Experiences of Dutch and Swedish Occupational Therapists and Teachers of Their Context-Based Collaboration in Elementary Education

ABSTRACT

Context-based collaboration between teachers and occupational therapists has shown promise as a strategy to enhance teachers’ capacity to enable the participation of children in elementary schools. In this study, we applied the Canadian Partnering for Change (P4C) model as a collaborative, coaching- and context-based approach in the Netherlands and Sweden. The aim was to gain insight into teachers’ and occupational therapists’ experiences of their collaboration applying P4C within their specific European elementary school context. To this end, we held semi-structured interviews with 4 teachers and 4 occupational therapists and performed a conventional, inductive content analysis of the ensuing interview transcripts. We found that participants’ collaboration in the classroom context was a continuous, multi-stage process that we defined as a unique mastery journey toward collaborative learning and trustful partnership. Participants indicated that they needed time to become familiar with the new collaboration, how they learned from each other, and that they enhanced children’s inclusion by applying strategies collaboratively. The results carry implications for the embedment of collaboration in schools and offer relevant strategies that serve the inclusion of all children. We propose that future studies evaluate the effects of P4C and seek to obtain a holistic picture of collaboratively applied actions.

Keywords:

• Context-based Collaboration
• Elementary Education
• Participation
• Occupational Therapist
• Teacher
• Partnering for Change Model

Introduction

In Europe, collaboration between teachers and health care professionals aimed to enable inclusive education has attracted increasing attention (Hesjedal, Hetland, Iversen, & Manger, 2015; Wiedebusch, Maykus, Gausmann, & Franek, 2022). As enshrined in the Dutch law of inclusive education (Rijksoverheid, 2017) and the Swedish Education Act (Utbildningsdepartementet, 2010), all children are entitled to participate in a full range of educational experiences with or without extra support. Moreover, the European Parliament, Council, and Commission (2017) have stressed that inclusive education is a priority area of European cooperation in the field of education and training. The aim of inclusive education in a general education classroom is to ensure that all children, with and without special needs, can learn together. Such approach, however, leads to increased diversity in the classroom, requiring teachers to respond to children’s various demands. Although the majority of teachers favor such type of education (Cusiël, 2010), they do experience a high workload and feel they lack the knowledge and skills to effectively support this diversity in the classroom (Leinonen, Brotherus, & Venninen, 2014; Pijl, 2010). Indeed, Phillips (2021) has argued that teachers’ support for letting diverse children participate in school situations, albeit high in rhetoric, is typically low in practical application. To address this shortcoming, schools have more frequently started to look for expertise beyond their own discipline. Similarly, Dutch and Swedish policy guidelines encourage health professionals to work at school with children and to coach and collaborate with schools as well (Peeters, Sharmahd, & Budginaite, 2018). Involving professionals from two different sectors (Friend, Cook, Hurley-Chamberlain, & Shamberger, 2010), such collaboration between health and educational contexts has been referred to as “intersectoral collaboration” (Wintle, Krupa, DeLuca, & Cramm, 2021).

Numerous studies have emphasized that collaboration between professionals from both the school and health sectors in school teams is one of the most promising factors that foster the success of school inclusion (Hoppey, Black, & Mickelson, 2018; McIntosh, Dale, Kruzliakova, & Kandiah, 2021; Mulholland & O’Connor, 2016) and that enhance teachers’ knowledge, skills, and attitudes (Borg & Drange, 2019). Combining different fields of knowledge has been considered an ideal method to allow children to successfully participate in education (Piškur et al., 2021). As such, the school context has increasingly become a place of collaboration (Edwards, 2009; Stone & Charles, 2018) where various health care professionals, occupational therapists (OTs) included, have made their entry. With their knowledge and analysis of the impact of environmental factors on occupations, OTs are able to understand children’s needs in inclusive education from a different perspective, thereby complementing that of teachers (O’Donoghue, O’Leary, & Lynch, 2021; Wilcock, 2006). Although OTs have traditionally worked with children outside the classroom context (Kaelin et al., 2019), previous research has demonstrated that they do not consider picking out children with special needs for individual therapy at school an effective strategy. Instead, they prefer to adopt a more holistic approach and work on class level. In a similar fashion, research in occupational therapy has suggested that services in the school context should be integrated (Watt, Richards, Woolley, Price, & Gray, 2021).

