Abstract
Background.
School-based occupational therapy (SBOT) is shifting from pull-out interventions for students with special needs to tiered models focused on inclusion and participation. There are several noted benefits of tiered models. However, research has suggested that challenges exist in the transition to tiered models that are consistent with ethical tensions. It is unclear how occupational therapists are navigating the transition to tiered models, including addressing ethical tensions.
Purpose.
The purpose was to advance knowledge and understanding regarding ethical tensions experienced by school-based occupational therapists in transitioning to tiered models of SBOT. The research question was: What are the perceived ethical tensions experienced by occupational therapists in transitioning to tiered models of service delivery in SBOT?
Method.
Interpretive description was employed. Interviews were conducted with 11 self-nominated occupational therapists. Data analysis consisted of preparation, organization, and interpretation followed by a member checking focus group.
Findings.
Occupational therapists experienced ethical tensions around five inter-related ethical principles—fidelity, veracity, autonomy, confidentiality, and distributive justice.
Conclusion.
The transition to tiered SBOT exacerbated or created ethical tensions. Engaging established implementation guidelines can provide a structured framework to inform large-scale service delivery changes, lessening ethical tensions while eliciting desired outcomes.
Introduction
In Canada and around the world, school-based occupational therapy (SBOT) services are currently shifting from decontextualized pull-out interventions for students with special needs to tiered models focused on inclusion and participation (Renaud et al., 2024; VanderKaay et al., 2021). Tiered models are intended to promote the delivery of fluid services across three tiers: tier one refers to system/school/classroom-wide universal services that are beneficial for all, tier two involves targeted services for students requiring additional support for specific issues, and are necessary for some, and tier three involves individualized services that are essential for a few (Campbell et al., 2016, 2023; Chu, 2017; VanderKaay et al., 2021). One such tiered model is Partnering for Change (P4C), which aims to build “
In Ontario, Canada, the Preschool Speech and Language and Children's Rehabilitation Services Guidelines outlined the expectation that SBOT services in Ontario be delivered via a tiered approach to service delivery (Ministry of Children Community and Social Services Ontario, 2023). The guidelines were intended to improve services in three important domains—access, experiences, and functional outcomes. Notably, specific implementation guidance for tiered SBOT did not accompany the guidelines. As a result, organizations providing SBOT attempted to respond by quickly shifting to attempting to deliver tiered services with little implementation guidance while also addressing previously existing waiting lists for services.
There are several fundamental differences between traditional approaches to SBOT and tiered models of service delivery that could significantly impact implementation, and the extent to which these fundamental differences were considered is unclear. First, the underlying philosophical paradigm of traditional pull-out interventions is aligned with an illness model of health care, including a reductionistic view of health as the absence of impairment (Renaud et al., 2024). Tiered models, however, are philosophically aligned with a critical emancipatory paradigm focused on maximizing student engagement and participation in all school activities and contexts (Christner, 2015; VanderKaay et al., 2021). Second, traditional SBOT considers the occupational therapist as the expert who possesses specialized knowledge to provide remediation (Campbell et al., 2012), whereas in tiered models, all parties are considered equal collaborators. Tiered models focus on capacity building for all, and it is incumbent upon the occupational therapist to work toward establishing collaborative relationships (VanderKaay et al., 2021). Third, in traditional SBOT the clinical reasoning process remains consistent with that of a health care context, including administering standardized assessments (e.g., Peabody Developmental Motor Scales; Folio & Fewell, 2023), identifying impairments (e.g., fine motor skills), and developing deficit-based intervention goals (e.g., improve fine motor skills) (Campbell et al., 2016). In tiered models, assessments and interventions are meant to be conducted dynamically in the natural contexts of the school while the student is engaged in curriculum-based activities, and goals are curriculum-relevant and participation focused (VanderKaay et al., 2021).
Research into the delivery of tiered models of SBOT has elucidated several benefits including earlier identification of difficulties, better intervention outcomes, and increased prevention of potential issues (Lynch et al., 2023; Meuser et al., 2022; Missiuna et al., 2015; VanderKaay et al., 2021; Yngve et al., 2024). However, a small body of research has suggested that challenges exist (Cahill et al., 2014; Campbell et al., 2021; Wilson & Harris, 2018). Challenges include navigating the interface of regulated health services embedded within education contexts, understanding what practice “looks like” in tiered models (Campbell et al., 2021, p. 73), and perceived lack of time to fully implement tiered services (Cahill et al., 2014; Camden et al., 2021; Wilson & Harris, 2018). A research study conducted by a member of this research team regarding implementation of P4C during the 2009–2010 school year further elucidated challenges (Campbell et al., 2012, p. 56): One area of concern was how they used their time and resources. They were keenly aware that “there's only so much time” and “only so much you can do.”….Therapists also spoke of trying to strike a balance between providing services in the classroom within the P4C model and responding to individual teacher preferences to withdraw children from the classroom. They described their struggle in deciding whether to work with a whole class versus providing direct services to those who could benefit from individualized attention. Finally, they identified a concern that their services were not reaching [all] children with needs (p. 56).
