Occupational therapy | Brighton Journal of Research in Health Sciences

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3

An exploration of occupational therapists’ views and experiences of using evidence-based practice to develop professional knowledge in a local authority setting

Category: issue 1, volume 3 Tags: Occupational therapy 1 Comment

Introduction:

Occupational therapists are expected to engage in evidence-based practice and to be aware of the importance of research as the foundation of the profession’s evidence base. This appears to be the first study that has explored local authority occupational therapists’ views and experiences of evidence-based practice and how they use it to develop professional knowledge.

Method:

A focus group data collection method was employed. Two focus groups, comprising seven occupational therapists each were conducted. Occupational therapists who participated in the study had been working in the local authority setting from between six months to thirty years.

Findings:

Occupational therapists did not draw on research evidence to build their knowledge. Therapists valued the evidence of the lived experience of clients, their own and other’s knowledge and experience, including the perceived evidence-based knowledge of health colleagues. Therapists developed their knowledge using these sources of evidence, through reflection and participation in wide communities of practice. Therapists looked to others to lead on developing evidence-based practice in the local setting.

Conclusion:

Occupational therapists did not use an evidence-based practice approach to develop professional knowledge. Peer learning and role modelling strategies may enable occupational therapists to become more evidence-based in order to enhance their practice and meet professional standards.

Introduction

The purpose of evidence-based practice is to provide effective care and improve client outcomes, to promote an attitude of inquiry in health professionals and ensure resources are used wisely (Hoffman et al 2010). Evidence-based practice has also been viewed as a matter of professional survival, set against a backdrop of rationing resources, consumerism and managerialism (Taylor 2007, Trinder, 2008). The high value placed on evidence-based practice by the occupational therapy profession, is reflected in the College of Occupational Therapists’ Code of Ethics and Professional Conduct (COT 2015), the College’s Standards of Practice (COT 2011) as well as the Health and Care Professions Council Standards of Proficiency for Occupational Therapists (HCPC 2015), all of which require occupational therapists to engage in evidence-based practice and to be aware of the importance of research as the basis of the profession’s evidence base.

A local authority consultation exercise, in the researcher’s practice setting, was undertaken with staff groups to ascertain the values that underpinned their day-to-day work. Consultation with a group of occupational therapists revealed the importance they placed on evidence-based practice to justify the profession and their interventions. The occupational therapy literature has highlighted the value placed on evidence-based practice by occupational therapists although in practice, it has proved difficult to implement, with studies focussed on the barriers to research utilisation primarily in health-based settings (Robertson et al., 2013; Upton et al., 2014). Few studies have investigated how occupational therapists use different evidence types, including research evidence to construct knowledge and it would appear, none have explored evidence-based practice from the perspective of occupational therapists working in a local authority. The aim of this study was to gain insights into occupational therapists’ views and experiences of evidence-based practice and how they use it to develop their professional knowledge in one local authority setting.

Literature Review

An early, often quoted definition of evidence-based practice, derived from evidence based medicine, is: ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett et al 1996 p.71). Brannigan (2007) described the evidence-based process as using the best evidence from research, balanced with clients’ values, clinical judgement and resource implications. Nevo and Slonim-Nevo (2011) objected to the prominent role of research in the evidence-based practice process and in particular, the hierarchy of evidence where systematic reviews and quantitative randomised controlled trials were valued to the detriment of experience and professional judgement. Nevo and Slonim-Nevo (2011 p.1193) used the term ‘evidence- informed practice’, to represent the use of a broader range of evidence to be used in a client-centred, flexible and intuitive way by practitioners to support the client’s changing needs and situation. Reagon et al (2008) developed the idea of ‘multiple truths’ (p.433) from a grounded theory study, where evidence-based occupational therapy involved the systematic consideration of information from multiple sources and applied in conjunction with the client within a client-centred, occupational therapy paradigm. However, Hoffman et al (2010) argued that the term ‘evidence’ in evidence-based practice served a specific purpose, which was to highlight the need to value and use information from research which was often underused.

A systematic review of published research on the subject of occupational therapists’ attitudes, knowledge and use of evidence-based practice was undertaken by Upton et al (2014). Thirty-two research papers, published between 2000 and 2012 were reviewed: twenty-three were quantitative, eight were qualitative and one was a mixed methods design, carried out in health-based settings in a number of countries, including the United Kingdom. The strengths and weaknesses of the studies were discussed with fourteen out of a total of thirty-two papers rated as good or strong quality. This review found that whilst occupational therapists held positive views of evidence-based practice, a number of barriers to its implementation were identified: lack of time and caseload pressures; the culture of the organisation; limited research appraisal skills; poor access to research and tensions with client-centred practice. In an action research study, Robertson et al (2013) found that the barriers to implementing evidence-based practice reflected the findings of earlier research papers reviewed by Upton et al (2014), prompting questions about how occupational therapists constructed their knowledge, using evidence, through critical reflection and participation in communities of practice (Lave and Wenger 1991).

The seminal theory of Schon (1987) proposed that professionals developed their knowledge in complex and challenging practice settings through a framework of reflection-in-action (thinking and acting in the moment), and reflection-on-action (analysing and interpreting the event after it has happened). Brookfield (2009) argued that a deeper level of critical reflection was required to examine and challenge the assumptions and power dynamics that framed everyday practice. A key element of critical reflection is being able to view situations and actions from multiple perspectives, including those from theory and research, to lead to informed actions and ‘an appreciation of the bigger picture of implications, surrounding the problem at hand’, (Jay and Johnson, 2002 p.79). In evidence-based practice, critical reflection can provide a framework for exploring and managing the power imbalances between the different evidence types (Petr and Walker 2009), and reconcile the tensions that exist between the technical rationality of research and occupational therapy practice (Blair and Robertson 2005).

Professional knowledge has been described as more than a store of cognitive knowledge, involving shared values, beliefs, ways of reasoning and tacit knowledge that are constructed through the interaction between professionals (Higgs et al 2004). This interaction can occur through a process of engagement in a community of practice (Lave & Wenger 1991), defined as: groups of people who share a concern or a passion for something they do and learn how to do it better as they interact on a regular basis (Wenger 2007 p.1). In relation to evidence-based practice, Gabbay and le May (2004 p.3) undertook an ethnographic study in primary care teams, and observed that general practitioners and nurses rarely consulted research evidence but relied on collectively constructed ‘mindlines’, informed by brief reading, their own and other’s professional experience, patients, organisational demands and developed through informal interactions in fluid communities of practice. The researchers acknowledged that their research had been conducted in well-functioning teams and that their ideas concerning ‘mindlines’ needed to be tested in different settings.

In summary, the debates in the literature concern what constitutes best evidence in health and social care practice, based primarily on the opinions of academics rather than empirical research and the views and experiences of practitioners and clients. The occupational therapy literature comprises of mostly quantitative studies focussed on the challenges to putting research into practice in health-based settings and it would appear that few studies have been conducted in local authority settings. It also appears that little attention has been given to understanding how occupational therapists develop evidence-based knowledge, through strategies such as reflection or participation in communities of practice. The apparent gaps in the literature helped to define the research question: An exploration of occupational therapists’ views and experiences of using evidence-based practice to develop professional knowledge in a local authority setting.

