplinary health providers and administrative staff were located in two buildings in the largest regional town, while the physicians worked in distributed clinics across the region. Despite the lack of co-location each key informant reported a strong sense of collaboration and connection. The EMR was the key structure for collaboration and integration of occupational therapy into the Family Health Team; face-to-face interaction with physicians is limited.

Case 2: Small urban community family health team

Case two was a small Family Health Team with four separate sites located in a large urban setting with a culturally diverse patient population. The occupational therapist was located with nursing and other interdisciplinary health providers across the street from one of the main physician sites.

Lack of co-location was described as a key barrier in the integration of occupational therapy. The Family Health Team was planning a new building to house all team members.

Case 3: Large rural family health team, one occupational therapist

Case three was a large rural Family Health Team providing primary care to approximately 45% of the local population. Having only been recently approved as a Family Health Team, the team was largely in the development phase. The Family Health Team had four separate sites. The occupational therapists and other interdisciplinary health providers were located at one site along with the administrative staff. Each site had its own EMR that could not communicate between sites. At the time of the study the occupational therapist did not have access to the EMR. The long-term goal was to move to one accessible EMR system.

Case 4: Urban academic family health team

Case four was an urban academic Family Health Team with two sites; each with a full interprofessional complement of professions. Services were organized by interprofessional care teams, where patients were designated to a team of clinicians. Two full-time occupational therapists worked between the two sites. The Family Health Team was part of the university Department of Family Medicine and therefore had a dual objective of providing primary care services and training family medicine residents, along with an expectation of research.

Cross case analysis

Three main themes and eight subthemes were identified that influenced integration of occupational therapists into the Family Health Teams: understanding of occupational therapy, collaboration, communication and trust. See Figure  1 for visual outline of the themes and subthemes.

figure 1

Themes and Subthemes.

1. Understanding occupational therapy

Fundamentally, an understanding of occupational therapy was critical and the tipping point for integration into the team. As referrals originated from team members, a basic understanding of the role of occupational therapy and patients who could benefit were required. Interdisciplinary health care providers and nurses described previous and current working relationships with occupational therapists, which in turn led to an understanding of the occupational therapy role within Family Health Teams.

The other integrated health professionals have been amazing. So I think they have a good idea of what OT is and I think a lot of them have worked with OT in the past (Occupational Therapist) 2P11:33:82

An understanding of and experience with occupational therapy in turn created a level of respect and natural integration into the team.

There’s a very healthy respect among our IHPs [interdisciplinary health providers] for the skill sets that they have and there’s a desire to include one another in the initiatives that they take on (Executive Director) 2P1:14:23

However, physicians had less direct day-to-day contact with occupational therapists, and less familiarity with the role of occupational therapy.

I feel that most family doctors didn’t and still don’t have a great understanding of the OT role (Physician) 4P4:1:6

Ultimately respondents felt that when team members had a good understanding of occupational therapy, referrals were made to the service.

That was the basis of our success here… that people really get what we do (Occupational Therapist). 1P1:93:220

Conversely, less familiarity with the role of occupational therapy was felt to result in an underutilization of services.

It’s underused, because I don’t think everyone knows what the OT can do (Nurse Practitioner) 2P5:5:13

Educating the team

Occupational therapists across all sites used a number of strategies to educate physicians and team members about occupational therapy including formal presentations, educational rounds, ‘meet and greets’, information booths, brochures and information letters. Occupational therapists provided information about the profession, particularly, the services they currently offered within the Family Health Team along with examples of potential services that could be provided. All opportunities were seen as positive and contributing to an increased understanding of occupational therapy.

I’m working on trying to educate the team in what OTs can do (Occupational Therapist) 2P5:5:13

Promoting the role of occupational therapy was a particularly important element during the early integration into the team and a role that needed to be consciously adopted by occupational therapists.