Although these challenges have not been explicitly identified as ethical tensions, they are consistent with the definition of ethical tensions in the occupational therapy literature—circumstances in practice that involve uncertainty, distress, or dilemma that can be challenging to practitioners (Opacich, 2003). These ethical tensions in occupational therapy can result from a variety of circumstances including when ethical principles that are professionally valued or mandated by regulatory bodies (e.g., autonomy, confidentiality) are compromised or cannot be fully upheld (Drolet, 2018). Renaud et al. (2024) stated that although tiered models have the potential to “increase the effectiveness of services in the long term…implementation in the current societal context raises ethical issues” (p. 16).
There is a paucity of current research specifically exploring how occupational therapists have navigated the transition to tiered models. The objective of this study was to advance knowledge and understanding regarding the ethical tensions experienced by school-based occupational therapists in transitioning to tiered models of SBOT. The research question guiding this study was: What are the perceived ethical tensions experienced by occupational therapists in transitioning to tiered models of service delivery in SBOT in Ontario?
Method
Interpretive description (ID) methodology guided this research (Thorne, 2016). ID is aimed at addressing complex issues arising in clinical practice with a view to informing practice change. To do so, patterns from professional narratives are explored and interpretative recommendations are generated. Results can inform new professional directions. The principal investigator has previous experience studying ethical decision making in occupational therapy using ID (VanderKaay et al., 2019) and studying tiered models of service delivery (VanderKaay et al., 2025). Full ethics approval was granted by our institutional Research Ethics Board (Project ID# 15439).
Recruitment/Sampling
Consistent with ID we recruited self-nominated participants using research postings through relevant provincial professional organizations and emails to professional contacts at Ontario Children's Treatment Centres. Participants were occupational therapists who self-identified as: (a) registered in Ontario, (b) working in a SBOT context that is currently transitioning or has transitioned to a tiered model, (c) comfortable answering potentially sensitive questions about ethical tensions in practice, (d) willing to critically reflect on and explain ethical decision-making including identifying any required supports, and (e) English speaking.
Data Collection and Analysis
The principal investigator corresponded with potential participants by e-mail to arrange individual in-depth interviews. All interviews were conducted in English by the principal investigator on Zoom between January and March 2023. Upon obtaining informed consent, in-depth interviews involved open-ended questions using a semi-structured interview guide that allowed participants to express experiences, views, and insights on ethical tensions experienced. Interviews were audio-recorded and transcribed verbatim. Dedoose was used to manage data. Data analysis consisted of three discrete stages: preparation, organization, and interpretation (Thorne, 2016). Preparation involved “dwelling in [data] repeatedly and purposefully” through iteratively reviewing transcripts in detail several times (Thorne, 2016, p. 167). Organization involved line-by-line inductive coding followed by inductive focused coding to reorganize initial codes into new interpretive categories (Richards, 2009; Thorne, 2016). Interpretation involved refinement of categories into themes that reflect areas of ethical tension experienced (Thorne, 2016). Conceptualizing the findings in relation to established ethical principles resulted from in-depth interpretive data analysis process during which multiple strategies for organizing the data were considered (Thorne, 2016). Ultimately, structuring findings according to familiar ethical principles provided an accessible and clear approach for presenting findings in a manner that is relevant to practice (Thorne, 2016). One member-checking focus group was conducted following the Interpretation stage (November 3, 2023) to seek participant feedback regarding emergent study findings, allowing further refinement of findings and thereby promoting trustworthiness (Bazeley, 2013).
Quality Strategies
Researcher reflexivity was employed throughout to reflect on researcher positionality and to interrogate potential unconscious biases (Richards, 2009). Other strategies to promote quality included: ongoing analytical debriefing with associated investigators (triangulation), and analytical decisions detailed and justified in a research journal (dependability) (Lincoln & Guba, 1985).
Findings
Eleven school-based occupational therapists participated in this study. One participant identified as male and ten identified as female. Participants’ experience in SBOT ranged from 6 months to 10 years. Nine of the 11 participants attended the focus group. No participants were co-enrolled in the concurrent P4C realist evaluation (previously noted). Analysis revealed that occupational therapists experienced many ethical tensions in the transition to tiered models. Ethical tensions were grouped around five inter-related ethical principles—fidelity, veracity, autonomy, confidentiality, and distributive justice. It is important to note that while research and recruitment materials for this study were not specifically about P4C per se and instead focused on tiered models broadly, many participants in the study used the label Partnering for Change or P4C likely due to awareness of P4C in the Ontario context.