Method

A qualitative design, by means of focus group interviews, was applied to the research question. Qualitative research explores how human beings understand, experience, interpret and create the social world (Sandelowski 2004). The nature of the research question, which concerned exploring occupational therapists’ views and experiences of evidence-based practice, was therefore deemed compatible with the qualitative research paradigm. Focus groups collect qualitative data from a homogeneous set of people through a focussed group discussion and place a value on the interaction of group members to elicit information and collective viewpoints (Krueger and Casey 2009). Group interviews can have an advantage over individual interviews as they offer insight into how social knowledge can be constructed through the group process (Green and Thorogood 2004).

Participants

The research project gained ethical approval from the University of Brighton and the Local Authority Research Unit. Ethical issues included maintaining the anonymity of participants and mitigating power imbalances between participants and researcher and participants. An invitation to take part in the research and an information sheet were emailed to all occupational therapists employed by the local authority. Fourteen occupational therapists consented to take part from different teams across the local authority area, with a range of experience of working in social care of between six months to thirty years. The sample size allowed for the formation of two focus groups, each with seven participants, to allow for observing patterns and themes emerging within and across both groups (Krueger and Casey 2009).

The researcher

The researcher is employed as a learning and development officer within a local authority organisation and has a key responsibility for supporting occupational therapists in their continuing professional development. The researcher is not managed by the occupational therapy service and has no supervisory or managerial role with occupational therapy staff. The researcher acted as the moderator of the focus group discussions and due to being known to the participants, maintained a reflexive diary throughout the research process to raise awareness of researcher bias (Shaw 2010).

Data collection and analysis

A questioning route was devised, based on a process by Krueger and Casey (2009). Questions included:

What do you think counts as evidence?
What do you think is the best evidence?
How do you develop your knowledge using evidence?

Each focus group discussion lasted one and a half hours. An assistant moderator from the learning and development team, took notes of key points made in the discussions to assist with the analysis of the audio-recordings. A process of thematic content analysis, as proposed by Braun and Clarke (2006), was used to analyse the data: familiarisation of the data and transcription, initial coding, collating codes into themes, reviewing the themes before defining and naming them with ongoing analysis, relating the analysis back to the research question and literature in the final report.

Rigour

The study was fully supervised by an academic from the University of Brighton and guided by the quality principles for qualitative research as set out by Yardley (2008). These principles were applied as follows: 1. sensitivity to context by relating the research to theory and literature, being open to alternative interpretations in the data; 2. commitment and rigour through in-depth data collection and analysis; 3. transparency and coherence through the alignment of the research question, the methods used to collect and analyse data, the use of quotes to enable the reader to judge the adequacy of interpretations, and keeping a reflexive journal (Shaw 2010); 4. impact and importance of the study by examining the practical and theoretical implications of the research for occupational therapists working in a local authority setting and the wider professional context.

Findings

Three main themes were extracted from the data: I know I should but I don’t; evidence-based practice is different in social care; learning outside the classroom. The main themes and sub-themes represent the prevalence of views, the greatest amount of time spent on certain points and those that related directly to the research question.

I know I should but I don’t

Participants in both groups associated the term ‘evidence-based practice’ with the use of research and expressed their concern that research was rarely used to guide their practice. As one participant put it, ‘I know I should but I don’t. This theme runs as the thread throughout the following sub-themes: justifying occupational therapy, the barriers to using research in practice and looking to leaders and role models to develop evidence-based practice within the local setting.

Justifying what we do

The views of the participants concerning justification of their actions appeared to operate at two levels, dependent on whether research was used to justify the profession or formed part of their day-to-day practice with clients. In focus group one, research was perceived as having a critical role in justifying the occupational therapy profession with some anxiety expressed about the survival of the profession without it:

‘I suppose the scary thing is if there was some seismic change in our role, we would be thinking why wasn’t there more evidence to support it, with things changing as they are’.

Evidence-based practice was discussed as a broader concept in both focus groups, moving away from research as the dominant feature when working with clients. This was described as an intuitive process, rather than a more conscious evidence-based approach:

‘It’s about what you have worked on this week, the client evidence, your own experience, the evidence from your co-workers by having a chat with them. For me, there is rarely a process where I stand there thinking about a particular client, thinking about the best evidence to go forward’

Barriers and Challenges

Participants in both groups shared their concerns about the lack of time they had for developing their evidence-based practice, with few reporting experiences of using research. Participants in focus group two discussed their frustration at the value placed on quantitative research, which was viewed as being at odds with the ethos of occupational therapy practice and its limitations with the complexities of practice in social care:

‘In terms of day to day practice and the people we work with, it can get a bit messy and although random controlled trials can be useful for a particular subset of people, it’s very difficult to isolate that when you’ve got people with multiple conditions and lots of complications that go on’.

A further barrier was a lack of interest in using research evidence, due to a view that few studies were relevant to occupational therapy practice in a social care setting:

‘What’s the point in reading research on ten people in New Zealand that has no correlation to what we do….it can be hard to find up to date research about community based working, like practice around adaptations in the UK’

Leaders and role models

In both focus groups, participants highlighted the importance of leaders and role models to engage others with evidence-based practice and demonstrate putting research into practice, with one participant suggesting ‘if other people are passionate, it filters down, doesn’t it?’ Another participant agreed, but reported difficulties motivating peers and getting them to regard evidence-based practice as a priority:

‘You need someone to actually drive that forwards as I don’t think everyone has a person or a few people in that team to actually move things on. Because just setting up the journal club was a bit of pain, to try and get people to allocate time for it and want to do it and get involved with it’.

Participants in focus group one became excited about their idea of having a group of individuals, or a kind of leadership team, which they called a ‘super team’ who would have the necessary time and skills to search for and evaluate research evidence and make recommendations for practice change. The responsibility for putting research into practice was viewed as someone else’s responsibility, as opposed to an individual or shared responsibility:

‘Wouldn’t it be nice if we had an evidence-based practice team who actually had a role of recognising a gap in practice, gathering evidence, formulating it and making a recommendation for a change of practice, just delivering it’.

Evidence-based practice in social care is different

Evidence-based practice in social care was perceived by participants as shaped primarily by clients being seen as the expert in their condition and working in people’s homes, with comparisons made with hospital-based settings.

The client is the expert

Participants in both groups felt their clients often held the best evidence in terms of their personal experience of their disability, its impact on their day to day lives and the choice and control they wished to exercise with regard to the outcomes they wanted to achieve. This was a strong influence when making decisions, planning and evaluating interventions:

‘If they’ve had a lot of experience living with a health condition for a long time, sometimes they know what’s best. Sometimes we can come in with a big idea about what might change things and make things better, but actually, they’re the expert in it’.

Participants, especially in focus group two, spent some time discussing their experience of clients questioning their interventions and proposing their own solutions, triggering a process of consulting with colleagues and evaluating the risks involved:

‘Looking back, I discussed it with other people, colleagues and involved the moving and handling team and I guess, at the end of the day, I risk assessed, considered her capacity to make that decision and understand the risk’

Health are better at evidence-based practice

The nature of the work environment was considered a key influence when applying evidence-based practice and in focus group one, this was explored in relation to health-based settings. There was a view that health colleagues were better at being evidence-based in their practice, due to having a medical model approach aligned to the more highly regarded objective, measurable types of research which were perceived as more easily applied in clinical settings:

‘In a hospital, you have distinct evidence-based pathways you follow in a particular way. Whereas in the community, everyone is individual so it makes it more difficult to pick out one bit of evidence’.

‘In a hospital, everyone is in the same environment, so the same practice might apply more. You come across different things in the community’.