Engaging physicians: a physician champion

Physicians were seen as critical to the integration of occupational therapists as they were a key source of referrals. The identification of a physician lead, or physician liaison for occupational therapy was seen as an important strategy to enhance physician understanding and champion the occupational therapy discipline within the Family Health Team. Information from physician to physician was felt to have greater authority and credibility.

The communication was coming from a physician that they trust and he was saying ‘Use these services’ (Occupational Therapist) 1P1:94:221

A lack of physician engagement regarding the occupational therapy role was seen to significantly influence the integration of the role.

My regret about the occupational therapy program is that we haven’t done a good enough job of engaging the physician group in establishing that program … we’re definitely not utilizing her to the fullest extent that we could in her occupational specialization (Executive Director) 2P1:6:11

Enhancing understanding through research and teaching

Team members at the academic Family Health Team had additional requirements to engage in both research and teaching activities. As a result, site four had a number of unique strategies that served to increase the understanding of occupational therapy and support a deeper integration into the team.

There are two absolutely primary mandates of clinical care and education and then obviously scholarly work … you can’t really separate clinical cases from education in this [Family Health Team]. So our nurses are doing so much of the clinical care and we are reviewing our teaching and the allied health group, including the OT’s, are absolutely woven into that. From co-bookings, to horizontal electives, to the more structured learning opportunities with the rounds, to working with different groups of the learners so family medicine residents and allied health workers sharing the case together. Some of the family residents teach the more junior learner and then going to an allied health person for some input. (Physician) 4P4:26:38

Training was a reciprocal and iterative activity; building an understanding of occupational therapy and supporting collaborative patient care.

Occupational therapists were expected to participate in interprofessional teaching rounds, one-on-one resident training, education clinics and occupational therapy student mentorship. Each activity offered an opportunity for the team to be exposed to the role of occupational therapy and work with the discipline.

One of the really helpful things that [the occupational therapists] did is to take some time at our interprofessional rounds and walk us through their vision in 6 months. Here are the types of cases that are getting referred, and here are success stories of why it was helpful to be involved. Here are some priority areas for us to think about. And that was again, a really nice diplomatic way of increasing our understanding. (Physician) 4P4:11:14

None of the other sites had formal structures in which to provide physician education, nor were they involved in any residency training.

A number of team members were involved in research with occupational therapists at the affiliated University and had been previously exposed to the role of occupational therapy in primary care. This research experience was felt to support the integration of the occupational therapist by offering a deeper understanding of the role.

I think we were better positioned already for a level, a deeper level of understanding of the role of OT and PT in primary care. (Physician) 4P4:3:8

Enhancing understanding through research cultivated opportunities to integrate occupational therapy into clinic programs.

I didn’t know much about chronic pain and [the OT] has been working in chronic pain for over 20 years so I was interested in being part of the research project and she has been mentoring me in that role so we have now created a new [pain] group (Social Worker) 4P2:25:43

2. A culture of collaboration

While an understanding of occupational therapy facilitated referrals to occupational therapists, collaboration was seen as a benchmark of occupational therapy’s integration into Family Health Teams. Each site agreed that building team collaboration was a deliberate and intentional process.

We very deliberately, pretty much, do everything as a team with clinical work. (Physician) 4P4:22:36

Strong collaboration among interdisciplinary health providers was seen across all sites. In some cases assessments and interventions were conducted together with other interdisciplinary health providers.

[Occupational therapist] and I have gone to a couple of home visits together; because the person was appropriate for my services and her services . (Social Worker) 3P9:20:74

As many interdisciplinary health providers were also new to primary care they collaborated to support each other in their mutual integration into the team.

[the interdisciplinary health providers] … that’s my biggest source of support … so a lot of my referrals are actually coming from other allied health (Occupational Therapist) 3P11:33:82

Opportunities to collaborate at the point of care supported the integration of occupational therapy. However across sites there was notably less collaboration between the interdisciplinary health providers and physicians.