Yet, collaboration between two different professionals is rarely a natural process. Various authors have pointed out challenges of collaboration that must be tackled, including a lack of communication or time, and advice that is inappropriate to the context (Benbassat & Baumal, 2009; Benson, Szucs, & Mejasic, 2016; Cahill, McGuire, Krumdick, & Lee, 2014; Suc, Bukovec, & Karpljuk, 2017). These challenges often proved to be a source of frustration and were not considered as the way forward (Suc, Bukovec, & Karpljuk, 2017). In a similar vein, a recent meta-review (Mieghem van, Verschueren, Petry, & Struyf, 2020) stressed that, in order to build teachers’ capacities, it is important to develop effective collaborative programs that consider the specific teaching and organizational context (Kurniawati, de Boer, Minnaert, & Mangunsong, 2014; Roberts & Simpson, 2016). An integral, collaborative approach embedded in the school context is therefore recommended (Van der Bij, 2017). Apart from that, Meijer (2015) advocated the use of a more preventive approach that encourages the uptake of inclusive strategies for all children in a classroom rather than targeting individual children with participation restrictions only. Hence, to best support classroom diversity and to build teachers’ competences which will benefit all children, the school, teachers, and OTs should strive to improve coordination and collaboration among them (Bucci & Reitzammer, 1992).

Two recent scoping reviews (Anaby et al., 2013, Meuser, Piskur, Hennissen, & Dolmans, (2022) have demonstrated that the majority of context-based interventions still focus on applying supportive teaching methods to enable the participation of an individual child with or without a collaborative approach. Among these interventions, the Partnering for Change (P4C) model stands out as it aims to foster collaboration between teachers and OTs, leading to increased teacher capacity (in terms of knowledge, skills, and attitudes) (Campbell, Camden, & Missiuna, 2016) by integrating tailored coaching strategies into their context (Missiuna et al., 2012a). In Canada, this P4C approach has had a positive effect on school participation among all children, with and without special educational needs (Campbell, Kennedy, Pollock, & Missiuna, 2016).

Description of the Partnering for Change Model

The Partnering for Change model espouses the following four principles to which the “4 C” in its abbreviated form “P4C” refers: Building Capacity through Collaboration and Coaching in Context. According to the model, OTs are experts who enable children’s participation at school as it is their primary goal to enable people to participate in their daily life activities by modifying the occupation or the environment (Missiuna et al., 2012b). That said, it aims to create a context that facilitates the successful participation of all children in school through enhanced collaboration between OTs, parents, and teachers. This collaboration should take the form of a long-term, high-intense partnership in which partners complement, rather than merely work alongside, each other. The theoretical background underlying this approach is based on the Response-to-Intervention model (Fuchs & Fuchs, 2006; Missiuna et al., 2012b). According to this model, collaboration between teachers and OTs should take place on the following three levels: (1) Universal design for learning, meaning that instruction is based on principles that are valuable for all children in the classroom; (2) differentiated instruction, referring to the use of specific strategies to support a group of children experiencing special needs; and (3) accommodations to offer individual children additional support (Boyle, 2017).