Another reason suggested by the group, was that the NHS needed to be more robust in its evidence base, in order to respond to complaints and legal challenge. Their view possibly reflects the impact of media coverage of cases where failures in care and treatment have resulted in calls for disciplinary action and compensation. One participant posed the question ‘does it come down to, perhaps in health, a blame culture and a fear of being sued?’

Learning outside the classroom

Participants in both groups expressed similar views about the role of reflection, learning from doing and talking with their peers as critical to the development of their practice knowledge. Other sources for building knowledge, such as reading books, research articles, participating in courses or conferences were not mentioned.

Reflection

Terms commonly used by participants in both focus groups included: ‘I think all the time’, ‘I think a lot of my reflective practice is here, in my head’ to describe a continuous mental process of reflecting in the moment or after the event, in order to achieve the best outcomes for clients:

‘I use reflection to look back on my practice to see if I got the best outcome, or if I could have done something differently for a better outcome. Then depending on what your conclusion is, it would tailor my practice when I came to that situation again’.

‘…. even during involvement, you could use reflection to change the way you do something if you think, actually, I am on the wrong course here’.

Linked to this, was the term used in both groups of how knowledge and experience was shaped by a matter of ‘trial and error’ and that this was deemed as a crucial way of building an evidence base for interventions:

‘I think trial and error sometimes. We might have done something with someone else at some point which worked and we can maybe use that and that’s good evidence because if it worked for that person, it may work for this other person. But sometimes it doesn’t, but then you learn from that as well. It’s just as useful’.

Learning from and with others

There was consensus within and across both groups that learning from and with others was a vital resource for developing their practice knowledge. This moved beyond the idea of the knowledge and experience of immediate team members, to encompass a wide community of practice:

‘I know in our team; we are quite reliant on learning from each other. We throw things to the floor quite regularly and discuss stuff. So learning form others is quite day to day. Joint working with colleagues, carers, families and we can learn from all these different people’.

The knowledge held by health colleagues was also discussed and valued in both groups; particularly their knowledge and information regarding specific medical conditions and prognosis of individual clients:

‘I have worked with the neuro-team quite a bit and I tend to ask their opinion of that person or other people with that condition. They don’t have a crystal ball, but they tend to say this person will probably progress at this rate. So yeah, I will go to them because I value their opinion and evidence as well’.

These interactions possibly reflect those that occur in multi-disciplinary teams where opinions are sought on a case-to-case basis, compensating for occupational therapist only teams in this particular local authority setting. This also links to the earlier notion, that health colleagues were perceived to hold evidence-based opinions.

Discussion and implications

Occupational therapists in the study associated evidence-based practice with research and discussed rarely using research evidence due to time pressures, lack of relevant research and the tensions it presented with client-centred practice, themes that are consistent with the literature (Robertson et al 2013, Upton et al 2014). Research was valued more highly in relation to justifying the profession than in day-to-day practice with clients, when other types of evidence held greater importance, notably the lived experience of their clients and their own and other’s professional knowledge and experience. These findings highlight occupational therapists are not drawing on current research to inform their practice, although it is worth bearing in mind the limited research base in occupational therapy and social care. The reliance on their own and other’s professional knowledge and experience may pose a risk that practice can be outdated as well as subject to personal bias (Hoffman 2010). The provision of support, such as protected time alongside personal commitment, may enable occupational therapists to develop their evidence-based practice and adhere to professional ethics and standards (COT 2010, COT 2011, HCPC 2015).

A broader implication of the findings is that occupational therapists appeared more attuned to an evidence-informed approach, which can be understood as not excluding research, but valuing professional experience and the judgements of practitioners and clients who are in constant interaction with each other (Nevo and Slonim 2011). This suggests the need for further discussion within the profession about whether an evidence-informed approach is more congruent with occupational therapy practice in a social care context, mindful that research utilisation is essential to both evidence-based and evidence-informed practice.

A theme that emerged from the findings, not apparent in previous studies, was the perception by a number of occupational therapists that health colleagues were better at evidence-based practice, due to the nature of their work environment and use of research-based treatment protocols. However, the systematic review of Upton et al (2014) would suggest otherwise, since health-based occupational therapists in numerous studies, reported similar views and experiences to those held by social care occupational therapists participating in this study. Further research that explores the views and experiences of evidence-based practice of occupational therapists working in health and social care settings would be useful and timely, in light of the integration of health and social care (Care Act 2014).

Occupational therapists looked to others to lead on evidence-based practice and research utilisation, with little acknowledgement of individual responsibilities for implementing evidence-based practice, as required in professional ethics and standards (COT 2010, COT 2011, HCPC 2015). The views about leaders link with thoughts from Upton et al (2014 p.36) about the role of ‘knowledge brokers’ who could disseminate up-to-date research, and the findings from an action research study by Morrison and Robertson (2016), which indicated the importance of senior occupational therapists for demonstrating and motivating evidence-based behaviours in new graduates. An action-research project undertaken by Andrews et al (2015 p.4) identified facilitation as a crucial element for developing ‘evidence-enriched practice’ in health and social care with older people. The researchers used the metaphor of making a cake, with the facilitator acting as a ‘good cook’ who supported a collaborative approach to selecting, preparing, mixing and baking different types of evidence to achieve the desired result. The value occupational therapists placed on learning from each other, may lend itself to the development of peer learning approaches. Peer learning is defined as ‘the acquisition of knowledge and skill through active helping and supporting through status equals’ (Topping 2005 p.631), a strategy which may enable all occupational therapists to become ‘good cooks’ of evidence-based practice.

Occupational therapists discussed developing their knowledge through a process of reflecting-in-action and reflecting-on-action (Schon 1987), often describing this as a matter of trial and error, carried out in collaboration with the client. This may be understood as professional artistry, where individuals demonstrate a blend of creativity and expertise built up through reflection and experience (Beeston and Higgs 2001), or as the unique and innovative practice that requires audacity, courage and risk-taking (Higgs and Titchen 2001). Blair and Robertson (2005) highlighted the challenges for bridging the gap between the professional artistry of occupational therapy practice and research, and suggested critical reflection as a way of reconciling the tensions between the two elements. An implication for the organisation is how it can create opportunities for occupational therapists to develop their ability to become critically reflective, such as using supervision for reflective dialogue and critical analysis (Fook and Gardner 2007) and peer-based, critically reflective action learning (Skills for Care 2014).

As noted previously, occupational therapists believed a crucial way of developing knowledge was by learning from and with each other, and this extended beyond their immediate team members to include clients, carers, and health colleagues. This took the form of a community of practice (Lave and Wenger 1991), which was shaped around the particular needs and situations of individual clients. This appears to resonate with the research by Gabbay and le May (2004 p.3) where GPs and nurses integrated evidence from various sources, including ‘opinion leaders’, in negotiation with individual patients through daily networking to form collectively reinforced, tacit guidelines, named as ‘mindlines’. Opinion leaders were identified as trusted individuals, within or outside their teams, who were perceived to hold up-to-date, research-based knowledge in their particular field. For occupational therapists in this study, health colleagues were viewed as external opinion leaders, due to a belief that their practice was underpinned by research evidence. One of the key recommendations made by Gabbay and le May (2004) was to invest in opinion leaders to ensure their knowledge was research-based, alongside a collective responsibility to help strengthen the evidence-base of the ‘mindlines’ created by communities of practice. In connection with previous points, such leaders would need to facilitate collaborative approaches for strengthening the evidence-based knowledge of occupational therapists and the ‘mindlines’ of their communities of practice, in line with individual responsibilities for meeting professional ethics and standards and (COT 2010, COT 2011, HCPC 2015). Key individuals may help to build an evidence-based culture, by modelling the skills, knowledge and behaviours associated with evidence-based practice and facilitating peer learning that can enable all occupational therapists to become evidence-based practitioners.