The physician group is not engaged strongly enough with the other health providers (Executive Director) 2P1:16:23

Less collaboration with physicians was attributed to a number of factors. First and foremost primary care has traditionally been practiced as a solo enterprise.

[The physicians] have always been the general practitioner that has done everything for their patients (Executive Director) 3P7:41:104

There was a sense that interprofessional collaboration may diminish the physicians’ sense of control.

I am sure there are a lot of physicians that do not like the ball being taken from them (Physician) 1P5:16:53

As physicians could see the benefit of occupational therapy services, opportunities for collaboration would be enhanced.

As physicians refer to the occupational therapist and have comfort level in what they’re getting back, that [occupational therapy] will improve [patient care]. More referrals will come and there will be more of an interaction. (Physician) 3P10:55:22

As the shift to interprofessional teams was relatively new, it was also felt that physicians were not used to having access to so many resources and needed to gain comfort with a team based approach

They’re not used to having this type of resources available to them on a daily basis in their clinics (Executive Director) 3P7:49:118

Program based care

Each site offered a number of health promotion and chronic disease management and prevention programs ranging from mental health, falls prevention, chronic pain and diabetes management. Aligning occupational therapy services within current programs of care provided an opportunity to integrate into the team.

There’s a COPD group that’s held here and I provide some consultation to that group and I’m slowly tying to integrate myself into some other groups we’re going to be starting (Occupational Therapist) 1P1:4:9

Integration into programs occurred in a number of ways. In some cases occupational therapists noted a gap in program offerings, which led to the development of a new program. More frequently, occupational therapists or other team members identified programs that had high volume or wait lists that would benefit from an occupational therapy perspective.

Our program is really busy .. it’s great to have that opportunity to put that person with [the occupational therapist] that specializes and might be able to have the time to do it (Social Worker) 3P9:38:86

The program focus also provided new opportunities to collaborate and engage in program development.

One of our ideas is to have a caregiver stress program … that was going to be a collaboration between [occupational therapist] and myself and the mental health therapist (Social Worker) 3P9:31:76

At two of the sites physicians were aligned with specific programs, which provided a formal opportunity to connect with physicians.

Collaborating with each other

As essential as interprofessional collaboration was in supporting the integration of occupational therapy, the ability to collaborate with occupational therapy colleagues both within and outside of the Family Health Team was also important. Occupational therapists shared resources, engaged in clinical consultations, and provided strategies to each other to support integration into the team.

This whole group of occupational therapists [working in FHT’s] are pioneers in the OT role. So any way we can support one another (Occupational Therapist) 1P3:62:225

Having two occupational therapists at one Family Health Team was seen to facilitate the integration of the role in number of ways. Most importantly it provided professional support and confidence to try new roles and share ideas. Simply having two individuals increased exposure to occupational therapy within the Family Health Team and enhanced the professional profile.

To have each other … I can’t imagine doing this role … as one person (Occupational Therapist) 1P1:27:54

3. Communication and trust

Communication and trust were essential components of collaboration and the integration of occupational therapy, and were supported by a number of strategies including co-location, EMR and formal and informal meetings and gatherings.

Facilitating communication: the electronic medical record

A single and accessible EMR was a critical feature in supporting the integration of occupational therapy into Family Health Teams. The EMR enabled both formal and informal communication with physicians and other team members through the messaging system and patient records. The instant messaging function served as an internal communication system.

I think the EMR allows us to communicate effectively. We can instant message and that piece provides opportunity (Social Worker) 1P2:24:65

The EMR provided a means to collaborate when co-location of team members was not possible, supporting virtual interprofessional teams.

The EMR is fabulous because not only can you communicate back and forth, but everyone can see everyone’s charts. It is like one big family medicine chart. (Physician) 1P5:12:41

The EMR was also seen to support efficient and informed clinical practice.