Although this embedded, collaborative approach is known to be effective in Canada, there is no empirical evidence about its working mechanisms in Europe. Oftentimes, OTs are not part of the school system in Europe, and didactics also differ to some extent from the Canadian school system. However, it seemed promising to try out this approach outside the Canadian context and to consequently adapt the model for implementation in two European contexts. We therefore brought together researchers from both the Netherlands and Sweden to collaborate on this research which is part of a larger NordForsk-funded research project under the thematic “Education for Tomorrow” program. The research project is entitled “Politics of belonging: Promoting children’s inclusion in educational settings across borders (no. 85644).” With this study, we wanted to gain insight into teachers’ as well as OTs’ experiences of their collaboration applying the P4C approach within the Dutch and Swedish elementary school contexts. To this end, we formulated the following research question: “How do Dutch and Swedish teachers and occupational therapists describe their collaboration while applying Partnering for Change in two European countries?”

Materials and Methods

Design and Setting

Consistent with our research question, we chose a descriptive, qualitative study design (Sandelowski, 2000). We conducted two pilot studies in which we applied the P4C model in four Dutch (October, 2018 – April, 2019) and two Swedish (October, 2019-June, 2020) elementary schools, respectively. To ensure feasibility and appropriateness of the Canadian P4C approach, we adapted it to the Dutch and Swedish elementary school contexts.

Participants

A total of five Dutch and four Swedish teachers agreed to work together with a trained P4C OT in their classroom. All schools were mainstream elementary schools and children’s ages ranged from 6 to 12 years. We first sent a letter to the parents or placed information on the internal online platform of the participating classes to inform them about the study. We applied the following inclusion criteria: (1) The participating teacher and OT had not worked as a pair before; (2) the teacher participated voluntarily and was able to identify unmet support needs prior to the intervention; (3) occupational therapy practices were willing to participate; and (4) the teacher and OT were positive about the prospect of collaborating with each other intensively during the intervention period. In the Netherlands, the first and last author purposively contacted three occupational therapy practices in Southern Limburg and selected three OTs accordingly based on the inclusion criteria. In Sweden, we selected two OTs who had already been part of the school team as each of the purposively selected schools had one OT employed in the student health services.

Procedure of the P4C Approach

Prior to the start of the intervention period, all OTs took seven online training modules originally developed by the Canadian P4C research group. In the Netherlands, these original English modules were translated into Dutch, whereas in Sweden they were only partly translated into Swedish. Designed to increase OTs’ knowledge and skills in delivering P4C, the modules consisted of relevant readings, video clips, case scenarios, and experimental activities. The project leaders subsequently planned prior meetings with all participating schools. In the Netherlands, this kickoff meeting was intended to thoroughly inform all teachers and OTs about the P4C model and research project as well as to share experiences from a previous pilot study. The teachers and OTs who attended this meeting were paired and subsequently made first agreements about the times they would collaborate, while sharing mutual expectations. In Sweden, the second and third author organized a meeting with each school and the paired OT to describe the study and P4C. After these first meetings, teachers and OTs from both countries started their collaboration in the classroom.

To support OTs in the collaborative process, they participated in national online peer support meetings. In the Netherlands, these meetings took place biweekly and were led by the first and last author, whereas the second and third author organized five such meetings in Sweden, affording OTs the opportunity to ask questions and share their experiences. An expert therapist from the Canadian P4C team regularly joined the Dutch meetings for additional support. Once trained, the OTs from both countries spent four continuous hours per week in the classroom together with the teacher during a period spanning 12 to 16 weeks. One Swedish OT used digital communication, thereby spending less hours in school due to the COVID-19 pandemic. Finally, we invited teachers and OTs to plan joint reflection moments after each session without the children, which took 10 to 30 minutes each.