Limitations

The study involved a small number of occupational therapists in one local authority setting, so it cannot be regarded as representative of local authority occupational therapists as a whole. The participants who volunteered to participate, may have been predisposed to the idea of evidence-based and were also likely to feel comfortable with a group discussion format. One-to-one interviews may have captured more in-depth data about individual viewpoints which can be lost in a group discussion. Team managers were not involved in the study and on reflection; their inclusion may have added a useful dimension to the study due to being an important influence in the practice setting. A further limitation is that the research was carried out by one researcher using a single method of data collection, so the study can only represent one facet of the bigger picture of the subject matter.

Conclusion

The aim of this research study was to explore occupational therapists’ views and experiences of using evidence-based practice to develop their professional knowledge in a local authority setting. Occupational therapists did not draw on research evidence in their day-to-day practice due to time pressures, lack of relevant research, the tension with the client-centred ethos of occupational therapy and its limitations when working with people who have complex needs. Occupational therapists relied on the evidence of the lived experience of clients, their own knowledge and experience, the knowledge of others, including the perceived evidence-based knowledge of health colleagues. Knowledge using these particular sources of evidence was developed through reflection and participation in wide communities of practice which were shaped by the individual client’s needs and situation. Occupational therapists looked to others to lead on developing evidence-based practice in the local setting. Key individuals may help to develop an evidence-based culture, by modelling evidence-based practice and facilitating peer learning approaches that enable all occupational therapists to become evidence-based practitioners. Further research into how occupational therapists construct their knowledge and strategies that can enable them to develop professional knowledge that has a stronger evidence-base is required.

Debbie Ryan Learning and Development Officer OT, West Sussex County Council ; Dr Channine Clark, Principal Lecturer Occupational Therapy, Academic Lead University of Brighton

References

Andrews N, Gabbay J, le May A, Miller E, O’Neill M, Petch A (2015) Developing Evidence-Enriched Practice in Health and Social Care with Older People. Available at: https://www.jrf.org.uk/report/developing-evidence-enriched-practice-health-and-social-care-older-people Accessed on: 23.01.16

Beeston S and Higgs J (2001) Professional practice: artistry and connoisseurship. In: Higgs J and Titchen A, eds. Practice Knowledge and Expertise in the Health Professions. Oxford: Butterworth-Heineman,108-117.

Blair SE, Robertson LJ (2005) Hard Complexities – Soft Complexities: An Exploration of Philosophical Positions Related to Evidence in Occupational Therapy. British Journal of Occupational Therapy, 68(6), 269-276.

Brannigan K (2007) Making sense of research utilisation. In: Creek J and Lawson-Porter A, eds. Contemporary issues in occupational therapy: reasoning and reflection. John Wiley: Chichester, 189-216.

Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.

Brookfield S (2009) The concept of critical reflection: promises and contradictions. European Journal of Social Work, 12(3) 293-304.

Care Act (2014) Care and Support Statutory Guidance. London: DOH. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/315993/Care-Act-Guidance.pdf Accessed on: 25.11.2014

College of Occupational Therapists (2011) Professional standards for occupational therapy practice. London: COT. Available at: http://www.cot.co.uk/standards-ethics/practice-and-process-occupational-therapy Accessed on: 17.10.14

College of Occupational Therapists (2015) Code of ethics and professional conduct. London: COT. Available at: http://www.cot.co.uk/publication/baotcot/code-ethics-and-professional-conduct Accessed on: 17.10.14

Fook J, Gardner F (2007) Practising Critical Reflection: A Resource Handbook. Open University Press.

Gabbay J, le May A (2004) Evidence based guidelines or collectively constructed ‘mindlines?’ Ethnographic study of knowledge management in primary care. British Medical Journal, 329(7473),1013.

Green J, Thorogood N (2004) Qualitative Methods for Health Research. Sage Publications.

Health and Care Professions Council (2013) Standards of proficiency: occupational therapists. London: HCPC. Available at: http://www.hpc-therapistsuk.org/assets/documents /10000512standards_of_proficiency_occupational_therapists.pdf Accessed on: 17.10.14

Higgs J, Titchen A, Neville V (2001) Professional practice and knowledge. In: Higgs J, and Titchen A, eds. Practice Knowledge and Expertise in the Health Professions. Oxford: Butterworth-Heinemann, 3-9.

Higgs J, Richardson B, Dahlgren MA (2004) Developing Practice Knowledge for Health Professionals. Butterworth-Heinemann.

Hoffman T, Bennett S, Del Mar C (2010) Evidence-Based Practice Across the Health Professions. Churchill Livingstone.

Jay JK, Johnson KL (2002) Capturing complexity: a typology of reflective practice for teacher education. Teaching and Teacher Education, 18(2), 73-85.

Krueger RA, Casey MA (2009) Focus Groups; A Practical Guide for Applied Research. 4^th ed. Sage Publications.

Lave J, Wenger E (1991) Situated learning; legitimate peripheral participation. Cambridge: University Press.

Morrison T, Robertson L (2016) New graduates’ experience of evidence-based practice: An action research study. British Journal of Occupational Therapy, 79(1), 42-48.

Nevo I, Slonim-Nevo V (2011) The Myth of Evidence-based Practice: Towards Evidence-Informed Practice. British Journal of Social Work, 41, 1176-1197.

Petr CG, Walter UM (2009) Evidence-based practice: a critical reflection. European Journal of Social Work, 12(3), 221-232.

Reagon C, Bellin W, Boniface G (2008) Reconfiguring evidence-based practice for occupational therapists. International Journal of Therapy and Rehabilitation, 15(10), 428-436.

Robertson L, Graham F, Anderson J (2013) What actually informs practice: occupational therapists’ views of evidence. British Journal of Occupational Therapy, 76(7). 317-324.

Sackett D, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence-based medicine: what it is and what it isn’t. British Medical Journal. 312, 71-72.

Sandelowski M (2004) Qualitative Research: The Sage Encyclopaedia of Social Science Research Methods. Sage: Thousand Oaks.

Schon D (1987) Educating the Reflective Practitioner. San Francisco: Jossey Bass.

Shaw R (2010) Embedding Reflexivity within Experiential Qualitative Psychology. Qualitative Research in Psychology. 7(3), 233-243.

Skills for Care (2014) Critically reflective action learning: Improving social work practice through critically reflective action learning. Available at: http://www.skillsforcare.org.uk/Document-library/Social-work/Action-Learning/Critical-reflective-action-learning.pdf Accessed on 12.04.16

Taylor CM (2007) Evidence-Based Practice for Occupational Therapists. 2^nd ed. Blackwell Publishing.

Topping KJ (2005) Trends in Peer Learning. Educational Psychology, 25(6), 631-645.

Trinder L (2008) Introduction: The Context of Evidence-Based Practice. In: Trinder L and Reynolds S, eds. Evidence based Practice: A Critical Appraisal. Blackwell Science Ltd, 1-16.

Upton D, Stephens D, Williams B, Scurlock-Evans L (2014) Occupational therapists’ attitude, knowledge, and implementation of evidence-based practice: a systematic review of published research. British Journal of Occupational Therapy, 77(1), 24-38.