The OT gets a snapshot of that patient and they’re better equipped to do what they need to do. And to get to the point a lot quicker (Physician) 1P3:40:127

Building trust: co-location

While an integrated EMR provided a foundation for communication, the opportunity for team members to connect face-to-face was pivotal in developing relationships and supporting the integration of occupational therapy. The importance of occupational therapy being located with the entire team cannot be underestimated. Only one of the four cases had a full interprofessional team located in the same building, however two of the other cases had plans to consolidate their clinics. Co-location offered opportunities for occupational therapists to engage in informal communication, have ‘hallway consults’ and be visually present; all of which contributed to understanding the OT role and building of trust.

There are other times where you are not sure if [occupational therapy] would be helpful or not. It is much more relevant to have an [informal] case conversation first and then whatever you end up writing in [the EMR] references the conversation, which is obviously much richer. (Physician ) 3P4:15:22

One site created team rooms where all team members worked in a common desk area, along with common lunch rooms and meeting spaces. When co-location occurred only with other interdisciplinary health providers and nurses, the benefits of communication and understanding were also identified; however as physicians were a key source of referrals their physical presence was viewed as a critical.

Physically we don’t see the [physicians] very often. I think that can spark some reminders, or spark some ideas, as well as is great for relationship building. (Social Worker) 4P9:45:110

Interprofessional meetings and gatherings

Formal meetings provided opportunities for team members to interact, most notably in cases where occupational therapists were off-site from physicians.

Just going to the meeting is an opportunity to talk, see what everyone does (Occupational Therapist) 1P1:66:143

Just as important as meetings, social gatherings supported team building and enabled the team to get to know each other as individuals.

We’ve spent some good networking sessions … you get to know that person and all of a sudden “OK, I’ll trust you with my patient” (Executive Director) 1P3:19:73

Ultimately, the integration of occupational therapy into the primary care teams was grounded in three key factors: trust, understanding, and communication. Meetings and gatherings provided opportunities to facilitate connections and team building.

Integration has been described as one end of the continuum that extends from complete autonomy and independence at one extreme to complete integration of professional services at the other [ 25 ]. In this study, the integration of occupational therapists was observed to range along this continuum and varying both between and within the Family Health Teams. In these cases, occupational therapists were more integrated with the other interdisciplinary health providers such as social workers and pharmacists, than with either nurses or physicians. Vertical and horizontal integration have been used to describe the integration of health services. Horizontal integration refers to the grouping of similar organizations or services, while vertical integration “services a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined community” [ 26 ]. Within the Family Health Teams occupational therapists tended to work closely and collaborate with other allied health professionals in the delivery of health services. Allied health professionals had a common goal of supporting the physicians in the delivery of primary care. While each had different disciplinary perspectives, occupational therapists could be described as being horizontally integrated with their allied health counterparts. Each was remunerated in a similar fashion, worked in close physical proximity, had informal communication structures and provided some degree of collaborative patient care.

In contrast, occupational therapists had relatively little direct contact and few interactions with physicians. The occupational therapy role was seen as supporting the continuum of health services within the Family Health Team and integration could be envisioned as being vertical relative to the physicians. This is congruent with the literature reporting that a key barrier in the implementation of interprofessional teams has been the hierarchical structures within primary care [ 27 – 29 ]. Of note, however is a recent study suggesting that younger cohorts of male physicians are more likely to collaborate with occupational therapists, and other health professionals than older counterparts or younger female physicians [ 30 ]. Occupational therapists at the academic site experienced a high level of integration into the team, including with physicians, nurses and other interdisciplinary health providers. Given the focus on collaboration and teamwork in the training of family medicine practitioners, it makes sense that younger physicians who have had experience with interprofessional collaboration enact this as practicing physicians.