Data Collection and Instrumentation

After the intervention period, we held individual, semi-structured interviews with all participating teachers and OTs to obtain their experiences. In the Netherlands, participants could choose whether interviews were held at school, a private practice, or at home. In Sweden, however, all interviews took place via video conferencing, not only because of the COVID-19 pandemic but also due to the long distances. All participants gave their informed consent prior to the interviews which lasted between 0:25 h to 1:15 h and were audiotaped. To enhance credibility, we gave each interviewee the opportunity to refuse participation (Shenton, 2004). We first developed two semi-structured interview guides in English, one for teachers and one for OTs, and subsequently translated these into Dutch and Swedish. The interview guides comprised one main question (Could you tell about your experiences of having a P4C expert in your classroom?) and three subsequent questions (What challenges have you experienced during the P4C process? What kind of successes have you experienced? What would you like to change/adapt in the way P4C was applied?). Interviews were conducted by the first, second, and third author. After data collection, we subjected eight interview transcripts to further analysis (four Dutch and four Swedish transcripts, 2 from teacher interviews and 2 from OT interviews each). In the Netherlands, we assigned one OT to three classrooms. As we only wanted to include transcripts of distinct teacher-OT pairs, we only selected one of the Dutch teacher transcripts that was most rich in information for further analysis. In Sweden, we only included interviews with general education teachers and paired OTs.

Analysis

We adopted a systematic approach to scrutinizing our data, by performing a conventional, inductive content analysis (Bengtsson, 2016; Hsieh & Shannon, 2005). All interviews were transcribed verbatim and, as such, we considered all transcripts as one unit of analysis. In order to organize and elicit meaning and to draw realistic conclusions from the data collected (Polit & Beck, 2006), we analyzed the data using open and axial coding. The first step was to identify meaning units from the first four interview transcripts and to label these with a code that needed to be understood in relation to the context. The Dutch team (first and last author) started by scrutinizing two Dutch transcripts, whereas the Swedish team (second and third author) examined two Swedish transcripts. The units identified were then translated into English and discussed during a first debriefing session between the two teams. To increase credibility, both teams performed the analysis separately. Three debriefing sessions followed to reach mutual understanding on the codes and themes identified, which resulted in a total coding list. Based on these codes, the Swedish team translated relevant extracts from Swedish transcripts and delivered these to the first author who checked whether all content aspects had been covered in relation to the study aim and revised the coding list accordingly. In the next stage, the researchers used axial codes to create categories of topics. At all stages, the second, third, and last author reviewed the codes and provided feedback. In the last stage, we used the axial codes to formulate major themes that best summarized the data. Finally, to enhance credibility, we performed a member check by sending the results of the analysis to respondents for approval (Lincoln & Guba, 1986).

Results

From the analysis of the interviews we learned that teachers and OTs from the Netherlands and Sweden described their experiences of their collaboration applying the P4C approach within their respective school contexts as a “Collaborative journey toward a trustful partnership and co-designed strategies that enhance classroom inclusion.” This description depicts a journey that teachers and OTs undertook together. During this process, participants reported that they experienced an initial phase of insecurity, after which they started to establish a mutual relationship, thereby broadening each other’s perspectives, up to a point where they found themselves co-designing and applying inclusive, environmental strategies in the classroom context.

An Initial Phase of Insecurity Among Teachers and OTs

All teachers proudly described their journey and their associated achievements. When they signed up for this project at the start of the P4C approach, most of the teachers did not really know what it would be like to have an OT observer in their classroom. They were unsure what to expect from the P4C model based on the information they had received beforehand and knowing what OTs usually offered. Therefore, they remembered well how insecure they felt at the very beginning of this journey. As Dutch teacher Teun explained:”[You] jump in at the deep end without knowing exactly what this means.”

Moreover, teachers from both countries mentioned that the presence of another person in their classroom made them feel very vulnerable. In the beginning of the collaboration, they felt a certain tension as Dutch teacher Jolien commented: “Having another person observe you brought up feelings of stress.” After the first sessions together in the classroom, however, teachers from both countries explained that former doubts and suspiciousness gave way to openness and curiosity about their different perspectives and that “it almost felt like getting into a relationship.” OTs from both the Netherlands and Sweden reported similar feelings of insecurity. In the beginning, they did not yet understand how they could be of additional value to the teacher in the capacity of P4C therapist in the classroom. Furthermore, being at school in quite a different role than usual made them feel uneasy. This transition from being a traditional OT to a P4C expert was experienced as “not always an easy one.” Nevertheless, the open attitude of the teacher removed some of their insecurity and made them feel welcome:

The teachers have been open-minded. It feels like they have seen it more as a support. In any case, there is nothing that they have expressed to me [e.g., concerns of rivalry] or that I have felt that way

(Astrid, OT, Sweden).