Wenger E (2007) Communities of practice. A brief introduction. Available at: http://www.ewenger.com/theory/ Accessed on: 21.02.15

Yardley L (2008) Demonstrating validity in qualitative psychology. In: JA Smith, ed. Qualitative psychology: A practical guide to research methods London: Sage, 235-251.

Jun
21

By David Bauckham

The impact of sensory integration groups on the participation of children and young people with learning disabilities: perceptions of therapists and teaching staff

Category: issue 1, volume 3 Tags: Children and young people, Learning disabilities, Occupational therapy, Participation, Sensory integration Leave a Comment

Accessible summary

This study explored occupational therapy groups based on a technique called “sensory integration”. Children and young people with learning disabilities in a school and college took part in these groups.
Therapists and teachers reported increased skills such as confidence, communication and turn taking.
They also felt that participation in the groups themselves and later activities increased.
The study suggests how the effects of these groups could be measured in future research.

Abstract

Background: Sensory integration techniques which follow the theory outlined by Ayres (1972) are widely used by occupational therapists as an intervention for children and young adults with learning disabilities, but their efficacy is unclear. Research studies have suggested increased levels of participation and other positive behavioural changes following group sessions using sensory integration techniques, but literature reviews have highlighted a scarcity of evidence supporting their use.
Materials and Methods: A qualitative study in which therapy and teaching staff of children and young adults with learning disabilities aged between 5 and 22, at a school and a college in England, were interviewed to gain understanding of their perceptions of the impact of these groups.
Findings: Groups involving sensory integration techniques were perceived to have a positive effect on the abilities and participation (in both the group itself and subsequent learning and other activities) of children and young adults with learning disabilities and other complex needs in educational settings.
Conclusions: The findings are of relevance to occupational therapists and others working with young people with learning disabilities in special educational and other settings. In particular, they suggest variables that may have the potential to be measured in future research evaluating such sensory integration groups.

Introduction

This article describes research exploring teachers’ and therapists’ perceptions of the impact from children and young adults’ participation in occupational therapy sensory integration groups. Sensory integration theory seeks to explain how an individual organises sensation for use in everyday activities. It was originally developed by Ayres (1972) who investigated how perception, adaptation and learning may be affected by disruption to sensory input. Her theory proposed that the brain assimilates, organises, processes and interprets information from the senses allowing individuals to adapt and interact appropriately with the environment. This promotes optimal functioning, including participation in activity and regulation of behaviour (Ayres, 2005, Watling and Deitz, 2007, Smith et al., 2009). Sensory integration is both a theory and an intervention approach with individuals and groups.

The scope and prevalence of sensory integrative problems may be concerning for families, therapists and teaching staff of young people with learning disabilities, autism and other complex needs. People with learning disabilities have a significantly reduced ability to understand new or complex information, to learn new skills and to cope independently, which starts before adulthood and therefore has a lasting impact on development (Department of Health, 2001). People on the autistic spectrum may behave in restrictive or repetitive ways and experience social or communication difficulties. Individuals with either diagnosis who additionally have sensory-integrative problems may find it challenging to take in and interpret sensory input from the environment, discriminate between different sensations, self-regulate behaviour, maintain posture, use both sides of the body together, sequence activities and plan movement (Bundy, Lane and Murray, 2002, Urwin and Ballinger, 2005, Miller, 2007). Physical, psychological and social impacts are highlighted in the literature (May-Benson and Koomar, 2010, Polatajko and Cantlin, 2010). Quality of life can be severely disrupted, with long term impact on health and wellbeing into adulthood, including social isolation, depression, anxiety and dependence on specialist care (College of Occupational Therapists, 2012).

To address this, Ayres (1972) proposes occupational therapy with a sensory integrative approach on an individual basis from appropriately trained therapists. Many occupational therapists adapt aspects of the original neuro-science theory to make it more relevant for their setting (Smith Roley et al., 2009), for example, running groups rather than individual sessions.

A search of the literature revealed 26 studies related to occupational therapy using a sensory integration approach to promote participation by children or adults with sensory-integrative problems. Three were based in the United Kingdom, one in Canada and the remainder in the United States. All considered children except for one which related to ‘children and adolescents’ and two concerning adults. There were a variety of study designs: systematic or other literature reviews; phenomenological or other qualitative studies seeking the perspectives of parents or teachers; and quantitative research, including single and multiple-subject case studies and longitudinal studies.

The literature suggests that sensory-integrative approaches are widely practiced by occupational therapists with children (and to a lesser extent adults) with sensory processing problems, including those with learning disabilities (Cohn, 2001) and autism (Watling and Deitz, 2007). A number of studies have reported positive impacts, for example:

Changes in motor skills, balance, co-ordination, social skills, attention and behaviour in school age children (Stonefelt and Stein, 1998), all skills considered central to cognitive, social and academic development.
Reductions in behaviours of concern, such as assaultive, impulsive or self-injurious behaviours (Urwin and Ballinger, 2005) and aggression (Roberts et al., 2007).
Gains in self-esteem after six months of intervention that were sustained 3 months later (Polatajko et al., 1991), though not significantly greater than gains by a control group.
Significant gains in attention and in cognitive and social skills (Miller et al., 2007) compared with children receiving no treatment and an alternative activity–based treatment.
Possible positive outcomes in motor performance, sensory processing, behaviour, academic and psychoeducational performance and occupational performance, all potentially maintained after the cessation of the intervention (May-Benson and Koomar, 2010).
Reductions in stereotypical behaviours, improvements in communication and social skills, improvements in quality of life, access to typical environments and academic ability (Lang et al., 2012).

There are, however, limitations with much of this research and reviews have cautioned about the conclusions that can be drawn from it (May-Benson and Koomar, 2010). The majority of the literature focuses on school-age children and few studies are from the UK. Sample sizes are generally small and the heterogeneity of individuals with sensory integrative problems means that studies have often focused on particular diagnoses, though limited description of participant characteristics often makes comparison between studies difficult. For example, in the studies reviewed by Lang et al. (2012), most participants were diagnosed with autistic spectrum disorders, however, insufficient information was provided to determine if they also had learning disabilities. Isolation of the impact of sensory integration is often absent, with many participants also receiving additional therapy, for example behavioural or speech and language interventions. As a result of the limitations with the existing evidence base, some question whether it is appropriate for sensory integration interventions to be so widely used (Lang et al., 2012).

Changes following sensory integration groups are suggested to support participation in subsequent learning and other activities (Watling and Deitz, 2007), but few studies have measured such changes in participation. As this is key to development and impacts on health and wellbeing, it could be explored further to inform practice (Cribbin and Lynch, 2014). Watling and Deitz’s qualitative study (2007) demonstrates the potential of staff and caregiver perspectives to provide some insight into changes in participation following sensory integration interventions, in contrast to questionnaires which may have restricted parents, teachers and occupational therapists in articulating their opinions (Stonefelt and Stein, 1998).

Although there is suggestion of positive impact from sensory integration groups, the exact nature of this could be clearer, which makes it challenging to measure. This research therefore aimed to explore how occupational therapists, teachers and teaching assistants working with children and young-adult learners perceived sensory integration groups to impact on the participation of children and young adults with learning disabilities.