This study also found that the extent of occupational therapists integration into Family Health Teams was influenced by the nature of services provided. Integration was more fully realized within chronic and complex disease programs of care, such as a diabetes or seniors program, than one- time referrals to occupational therapy. This study suggests a plausible explanation for this phenomenon. The more structured programs served to identify and formalize a team of providers and offered an opportunity to develop common patient goals and a shared vision of service delivery. This in turn facilitated communication and the implementation of processes to support the programs, such as meetings and common program outcomes. Russell and colleagues [ 31 ] examined chronic disease management programs and found that organizational features had the greatest influence on patient outcomes. In particular, those clinics with the presence of a nurse practitioner had better outcomes and high-quality chronic disease management care was found most commonly in clinics with an interprofessional team. The success of chronic disease management programs in part contributed to the collaborative nature of the care, highlighting the importance and benefit of integrating professionals within programs of care.

At the same time it is recognized that not all care provided by occupational therapists within primary care teams will be program based. Leutz [ 32 ] described five laws for integration, one of which was “you can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people” (p. 83). This may hold true for occupational therapists in the sense that certain elements of their work within the teams may be more individual and consultative in nature.

The literature has described a number of factors that support interprofessional teamwork in primary care [ 21 , 28 , 29 ]. Xyrichis and Lowton [ 21 ] identified both team structures and team processes that support collaboration. As was seen in this study, Family Health Teams with a greater number of structures to support teamwork had occupational therapists that were more fully integrated. Processes that were seen to support the integration of occupational therapist included co-location, a common EMR, formal and informal communication structures and team meetings. Each of these processes naturally facilitated the integration of occupational therapy into the team by building trust, understanding and familiarity. It was the processes and structures, more than the personal characteristics of the occupational therapist that appeared to influence integration. However, the two sites with the greatest supports also had occupational therapists with substantial work experience. Further research is required to explore the relationship between personal characteristics and the integration process. A recent study [ 22 ] examined teamwork within twenty-one Family Health Teams in Ontario, Canada. A survey was used to identify organizational factors contributing to the functioning of an interprofessional primary care team. The study found that culture, leadership and EMR functionality predicted team climate. Each of these elements was also seen to support the integration of occupational therapy in this study.

Studies examining the integration of pharmacists reported some lack of understanding of the role of the pharmacist, but not to the extent found in this current study [ 13 – 15 ]. It is not surprising that the lack of understanding about a profession’s role impedes their integration into the team. The current siloed approach to the training of health care practitioners and practice of health care may be a contributor [ 33 ]. For disciplines new to primary care, there will be a natural learning curve about both the roles of other professionals as well as their own role in a new practice setting. Kolodziejak and colleagues [ 15 ] outlined a step-by-step process to support the integration of pharmacists into established primary care teams. Part of the process of integration included defining the role prior to joining a team and determining early credibility. The current study found a number of intentional strategies were used to integrate occupational therapy within the team, however more formal guidelines to Family Health Teams who have new professionals could further support integration.

The study also found that informal and formal support by occupational therapy colleagues was also helpful in supporting integration. Communities of practice have been shown to support knowledge translation [ 34 , 35 ] and this could be another intentional strategy that is enacted.

Interprofessional education occurs “when two or more professions learn with, from and about each other to improve collaboration and the quality of care ” [ 36 ]. In the case of the academic Family Health Team, the educational processes designed to support physician learning provided a natural opportunity and environment to educate team members of their roles. Without such structures, the occupational therapists at the other sites did not have a forum to provide formal physician education. A growing amount of literature on interprofessional education suggests that experiential based learning is an effective strategy to teach health professionals the competencies of collaborative practice [ 37 , 38 ]. While there are only a small number of academic Family Health Teams, there is much to be learned about the research and teaching activities that can support the integration of new team members.

It must be remembered that this study was limited to four sites. Given the influence of structures and processes on collaboration and integration, it is anticipated that additional sites might have provided further insights into the variety of other assets or constraints to interprofessional integration. Occupational therapy is a new profession within Family Health Teams and the paper focuses on the early integration in the team. Therefore the integration of occupational therapy will continue to evolve and be shaped by individual, team and organizational development. The study was exploratory in nature and while it provides insights into the emerging role of occupational therapy within a primary care context, the results cannot be broadly generalized.