Toward a Mutual Relationship

Both Dutch and Swedish teachers underscored the importance of taking the time to get to know each other and to talk about the observations OTs had made, to analyze them together, and also to discuss their mutual expectations. In the words of Dutch teacher Teun:

That you have the possibility to spend 15 or 20 minutes only the two of you – to have that time in order to succeed. That is one of the reasons why, in the end, we‘ve collaborated so successfully [to be able to apply new classroom strategies together].

Yet, however desirable all participants perceived these shared moments to be, for various reasons there was not always sufficient time to organize such meetings, as OT Astrid from Sweden pointed out:

I wish we had had more time to see each other and [to] sit down and talk. Sometimes we talked a bit after class but then I gave suggestions for adjustments in an e-mail. Actually, you might plan a short moment each week but now it has not really worked out in practice.

Such circumstances sometimes called for an extra time investment. OT Ella from Sweden, for instance, tried to make sure that she was also present in the school’s coffee room and corridor so that she could have some additional time with the teacher. Other factors that were considered relevant to achieving a mutual understanding were OTs’ knowledge about the school context and class dynamics and both partners speaking the same language. In the Dutch context, for instance, teacher Teun was very pleased that OT Karen already knew a lot about the school system, for they could quickly understand each other. Teachers and OTs, moreover, felt that sharing their thoughts and experiences on both a private and professional level and being on the same page made them move forward – from an initial “click” to a more confidential relationship. Andreas, another teacher from Sweden, pointed out that discussing observations weekly with the OT made them more aware of the complementary value of each other’s expertise. Also Teun noted that such a confidential relationship had an important impact, and Ella, too, shared his view, affirming that “a strong relationship has been the ‘alpha and omega’ because otherwise it may be far from possible to get to trying out new strategies.” In addition to the above, participants stressed the importance of investing time, not only in building a connection with the children, but also in getting familiar with the routines, norms, and values of the whole school team. All teachers were very glad that the children accepted the OT quickly. OTs, too, observed that children started missing them on the days they were not there, welcomed them back happily, and wanted to sit next to them.

Broadening Each Other’s Perspective

Teachers and therapists all agreed that, once a confidential relationship had been established, their P4C collaboration helped them to gain a broader perspective. OTs, moreover, felt that they would not have learned as much, nor would they have understood the “whole picture [holistic perspective of the whole classroom],” had they not spent such a long time in the classroom. Sometimes, these new insights even made them question their previous approaches:

Before, when you picked up an individual child from class and brought them back, you would give your advice and say “see you next week” and then you would just hope that the teacher fitted that in. Now I have a much better idea of how I could give my advice differently or be more active in implementing strategies myself

(Rianne, OT, the Netherlands).

According to Dutch OT Karen, her interaction with children in the classroom was of a completely different dynamic compared to what she was used to when working with individual children. Consequently, she also recognized a need for different skills:

When Teun [teacher] left the class for a while, they [the children] really tested me. So I needed certain skills to make it clear to the children that I am also a teacher. It [role] was new, so this is why it is a challenge. Not that it was difficult, but you really have to make a switch.