Method

Qualitative research was completed by the first and second authors involving interviews with therapy and teaching staff at a special educational needs school and college for children and young people aged 5-19 and 18-23 years respectively. Both settings supported children and young people with complex needs including autism, speech and language difficulties, developmental delay and moderate-to-severe learning disabilities. The first author had previously undertaken a student placement in the school, but the authors had no other connection with either setting. The research explored teaching and therapy staff perceptions of the efficacy of the sensory integration groups, in which a number of learners took part, providing insight into some of the complexities of participation for young people experiencing altered sensory needs. It aimed to suggest appropriate variables that could be measured in future evaluations of such groups.

Participant information sheets outlining the study purpose were distributed to eligible participants via the therapy management teams at both settings. Staff were sought who were sufficiently familiar with learners’ usual behaviour to notice any impacts of participating in sensory integration groups (for example, from working directly with them on the same day as the sensory integration group). Different professions were sought as suggested by Doig et al. (2008) and four occupational therapists, two senior teaching assistants and a speech and language therapist volunteered. There were seven participants in total and the workplace of each is given in brackets following their pseudonyms, which are used to maintain anonymity. Sally (School) is a senior occupational therapist with over ten years’ experience working with children with learning disabilities. Jane (School) is an occupational therapist with one years’ experience. Fiona (College) and Rachel (College) are both occupational therapists working at the college for over four years. These occupational therapists themselves ran the sensory integration groups in which 5-6 learners (in the college) and 5-10 learners (in the school) took part. They demonstrated deeper understanding of the purpose and techniques used in the groups. The other participants were familiar with those taking part in the groups and had worked with them in other roles providing therapeutic intervention, teaching or teaching support: Felicity (School), a speech and language therapist with over four years’ experience; Pauline (School) and Emma (College), teaching assistants with over two years’ experience.

Semi-structured individual interviews allowed for flexible data collection as participants were able to discuss learners of their choice. Participants were asked to discuss their perceptions of any effects on engagement or participation that they had observed following sensory integration groups. They were requested not to disclose information which might compromise the anonymity of learners discussed.

Questions explored participants’ understandings of the purpose of the groups and the reasons for learners’ referrals. They were asked to focus upon participation difficulties visible prior to the groups and then encouraged to describe any changes in behaviour, participation or engagement in daily activities they may have subsequently observed, whether during, immediately following the sensory integration groups, or longer-term. Participants were also asked to consider current evaluation methods or methods of gaining feedback from stakeholders to offer insight into outcome measurement. Each interview was transcribed verbatim. Ethical approval was granted by the University of Brighton School of Health Sciences Research and Governance Panel.

The theoretical flexibility and clear stages of thematic analysis gave guidance and structure to data analysis (Braun and Clark, 2013). Themes were identified in the data by identifying repeated ideas, terms, phrases or words between the participants. An inductive approach allowed findings to emerge from the raw data rather than prior expectations. All data was given equal attention, allowing for unanticipated insights and adding credibility. Data from the school was coded by the first author by hand whilst data from the college was coded by the second author with assistance of qualitative data analysis software. Braun and Clark (2013) describe how analysis in this method will be influenced by the knowledge, viewpoint and epistemology of these authors, whose positive perceptions of sensory integration from previous observations risked influencing analysis. They were therefore mindful of this and reflexive in order to minimise this risk by placing equal emphasis on data that was not supportive of its efficacy. Keeping reflexive diaries to explore presuppositions and the analytic process contributed to trustworthiness (Banner, 2010).

Findings

The findings relate to perceived changes in behaviour and participation in learning and other activities of young adults and children with learning disabilities, from participating in occupational therapy sensory integration groups at two specialist educational settings.

Rachel (Occupational Therapist, College) described the adult learners as:

“…quite low in their functioning, developmental delay…minimal or non-verbal…not very confident with their own body and their non-execution of certain movements.”

Sally (Occupational Therapist, School) summarised the child learners:

“…social difficulties, difficulties concentrating, difficulties engaging in work, difficulties regulating sensory input…can be sensory seeking.”

The occupational therapists described the groups in detail. In the school, learners were timetabled to attend a daily sensory integration group which had been running since the start of the academic year (around 7 months) and consisted of three ordered stages of activity. Each stage involved the use of different sensory-based equipment to facilitate alerting, organising and calming activities. The activities included the use of therapy balls, swings, skateboards and rope, beanbags and sensory-based soft play equipment. The specific activities and specialist equipment were described as promoting sensory input to stimulate the central nervous system. Following Ayres (2005) this was described as enabling individuals to better-regulate their responses to the environment. Learners also attended individual sessions using a sensory integrative approach which often used one or two of the sensory-based activities from the group.

In the college sensory integration groups were staged for one hour per week and had been running for around 18 months. Similar techniques aimed to improve motor skills, body awareness, planning and execution and to enable identification of behavioural areas of strength or behaviours impacting on learning, for example, problems with waiting or taking turns. These groups involved the same five learners.

Sally (Occupational Therapist, School) described activities as alerting, organising and calming, completed in that order and Fiona (Occupational Therapist, College) explained the set routine of ‘alerting’ activities followed by stimulation of a pre-selected sense (such as taste or touch) and finishing with a period of relaxation. Alerting activities included bouncing on balls or wafting a parachute as a group. Rachel (Occupational Therapist, College) clarified that relaxation might involve weighted blankets, bean bags, listening to music or using ‘sensory baskets’:

“….I rock [the cushion on which he is laying] slowly or he quite likes to have a duvet cover over him…shutting out all the sensory information…..the result is that when he leaves he’s much better in terms of his ability to engage with classroom requests” (Sally, Occupational Therapist, School).

Two overlapping themes were identified: perceived changes in performance capacity and perceived changes in participation following the groups, though participants described their uncertainty as to the extent to which these changes could confidently be attributed to the groups.

Perceived changes in performance capacity

Participants described how the groups supported individuals’ ability by impacting upon arousal level, attention, awareness, motor planning and cognitive functioning. It was suggested that sensory integration groups promoted the regulation of very high or very low arousal levels seen in children and adults with learning disabilities, autism and developmental delay, thereby improving levels of participation (see second theme). Emma (Teaching Assistant, College) described the learners as being:

“under responsive and … [having] a really low arousal level…They need sensory input… for regulation, to get them ready to go…”

Sally, (Occupational Therapist, School) explained how sensory integrative interventions provided sensory input into an ‘under responsive system’ and enabled the learners to be sufficiently alert for further therapeutic input.

Participants spoke of how learners could be over or under responsive to their environment, causing an imbalance in arousal levels, interrupting participation:

“He’ll jump and jump….you know he’s in that high arousal state and he needs bringing down with heavier input really to get him ready to attend.” (Jane OT)

The ways they perceived the groups to increase participation in learning activities are further explored within the second theme. In both settings, participants considered the groups to have an immediate impact on, for example, sustained attention and appropriate behaviour:

“…to give some intense vestibular input…..to get that sensory system working…..you can see the difference in five minutes he becomes alert…I can then work on different interventions” (Sally, OT).

Sally (Occupational Therapist, School) described a learner “engaging for longer during the sessions, being able to participate for the whole session.” School participants spoke of visible changes of a short duration, with increased focus lasting for fifteen or thirty minutes, though Jane (Occupational Therapist, School) described the sensory integration groups supporting learners to get ready for a subsequent learning or other activity, because they were then more alert and able to concentrate.

The majority of learners discussed were described as experiencing physical and cognitive difficulties interrupting participation in learning activities, including motor planning, balance problems and gravitational insecurity. Participants referred to improved co-ordination amongst learners, with Rachel (Occupational Therapist, College) considering one learner to have ‘developed a sense of body awareness’ enabling a better regulation of force and control or movements. As a result, they learned to throw gently or slowly, rather than forcefully or aggressively, with Fiona (Occupational Therapist, College) regarding this as helping social development, as such behaviour ‘would frighten people’.