This study builds the foundation for further research. A longitudinal study would provide insights into how health professionals are integrated into teams over time. It would also be of value to understand how integration influences health outcomes and more specifically to use a framework of systems integration in which to understand interprofessional primary care teams. Finally, it would be important to explore how professionals within Family Health Teams were integrated into the broader community services.

Conclusions

With an increased emphasis on interprofessional primary care, new professions will continue to be integrated into primary care teams. Based on the current study the following strategies and structures should be considered to support occupational therapists entering primary care teams.

Occupational therapists entering primary care need to formally include the education of team members in their professional role. Education on the role of occupational therapy and services provided needs to be directed to all team members, with specific focus on physicians.

Occupational therapists need to ensure they gain full access to the EMR to support both informal communication, through the internal messaging features, as well as formal patient documentation and referrals.

Occupational therapy fieldwork placements can provide a mechanism to engage the team in learning about other professions. Student occupational therapists should also be involved in the education of team members.

When possible, occupational therapists should actively participate in educating students from other health disciplines, including offering shadowing opportunities, providing handouts, arranging co-bookings or developing inservices.

Occupational therapists need to actively develop their role in existing interprofessional groups and programs offered within the primary care setting. Working within a structured program provides an opportunity to work closely with team members and can facilitate a deeper understanding of the occupational therapy.

Occupational therapists need to attend networking events, meetings, inservices and social functions to build relationships with team members.

The study adds to the growing body of literature that has identified structures and processes to support interprofessional collaboration in primary healthcare. Exploring the integration of an emerging discipline in primary care underscores the necessity of ensuring team members have an understanding of the roles and scope of each team member. The study also highlights the critical role that communication structures, such as formalized meetings and EMR’s, have in supporting the integration of new professions.

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Acknowledgements

We wish to acknowledge the Family Health Teams who participated in the study. We would like to thank Dr. Lyn Shulha for her support and insightful comments on the final drafts of the manuscript. We would also like to thank Kristina Sheridan and Tanya Cerovic for their assistance with transcription and data management. The study was funded by the Primary Healthcare Seed Funding.

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Christie Brenchley

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Candace Crawford

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CD, LL, CB, CC contributed to the design of the study. CD participated in the coordination and acquisition of data. CD, LL, CB contributed to the analyses and interpretation of data. CD participated in the draft of the manuscript and LL, CB, CC provided feedback and approval of the final draft. All authors read and approved the final manuscript.

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Donnelly, C., Brenchley, C., Crawford, C. et al. The integration of occupational therapy into primary care: a multiple case study design. BMC Fam Pract 14 , 60 (2013). https://doi.org/10.1186/1471-2296-14-60

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Maureen E. Neistadt , Jennifer Wight , Shelley E. Mulligan; Clinical Reasoning Case Studies as Teaching Tools. Am J Occup Ther February 1998, Vol. 52(2), 125–132. doi: https://doi.org/10.5014/ajot.52.2.125

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Objective. Students are taught how to apply clinical reasoning methods through a variety of teaching methods, including the use of case studies. Various types of case studies have been described in the literature: paper cases, videotape cases, simulated client cases, and real client cases. This study examined the effectiveness of a new type of paper case study—the clinical reasoning case study—in teaching the clinical reasoning process to occupational therapy students .

Method. Four seniors in an undergraduate occupational therapy program completed intervention plans in response to both traditional medical model and clinical reasoning paper case studies. Qualitative methods were used to analyze intervention plans and videotaped discussion about this learning experience .

Results. Themes discovered in the data sources suggest that compared with traditional case studies, the clinical reasoning case studies increased the quality of participants’ intervention plans, participants’ confidence levels about their plans, and participants’ understanding of the clinical reasoning process. Participants also reported preferring clinical reasoning case studies over traditional paper case studies .