Although this change of perspective was a bit smaller for OT Astrid from Sweden who had already worked as a classroom OT before, she did feel that her role as a P4C therapist was now taken more seriously. All teachers considered it a benefit to have another pair of “professional eyes.” “Otherwise you are very lonely as a class teacher,” teacher Wilma (Sweden) admitted. According to a Dutch teacher, the interaction wouldn’t be as valuable if they had to partner up with a colleague with the same background: “The unique quality is the different knowledge and experience the OT adds during P4C.” Teachers from both countries reported that OTs’ different perspectives made them more aware of what they were doing and why. Dutch teacher Jolien, for instance, realized that she was normally very much focused on what to teach and had no time to see all other things happen. After observing her, OT Rianne told her “when you did that, this child couldn’t follow you,” which made Jolien become more observant in similar future situations. Likewise, Swedish teacher Wilma acknowledged that OTs’ different, added perspective made her grow and opened her eyes to things she would not have noticed before:

An OT sees students from a more positive perspective. Teachers often assume that the student makes mistakes and the teacher does the right thing. Now, I start from what I can do differently to improve instead of seeing what this student cannot do. An OT also sees things from the student’s perspective. What does this student need? I guess that’s also what makes it nice to have her in the classroom. It is based on the children and not based on us, do you understand the difference?

Finally, after ongoing observations and analysis of “breaking” moments, teachers started to realize that sometimes when children reacted inappropriately (e.g., by being distracted or causing disturbance), this was actually caused by their own behavior, for instance by giving instructions that did not apply to all children or by mismatching the physical classroom context.

Co-Designing and Applying Inclusive, Environmental Strategies in the Classroom Context

Participants indicated that when both parties felt they had reached a trustful partnership, their collaboration hit another level. Seeing each other as equal partners with a complementary perspective made it possible to co-design and try out strategies that served the participation of all children, as OT Astrid from Sweden underlined: “The teacher received an award for her work with accessible learning environments. It was great fun. She wrote to me that ‘yes it is because of your support that I have been able to do this.’”

Teachers, however, were not the only ones who experienced personal growth. OTs, too, observed that they would not be able to design strategies that matched all the children and classroom context on their own. What motivated them was the fact that working according to the P4C principles placed responsibility on both. Together with the OTs, for instance, teachers analyzed how the instruction should be given and contemplated alternative ways. As teacher Wilma from Sweden explained:

Some of the children in the class have difficulty in understanding the instructions. Then you need to be concise and try to make it as easy as possible for them. Perhaps you write down what to do on a piece of paper that they receive, so they can check that they have done all the parts, or present it on the board.

In a similar fashion, teachers and OTs worked together to enhance classroom engagement by arranging the classroom or the existing materials differently. Teacher Wilma from Sweden, for instance, changed a boy’s seating by moving him from the back to the front of the class and remarked: “This boy became more active during the class because he got more attention.” OTs from both countries sometimes suggested to the teachers that, when addressing the class as a whole, they use visual materials as an additional support strategy. As some children needed more structure to be able to work on the task, OTs proposed the use of a structured visual road map (Goal-Plan-Do-Check method) when instructing all children at once:

There is a variant of a visual roadmap on the wall, so that the children know which steps they need to follow to structure a task. Now, the teacher has started to explain how to calculate using this structure. Next to this, the teacher started to circle numbers with the same color to make it even more understandable. And now you see that the children are more focused.

(Karen, OT, NL)

By providing more structure beforehand, participants observed that individual children worked more independently. That is to say, they sought less confirmation during their work and felt safer to try out things on their own without asking for help. As Swedish teacher Andreas pointed out: “They [children] know what to do. I can feel a calmer classroom. It is as if the anxiety disappears for many pupils and especially the question of what will happen next.”

All teachers considered it a huge relief when they saw that children understood what to do, how to work, and were able to complete tasks successfully. This also held true for the changes to the classroom environment that caused participants to experience a calmer classroom atmosphere. To name an example, Dutch OT Rianne proposed to teacher Jolien that all necessary learning materials be organized in boxes as the current situation was also a source of noise and disturbance to children’s workflow. After conferring with Jolien, the pair worked out an appropriate solution:

We thought together that maybe one box with materials would be more handy; one box for each group of children. And then we only asked one child to bring these boxes to the groups of children, instead of all children at once. That was Rianne’s advice.