This theme highlights how sensory integration groups are considered to impact on an individuals’ underlying abilities to complete an activity. The second theme explores how these impacts may impact on behaviour and participation in activities.

Perceived changes in observed participation

Participants described changes they had observed in the behaviour and participation of five adult and six child learners within the sensory integration groups. No reference was made to learners’ behaviour remaining unchanged, nor to any aspects of the groups considered by participants or others to be negative.

The groups were described as seeming meaningful for group participants as they were able to complete them in a fun and enjoyable way with others, impacting on self-efficacy, confidence and social interactions. Emma (Teaching Assistant, College) described one learner as initially reluctant to engage, initially needing ‘coaxing or persuading’, but he appeared, to learn to view the groups as a positive environment, participating willingly, which she considered to be “him saying that ‘I’m happy to be here’”. Feedback received from a teacher was also reported; “that he is a lot better after a relaxation session.” She went on to describe another learner who slowly increased time spent in the group, and whose achievement of a target to remain for ten minutes, suggests that the groups resulted in increased participation. Fiona (Occupational Therapist, College) described a different learner:

“…(initially) he would come in for five minutes…he wouldn’t come in at all… and accessed almost the whole session today.”

Participants in the school described the behavioural, learning and sensory needs of the children and their difficulty with self-expression. They explored how the sensory integration groups met these needs and were adapted for optimal participation. Participants in the college felt the groups may have impacted positively on behaviours which enabled increased participation in activities, including reduced aggression and prompting. Emma (Teaching Assistant, College) referred to one learner’s greatly improved ability to wait for their turn (for example for the trampoline) during the groups.

Changes in confidence and communication were referred to frequently throughout the interviews. Fiona (Occupational Therapist, College) described a learner now entering the room confidently and willingly and alternating between activities more independently. This learner also displayed increased independence by flushing the toilet with confidence which had not happened previously. The sensory integration groups were also thought to support development of peer relationships:

“doesn’t have any friendships…needs social communication aside from that kind of input … the group is good as it gets him used to it.” (Jane, Occupational Therapist, School).

College participants reported that any immediate changes following the sensory integration groups were visible for the remainder of the day, although any carryover to the following day was uncertain.

All participants appeared to link increased time spent in the groups with increased participation in subsequent learning activities:

“When they come back [from the groups] they are much more settled…..it can be helping them to calm down and re-engage in the next sort of lesson or next part of the lesson” (Felicity, SLT)

Emma (Teaching Assistant, College) described how one learner’s participation levels changed following the groups. Initially they were ‘unsettled and difficult to manage’, but they became more ‘co-operative, focussed and communicative’. She felt that the groups ‘calmed’ and ‘settled’ this learner in preparation for the next academic lesson.

Different staff members worked with learners at different stages of the day and the occupational therapists, for example, had limited contact with learners following a group. As a result they mainly described behavioural changes during the groups. Difficulty evaluating outcomes was referred to by all college participants, who highlighted the difficulty gaining feedback from learners themselves, mainly due to their cognitive abilities. Nonetheless, indirect feedback could be sought from behaviour during and following the sensory integration groups:

“…he is happier on Wednesday afternoons…smilier… calmer…whereas normally he’s quite manic and very er pacing” (Emma, Teaching Assistant, College).

“…engaging for longer and able to participate for the whole session really” (Rachel, Occupational Therapist, College).

Sally (Occupational Therapist, College) acknowledged the challenge of evaluating the impact of the groups, raising the possibility that it could be participation in activity, rather than sensory integration per se, that resulted in behavioural changes. All participants saw the groups as part of wider therapeutic input:

“I don’t think it is all OT, I think it’s global, I think we play a part in it.” (Fiona. Occupational Therapist, College).

Discussion

Accessing the subjective experiences of college and school staff working directly with learners allowed opportunity to explore subtle behavioural changes following sensory integration input, as encouraged by Watling and Deitz (2007). This has provided insight into the impact on participation within the educational context. The findings suggest that therapists and teachers working with individuals with learning disabilities, autism and other complex needs consider that occupational therapy groups based on sensory integrative principles can have a positive impact on the underlying abilities and participation of those attending. Measuring that impact is, however, perceived to be difficult and the degree to which improvement results from the sensory integration groups or other therapeutic input is uncertain. These findings resonate with similar studies, as will now be discussed.

For children with complex needs such as autism and learning disabilities, the process of interpreting the sensory demands of the environment can be disrupted, resulting in difficulties participating in key activity necessary for development such as learning, play and social interaction (Ayres, 2005, Schaaf and Nightlinger, 2007). The complexities of impaired sensory processing and resulting disruption to participation were described in detail by participants, who referred to sensory integrative problems leading to anxiety and challenging or self-injurious behaviour, reflecting other studies (Urwin and Ballinger, 2005, Schaaf et al., 2013). The most common reasons for referral to the sensory integration groups (motor planning, response regulation, challenging behaviour and ability to remain in and participate in teaching sessions) are all key areas in which these populations may experience difficulties. This supports the highlighted need for regular, intensive, individualised intervention (May-Benson and Koomar, 2010, Polatajko and Cantlin, 2010).

The findings in both studies suggest that participation in sensory integration groups is perceived to be beneficial in addressing several of these issues for children and young adults. Participants described changes in underlying capacities and behaviour leading to increased participation, in particular improved engagement in learning activities and self-help skills. This resonates with many of the studies conducted with children (for example Case-Smith and Bryan, 1999 and Smith Roley et al., 2009) which might suggest that those authors’ findings are equally applicable to young adults. Improved cognitive and motor planning skills have been suggested elsewhere to lead to increased engagement in learning activities and self-help skills (Ayres, 1972, Schaaf and Nightlinger, 2007) promoting academic learning, flexibility, social interaction and development of interests.

All school participants described learners appearing calmer following the sensory integration groups, suggesting that attendance had improved regulation of arousal levels and integration of vestibular, proprioceptive and tactile sensory systems. This supports the use of sensory integration-based interventions using equipment such as weights, swings and scooter boards to help promote the integration of these systems. In both settings, references were made to improved behaviour as a result of attending the groups. Although this has not been widely explored in the literature, perceived reductions in challenging behaviours have been found in other studies (Urwin and Ballinger, 2005, Watling and Deitz, 2007). Improved arousal regulation was perceived to promote engagement in subsequent activities, (as argued by Urwin and Ballinger, 2005 and Waitling and Deitz, 2007). Examples given by participants include leisure activities (listening to music and dance classes) and self-care activities (eating in the dining hall and exercise). Improved arousal regulation and the increased attention and focus observed in some participants following intervention fits with Ayres’ theory (2005), and adds to other evidence of the effectiveness of sensory integration in promoting children’s participation (Schaaf and Nightlinger, 2007, Watling and Deitz, 2007). Schaaf and Nightlinger (2007) reported improved attention in play and school activities alongside increased independence in self-care activities, following individual sensory integration-based interventions.

Participants highlighted how taking part in the sensory integration groups themselves was an opportunity for socialisation, development of skills such as turn taking and waiting, valuable for young people with complex needs such as autism and learning disabilities (Cosbey et al., 2010). These groups were perceived by participants as having become meaningful to some learners and changes in behaviour, and levels of participation within the sensory integration groups themselves were seen as important in the context of these young people with complex needs.