Fidelity: Implementing as Designed
Occupational therapists reported that they struggled to be faithful to the tenets of the tiered model they were aiming to implement. In many cases, occupational therapists reported that they were not actually delivering tiered services despite services being labeled as such by their organizational leadership (e.g., managers). Participant #5 stated “I actually take P4C out of my notes because I do not think what we are doing is P4C.” This issue with fidelity was reportedly due to several interrelated reasons. First, resource limitations precluded transition to a tiered model. Adequate time was not allocated for universal services. Funding was not provided for whole-school or whole-class interventions so occupational therapists were pressured to meet tier one whole class interventions with individual students’ funding (i.e., Special Equipment Amount in Ontario). Participant #11 stated: I had a school where [school staff] really wanted a sensory room. They wanted certain items in the sensory room and then they wanted me to tell them which students would qualify for those items in the sensory room. Just tell us what you need to see, and we have students with all kinds of needs. Just tell us and we will put the students in front of you and get it done and do what we have to do. That was a very draining experience. That felt very ethically uncomfortable.
Another main factor impacting fidelity was limited understanding of tiered service models. Several participants noted that they did not fully understand tiered models themselves (e.g., confusion regarding the types of service delivery at each tier) or how the tiered model interfaced with other service-delivery models that they were being asked to implement concurrently (e.g., solution-focused coaching). So, the expectation that they simultaneously learn about, explain, and implement a tiered model created significant ethical tensions. Participants also reported significant knowledge gaps among occupational therapy managers (who were meant to provide leadership during the transition) and school-based personnel (i.e., principals, resource teachers, teachers).
Finally, processes for the implementation of tiered models were not fully in place prior to implementation. This was particularly problematic because implementation of tiered services necessitates that several siloed systems coordinate, but they did not (i.e., children's treatment centers, education system, occupational therapy regulatory body). Processes, including intake, time-tracking, documentation, and discharge were not reflective of a tiered model embedded in education and instead primarily reflected the traditional pull-out services reflective of a decontextualized remediation model. Occupational therapists were being asked to document “universal services” for individual students who had a traditional referral to “hit targets” (P. #10). Participant #8 stated that organizations were “trying to fit [tiered services] into their box” because when universal services were being delivered most of the day, the services could not be documented within existing, unchanged record keeping systems, so instead they had to be linked to a small number of students, which appeared in documentation as though the OT was unproductive. Overall, productivity reporting methods used by occupational therapists in this study were not consistent with tiered models and were designed for documentation of one-to-one intervention only. Participant #8 stated: Sometimes I am in a classroom for an hour building capacity…or maybe I am doing three classroom visits that take three hours of my day, and I have still not met the criteria of your five visits, but I have done amazing stuff, and I have spent three hours in classrooms. It is really weird. They still want us to fit in this old system that we are not in anymore. They need to let that go and realize that this model is just different. I think it would reduce a lot of pressure off us to get these visits in and feeling like those direct interactions are all that count. Why is that the most valuable for my time? Why is my five-minute conversation talking to a teacher in the hallway…why doesn’t that count when that is me building a relationship with the teacher at the school? I just feel like stuff we do that matters and they say they think it matters but it isn’t always shown that it matters because we are still trying to fit into this old model and old way of thinking that if we are doing publicly funded then they need to this, this, and this to show that they are doing work.
Veracity: Being Truthful
The concern about truthfulness was noted at three levels—the individual occupational therapist, their documentation, and management. Individual occupational therapists were being asked to indicate that they were delivering tiered services, often committing to school staff that they would attend the school regularly (e.g., every 2 weeks) while knowing that this would simply not be feasible due to caseload size and the number of schools that they were assigned to support. Participant #10 stated “I feel like we say we are doing something, and it does not necessarily feel like we align with that…I feel like we overpromised and underdelivered.” Occupational therapists reported nuanced concerns with veracity involving each tier of the model. At tier one (universal services), ethical tensions with veracity were experienced when letters were sent to all families at the beginning of the school year informing families of the availability of universal services when realistically universal services were not viable for several reasons, including limited time at the school, lack of training regarding how to deliver tier one services, and demand to prioritize children on previous wait lists for service. At tier two, veracity concerns existed regarding obtaining consent and tier two services were sometimes leveraged to bypass consent. For example, Participant #5 reported that tier two services could be “sneaky” in that occupational therapists were asked to create and deliver a tier-two intervention with one child in mind to avoid the process of obtaining consent required for tier three services. At the level of tier three, occupational therapists were being asked to deliver the previous model (i.e., pull-out individual one-on-one assessment and treatment) to students who had been on the waiting list to clear the waiting list, while naming the service a tier three service, which is inconsistent with tiered models of service delivery. In tiered models, services at all tiers are intended to be educationally relevant, delivered in authentic school contexts, and involving close communication with the educator, which differs significantly from the decontextualized one-to-one service that had been provided previously.