(Jolien, teacher, the Netherlands)

Another example is that Dutch teacher Teun consulted with OT Karen about possible ways to make children more attentive to their own awareness level. Consequently, Karen referred to the impact of having an emotion ladder poster in the classroom for all children, a strategy that was originally developed for individuals or groups of children:

Well, I made this emotion ladder with four color zones. The teacher and I agreed that every time the children came in, this ladder would be hanging next to the door, [and] the children could put a peg with their name in the right zone. And in the beginning we saw that a lot of children were in the blue zone. They were tired, they weren’t fit … things like that. You could see after the first break that their emotions moved more into the green direction. But after a while, most of them were also in the green zone when they arrived in the morning.

Such observable, positive outcomes encouraged both Dutch and Swedish teachers to continue their use of the respective strategy. However, they did not always have time to go a step further, which could be a source of frustration as one teacher described:

These are the things you would like to have more opportunity to use them with children. You could do a lot more [with these strategies]. You just don’t have enough time for that.

(Teun, teacher, the Netherlands)

Discussion

The purpose of our study was to gain insight into the experiences of Dutch and Swedish elementary school teachers and OTs of their collaboration applying the P4C approach with a view to enabling the participation of all children. Overall, teachers and OTs described their collaboration in the classroom context as a unique mastery journey toward collaborative learning and trustful partnership during which they passed through various phases. In the beginning, they experienced feelings of insecurity about the collaboration and the scope of the P4C approach in addition to a need to get familiar with each other and the context. At a more advanced stage, participants felt they complemented each other’s capacities up to a point where they found themselves co-designing, applying, and evaluating strategies together for the benefit of all children.

From our findings we may derive several factors that can have a positive impact on teacher-OT collaborations in the classroom. First, it is important that all collaborators overcome their initial feelings of uncertainty and anxiety. Indeed, previous research has already pointed out that, when engaging in a process of collaboration, partners must take the time to get to know each other in order to establish a relationship (Sileo, 2011). To this knowledge, our study adds that this first phase is considered an essential prerequisite to a fruitful collaboration, even in such an intense and embedded collaborative approach as P4C.

Second, the participants in our study emphasized the importance of learning to understand each other’s “language.” To be able to do so, they needed not only informal time together, but also time to share reflections and to discuss the whole classroom situation. This finding resonates with earlier studies (Rytivaara, Pulkkinen, & de Bruin, 2019; Scruggs & Mastropieri, 2017), such as the one by Villeneuve and Hutchinson (2012) who evaluated an in-school collaboration between teachers and OTs. In this study, the authors found that frequent, ongoing contact among participants (e.g., informal hallway conversations) facilitated cooperative working. Similarly, Haddara and Lingard (2013) stressed the importance of knowing not only each other’s routines, norms, and values, but also their professional expertise.

A third factor that may facilitate teacher-OT collaborations is an appreciation of the added value of bringing together each other’s expertise. Awareness of this added value seemed to make teachers and OTs more open to reciprocal ideas and more prepared to try out new, inclusive strategies in collaboration. Participants went on to describe how this helped to build their own capacities. These findings lend further credence to Ritter’s study (2019) that also highlighted the importance of viewing the collaboration as an added value that benefits children’s inclusion.

Finally, the fact that P4C partners gave each other tailor-made recommendations and had immediate, joint reflection moments in the school context about the effects of strategies applied emerged as crucial success factors in building their capacities. Several authors have indeed called for programs that offer teachers such tailor-made recommendations based on their individual needs (Qi & Ha, 2012; Roberts & Simpson, 2016). Other, more recent studies have also confirmed the positive impact of in-school collaboration on teachers and OTs’ capacities (Kramer-Roy et al., 2020; Rocchio Mueller & Garfinkel, 2021).