As well as visible changes within the groups there were suggestions of longer-lasting benefits, such as subtler behavioural changes over longer periods. This included enhanced confidence and learners developing a sense of self identity, reflected also in other studies (Urwin and Ballinger, 2005). This all suggests potential for the benefits of sensory integration groups to be transferred beyond the immediate setting to further enhance the quality of life of young people with learning disabilities. Lasting impact following the groups was, however, difficult for some participants to judge, as not all of them worked with learners immediately following sensory integration groups

Limitations

Similar to other research in this field, this is a small scale study. The findings represent the perceptions of a small number of participants, discussing learners who had participated in sensory integration groups in two educational settings. As such, the potential for generalisation is limited, though detailed description allows transferability by the reader.

Key participants in the studies, the occupational therapists, were involved in setting up and leading the groups. They were in a position to have insight into the immediate impact and effectiveness of the groups, though the possibility of them wishing to portray them in a positive light needs to be considered. They arguably had a vested interest in seeing the outcomes of the sensory integration groups as the cause of perceived changes in behaviour either immediate or longer term following the intervention

Sensory integrative problems do not exist in isolation and the nature of learners’ additional cognitive and behavioural issues were only partially described by participants. In both settings the young people received a wide range of therapeutic, behavioural, and educational interventions and participants raised the possibility of these, or the act of participation in a group activity (rather than specifically a sensory integration group) also contributing to changes in behaviour.

Conclusion

Sensory integration techniques are commonly used by occupational therapists with young people and adults with autism and sensory and learning disabilities but there is a paucity of supporting evidence for this. This qualitative research suggests that group sessions involving sensory integration techniques are perceived to have a positive effect on the abilities and participation of children and young adults with learning disabilities and other complex needs in educational settings. It has provided rich descriptions of materials and activities used, specific changes in participation, perceived long- and (in particular) short-term impact of the sensory integration groups, contributing to calls for a stronger evidence base and a better understanding of the relationship between sensory integration therapy and the everyday lives of children and families (Cohn, 2001, Arbesman and Lieberman, 2010, Polatajko and Cantlin, 2010).

The findings are of relevance to occupational therapists and others working with young people with complex needs in special educational and other settings such as community, inpatient and residential settings. The findings add to evidence from other studies supporting the use of sensory integrative activities to increase independence and participation, particularly in learning activities (Urwin and Ballinger, 2005, Watling and Deitz, 2007). In particular, they suggest variables that may have the potential to be measured in future research, which could triangulate perceptions of the impact on performance capacity and participation, using observation or other methods of evaluating such changes.

Alice Harland, Community Learning Disability Team; Craig Swarbrick, Brain Injury Rehabilitation Trust; Dr. David Haines, University of Brighton

References

Arbesman, M. and Lieberman, D. (2010). Methodology for the systematic reviews of occupational therapy for children and adolescents with difficulty processing and integrating sensory information. American Journal of Occupational Therapy. 64(3):368-374.

Ayres, A. J (2005).Sensory Integration and the Child 25th Anniversary Edition. CA: Western Psychological Services.4-14.

Ayres, A. J. (1972).Sensory integration and learning disorders. Los Angeles: Western Psychological Services.

Banner, D. (2010). Qualitative interviewing: preparation for practice. Canadian Journal of Cardiovascular Nursing. 20(3): 27-30.

Braun, V. and Clark, V. (2013). Using thematic analysis in psychology. Qualitative Research in Psychology. 3 (2): 77-101.

Bundy, A., Lane, S., Murray, E. eds (2002). Sensory Integration: Theory and Intervention. 2nd ed. Philadelphia: F A Davis Co.

Case-Smith, J. and Bryan, T. (1999). The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. American Journal of Occupational Therapy. 53(5): 489-497.

Cohn, E. S. (2001). Parent perspectives of occupational therapy using a sensory integration approach. American Journal of Occupational Therapy. 55: 285–294.

College of Occupational Therapists (2015). Practice briefing: sensory integration. London: COT.

College of Occupational Therapists (2012). Research and development strategic vision and action plan for occupational therapists working with people with learning disabilities. London: COT.

Cosbey, J., Johnston, S. and Dunn, M.L. (2010). Sensory processing disorders and social participation. American Journal of Occupational Therapy. 64(3): 462-473.

Creswell, J.W. (2013). Qualitative inquiry & research design: choosing among five approaches. Los Angeles: SAGE Publications Inc.

Cribbin, V. and Lynch, H. (2014). Using sensory integration to understand and intervene with children who have sensory needs. Cork: University College for Sensory Integration Network.

Department of Health (2001) Valuing People. London: Department of Health

Department of Health (2011). Improving Outcomes in Mental Health: our shared objectives. In No Health Without Mental Health for people of all ages. London: DH

Doig, E., Fleming J., Kuipers P. (2008). Achieving optimal functional outcomes in community-based rehabilitation following acquired brain injury: a qualitative

investigation of therapists’ perspectives. British Journal of Occupational Therapy. 71(9): 360-370.

Lang, R., O’Reily, M., Healy, O., Rispoli, M.,Lyndon, H.,Streusand, W.,David, T.,Kang, S.,Sigafood, J.,Lancioni, G., Diddo, R., Giesbers, S. (2012).Sensory Integration Therapy for Autism Spectrum Disorders: A Systematic Review. Research in Autism Spectrum Disorders. (6): 1004-1018.

May-Benson, T., Koomar, J. (2010). Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. American Journal of Occupational Therapy. 64(3), 403-414.

Miller,L.J., Coll,J.R. and Schoen, S.A. (2007). A randomized control pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. American Journal of Occupational Therapy. 61, 228-238.

Polatajko, H and Cantlin, N (2010). Exploring the effectiveness of occupational therapy interventions, other than the sensory integration approach, with children and adolescents experiencing difficulty processing and integrating sensory information. American Journal of Occupational Therapy. 64(3), 415-429.?

Polatajko, H. J., Law, M., Miller, J., Schaffer, R., & Macnab, J. (1991). The effect of a sensory integration program on academic achievement, motor performance, and self-esteem in children identified as learning disabled: Results of a clinical trial. OTJR: Occupation, Participation and Health. 11, 155–176.

Roberts, J.E., King-Thomas, L. and Boccia, M.L. (2007). Behavioral indexes of the efficacy of Sensory Integration Therapy. American Journal of Occupational Therapy, 61: 555-562.

Schaaf, R and Nightlinger, K (2007).Occupational Therapy using a sensory integrative approach: a case study of effectiveness. American Journal of Occupational Therapy. 61(2): 239-246.

Smith Roley, S., Bissell, J. and Clark, G.F. (2009). Providing occupational therapy using sensory integration theory and methods in school-based practice. American Journal of Occupational Therapy. 63(6): 823-842.

Stonefelt, L.L. and Stein, F. (1998). Sensory integrative techniques applied to children with learning disabilities: an outcome study. Occupational Therapy International. 5(4): 252-272.

Urwin, R. and Ballinger, C. (2005). The effectiveness of sensory integration therapy to improve functional behaviour in adults with learning disabilities: five single-case experimental designs, British Journal of Occupational Therapy. 68(2): 56-66.

Watling, R. L. and Deitz, J. (2007). Immediate effect of Ayres’s sensory integration–based occupational therapy intervention on children with autism spectrum disorders. American Journal of Occupational Therapy. 61: 574–583.