Conclusion. The clinical reasoning case studies are effective teaching tools because they provide students with a holistic picture of the client and his or her occupational therapy treatment. In addition, these case studies model the clinical reasoning process by organizing client information according to the types of clinical reasoning that would be used to gather that information. Occupational therapy educators may find this type of paper case study useful in introducing students to the intervention planning process .

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Becoming occupation-based: a case study

Affiliation.

  • 1 1Department of Occupational Therapy, Eastern Kentucky University, Camille, Richmond, USA.
  • PMID: 24867352
  • DOI: 10.3109/07380577.2014.921751

This descriptive case study illustrates the experiences of a 55-year-old male with a chronic disability resulting from a stroke, living in the community and a clinician's trial using occupation-based interventions predominately in a rehabilitation setting. The participant engaged in occupation-based interventions three times a week for 5 weeks guided by the Canadian Occupational Performance Measure (COPM). Data were collected through semi-structured interviews during the intervention sessions and journal entries made by the therapist. Results suggested occupation-based interventions facilitated a transformation for both the client and the therapist by enhancing the participant's occupational performance and the ability to resume previous roles. The therapist's belief in the power and value of occupation-based practice was reinforced and validated, particularly in the rehabilitation of an individual with chronic stroke.

Keywords: Client-centered; occupation-based; occupational performance.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't
  • Activities of Daily Living*
  • Chronic Disease
  • Disabled Persons
  • Interviews as Topic
  • Middle Aged
  • Occupational Therapy / methods*
  • Occupations*
  • Stroke Rehabilitation*

IMAGES

  1. (PDF) Occupational Therapy Using a Sensory Integrative Approach: A Case

    occupational therapy case study research

  2. Occupational Therapy

    occupational therapy case study research

  3. (PDF) Experiences of occupational therapy students in the first

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  5. Occupational Therapy ADHD Case Study Assessment

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  6. Occupational Therapy ADHD Case Study Assessment

    occupational therapy case study research

COMMENTS

  1. Exploring the contribution of case study research to the evidence base for occupational therapy: a scoping review

    This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base. Methods

  2. How Qualitative Case Study Methodology Informs Occupational Therapy

    Case studies in the occupational therapy literature have explored phenomena relating to the delivery of intervention, theoretical concepts, clinical reasoning, and education and research methods and were situated in a range of different practice areas and contexts.

  3. Exploring the contribution of case study research to the evidence base

    This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base. Methods

  4. Exploring the contribution of case study research to the... : JBI

    Whilst these studies offer a justification for the use of case study research in occupational therapy and a call for greater uptake of the method, they present a narrow view of its use by focusing on a specific case study methodology or a limited literature search. To date, no extensive review of all the empirical case study research in ...

  5. PDF Case study research: building the occupational therapy evidence base

    Feb. 2024 Case study research: Building the occupational therapy evidence base one case at a time Leona McQuaidab* and Katie Thomsonac and Katrina Banniganad aDepartment of Occupational Therapy Human Nutrition and Dietetics, Glasgow Caledonian University, Glasgow, Scotland b ORCID 0000-0002-6819-8784 c ORCID 0000-0002-2558-2559

  6. Case study research: Building the occupational therapy evidence base

    Case study research can capture the context and complexity of occupational therapy practice. Cases can then be pooled to make a substantial contribution to the evidence base. Conclusions Occupational therapists should consider the use of case study research to produce practice related, meaningful research.

  7. Case study research: Building the occupational therapy evidence base

    35171068 10.1080/11038128.2022.2039758 Highlights a changing landscape in the literature about how best to conduct research in health and social care, particularly for complex interventions and describes a pragmatic approach to case study research for occupational therapy.

  8. PDF Exploring the contribution of case study research to the evidence base

    ing review explores case study research within occupational therapy in terms of how it is dened, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base.