This study was the first to apply and explore the P4C approach in a European context. As such, it was beyond the scope of our research to compare participants’ experiences between the two countries, meaning that we considered the experiences from both countries as one data set. Nevertheless, we found many similarities between the perceptions of Dutch and Swedish teachers and OTs on the one hand and those described by the Canadian research team on the other (CanChild, 2015; Pollock, Dix, Whalen, Campbell, & Missiuna, 2017; Wilson & Harris, 2018). According to Kaplan (2000), interventions are likely to be successful when they are based on an accurate and holistic analysis of the situation, and, ideally, when they have been designed in collaboration with all stakeholders. In all three countries, participants reflected on a local analysis of the specific elementary school context and were actively engaged in the same P4C approach. Moreover, the P4C approach responds to the individual needs of teachers in their specific context and does not provide a strict protocol. It may therefore not come as a surprise that the Dutch, Swedish, and Canadian participants -sharing similar contexts and potentially having similar needs as well- also shared similar perceptions.

Limitations

A few limitations deserve mention. First, in executing the research, a few context-specific differences existed between the Netherlands and Sweden, even though we applied the P4C approach and structured the study design in a similar way in both countries. For instance, we had the OT training modules translated into Dutch only, whereas in Sweden OTs had already been part of the school team before the P4C approach was adopted. Also the time OTs spent in the classroom differed slightly between the two countries, among others due to COVID-19 restrictions. However, these inter-country differences did not cause inconsistencies in our findings. Other limitations of this study were its relatively short duration (4 months only) and its small sample size compared to previous studies (Camden et al., 2021; Missiuna et al., 2012a). Finally, all the study data were based on participants’ self-perceptions.

Recommendations for Future Research

We welcome larger-scale replications of our study that evaluate the P4C approach with more schools, OTs, and teachers during a longer period of time. It could be valuable to include quantitative measures that evaluate changes in teachers and OTs’ knowledge and skills. We also invite future researchers to gather data about the content and actions that teachers and OTs took to enable children’s participation in the classroom. To obtain a more holistic picture of these actions, previous studies (Glennie, Charles, & Rice, 2017; Missiuna et al., 2012a) have recommended the use of daily logs as this data collection method is less time consuming and expensive than observations.

Conclusion

In this study, we have revealed a process of in-context, collaborative capacity building between teachers and OTs, in which participants first needed time to become familiar with this new collaboration, before being able to learn from each other and apply strategies collaboratively that enhanced children’s inclusion. Importantly, participants broadened each other’s perspective in the process, which they described as a very powerful effect.

From our study findings, we may derive several key factors that enable participants to reach this desirable stage. First, it is essential that teachers and OTs make time to get to know each other so that they can overcome feelings of insecurity. Moreover, OTs must be afforded the possibility to become familiar with the school context and both professionals should make an effort to understand each other’s “language.” Next, both partners should demonstrate, acknowledge, and appreciate each other’s added value within the collaboration process to enable the inclusion of all children. A final key facilitator of effective collaborations is to let both collaborators design tailor-made recommendations together and allow them to immediately reflect on the effects of the strategies applied in a trial-and-error process.

Implications for Practice

The study findings suggest that:

1. Teachers and OTs first need time to get to know each other and to establish a relationship. They should plan this time when the collaborative approach is implemented in practice.

2. Both partners should plan regular formal and informal (reflective) meetings to learn and understand each other’s “language.”

3. Teachers and OTs must recognize the added value of each other’s expertise. Only with such an open mind-set will they be able to appreciate and learn from an alternative, different perspective.

4. All parties should develop and evaluate context-based and customized strategies together as a team so that responsibility is shared, capacity can be built, knowledge circulation can be ensured and the implementation of strategies that benefit all children will be enhanced.

Acknowledgments

We wish to thank all the interview participants of this study and the supporting school boards. Furthermore, we wish to thank CanChild and the whole Canadian P4C team for giving us access to background information and the training modules. We particularly appreciate the effort made by Sandra Sahagian Whalen from the Canadian P4C team to support OTs with her expert experience during the training modules and peer-coaching moments.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by NordForsk under grant [number 85644].