  9. Exploring the contribution of case study research to the evidence base

    This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base.

  10. Exploring the contribution of case study research to the ...

    Studies will be excluded where the occupational therapy context cannot be clearly defined, for example, where they are multi-disciplinary focused or where a case study research design is not explicit (eg, a descriptive case report without data collection). All countries and practice settings will be included.

  11. Thinking in Stories: Narrative Reasoning of an Occupational Therapist

    This qualitative case study research (Thomas, Citation 2015) supported construction of a case that is both exemplary - as a good example of occupational therapy - and instrumental in facilitating readers' in depth understanding (Simons, Citation 2009) with the aim of bringing the case to life.

  12. Full article: How context influences person-centred practice: A

    How context influences person-centred practice: A critical-creative case study examining the use of research evidence in occupational therapy with people living with dementia Niamh Kinsella a Division of Occupational Therapy and Arts Therapies, Queen Margaret University, Musselburgh, Edinburgh, UK Correspondence [email protected]

  13. The integration of occupational therapy into primary care: a multiple

    The objective of the study was to examine how occupational therapy services are being integrated into primary care teams and understand the structures supporting the integration. ... Case study research seeks to investigate real life experiences within the context in which it occurs and involves the collection of detailed information using a ...

  14. An integrative review of case study methodologies in occupational

    Occupational therapy research would benefit from a higher number of case study designs to reflect the complexity, subjectivity and person centredness of the profession. Discover the...

  15. Conducting case study research in occupational therapy

    Results: Case study research offers occupational therapists a scientific methodology that can be used to understand and develop occupational therapy practice. Conclusion: This paper argues that case study research should be used more extensively by occupational therapists as the method respects the basic principles of occupational therapy.

  16. Exploring the contribution of case study research to the evidence base

    This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and...

  17. Multiple-Case Study Exploration of an Occupational Perspective in a

    This observational multiple-case study included video and audio-recordings of three participants (one male, one female, one nonbinary) completing the ACS-Aus (18-64) and semi-structured interviews at 1-week follow-up.

  18. How Qualitative Case Study Methodology Informs Occupational Therapy

    Case studies in the occupational therapy literature have explored phenomena relating to the delivery of intervention, theoretical concepts, clinical reasoning, and education and research methods and were situated in a range of different practice areas and contexts.

  19. Occupational Therapy Using a Sensory Integrative Approach: A Case Study

    This article presents a case report of a child with poor sensory processing and describes the disorder's impact on the child's occupational behavior and the changes in occupational performance during 10 months of occupational therapy using a sensory integrative approach (OT-SI). METHOD.

  20. Explanatory case studies: Implications and applications for clinical

    Explanatory case study methodology has been used to research complex systems in the fields of business, public policy and urban planning, to name a few. While it has been suggested by some that this might be a useful way to progress complex research issues in health science research, to date, there has been little evidence of this happening.

  21. Clinical Reasoning Case Studies as Teaching Tools

    Occupational therapy educators may find this type of paper case study useful in introducing students to the intervention planning process. Keywords: clinical reasoning This content is only available via PDF. Copyright © 1998 by the American Occupational Therapy Association, Inc. You do not currently have access to this content. Sign In

  22. Ethical considerations in qualitative case study research recruiting

    In the nature of case study research, the design evolved and was therefore not straightforward to explain fully in advance. I was encroaching on the potentially sensitive area of interactions between client and professional, and the occupational therapy of interest happened in people's homes, where I was seeking to observe and even film.

  23. Becoming occupation-based: a case study

    1Department of Occupational Therapy, Eastern Kentucky University, Camille, Richmond, USA. 24867352. 10.3109/07380577.2014.921751. This descriptive case study illustrates the experiences of a 55-year-old male with a chronic disability resulting from a stroke, living in the community and a clinician's trial using occupation-based interventions ...