At the level of documentation, occupational therapists were being asked to tie universal services to individual students to maintain organizational productivity measures. For example, one occupational therapist reported that they documented an individual student for several 15-minute blocks (as having received direct treatment) to account for a one-hour tier one service to the whole class. Participant #10 stated “we are not capturing what we should be capturing.”
Autonomy: Prioritizing Self-Determination
Participants reported concerns regarding autonomy on two levels—professional autonomy and student/family autonomy. Professional autonomy was limited in that service delivery was being imposed with little input based on the clinical reasoning of the occupational therapist. Many occupational therapists were being asked to follow a rotational structure of visiting schools approximately once every 3 to 4 weeks rather than using their own clinical reasoning to determine the frequency of service needed to address each school's needs (as per tiered models). Occupational therapists were also being told which services to provide when in a school and at which tier (e.g., tier #1 self-regulation intervention). Participant #8 stated that services would be more effective if “we are…making those decisions ourselves as clinicians and there wasn’t…this strict schedule we have to follow.” Participants reported that the ethical tension associated with decreased professional autonomy involved serious concerns regarding equity. More specifically, when visit (i.e., rotation) schedules and the interventions were being dictated from a managerial level, the participants could not be responsive to the needs of individual schools or students. Participant #1 stated: The ethical issues that come along with that is our high-needs schools tend to be in areas with lower socioeconomic background with bigger schools, bigger classrooms and we don’t get to spend [enough] time at those schools and my schools that tend to be in a nicer neighbourhood even have smaller sized class sizes…I get to spend a whole day there…and that is just really frustrating…and that is what I mean about equity and equality.
Ethical tensions with student/family autonomy primarily related to informed consent. In general, participants reported that there was a lack of clear understanding regarding when informed consent was required. Furthermore, participants were being asked to deliver interventions in ways that could circumvent the need for informed consent. For example, participants were asked to build tier one interventions based on the needs of one or a small group of students to avoid seeking consent. Participant #8 described the ethical tension stating that they were advised by their manager that even if an issue related to a single student, universal strategies could be provided to the whole class to circumvent consent. Participant #8 stated “I could not comprehend what a universal strategy is for a specific concern. To me, consent-wise that makes absolutely no sense.”
Confidentiality: Safeguarding Entrusted Information
Participants reported that confidentiality in tiered services represents a “grey zone” (P. #8). More specifically, teachers and school staff can discuss student concerns, including (potential) diagnoses, very freely without informed consent whereas occupational therapists, as regulated health professionals, are not able to do so (College of Occupational Therapists of Ontario, 2020). Participants reported being very unsure of how to navigate this “grey zone” (P. #8), particularly when some occupational therapists appeared more comfortable engaging in such discussion with school staff, thereby also creating tensions among occupational therapists. The issue of confidentiality may be more challenging in tiered service models because the occupational therapist is aiming to become embedded as part of the school team and as a result “teachers can be a little bit more frank” (P. #1). Although several participants reported efforts to be very clear with school staff that they were not able to discuss student information without informed consent (as described above), many teachers continued to share confidential information. Participant #8 stated “even when you ask teachers not to give names…you can tell them a hundred times…and they are still going to tell you the name of the client and that they have ASD, and they have trauma….” At times, to circumvent concerns with confidentiality, school staff will speak in hypothetical terms, but it is often clear who they are talking about. Participant #1 stated “teachers have come up to me and asked me questions and they have this unwritten thing, and they are not saying the student's name, but it is pretty clear who they are talking about and again, it is that ethical uneasy feeling….” Participants reported that there is a need to better determine how to implement tiered services in a way that aligns with regulatory body standards for confidentiality.
Distributive Justice: Allocating Resources and Services Fairly and Equitably
Occupational therapists reported concerns regarding how resources were being distributed, particularly the way services were being allocated. Allocations were approximately 1 day per school every 3 (and sometimes 4) weeks, which was not enough time to adequately deliver tiered services. As a result, intervention time was often spent on one classroom or a small number of students, and other classrooms or students received very little. Participant #5 stated “I support a lot of schools that have self-contained life skills classes, kids who get a ton of physical needs, safety needs, equipment needs, and in those schools, it is really difficult to get to kids with any other needs.” There was also a distributive justice concern reported because of occupational therapists having to straddle two systems (i.e., new tiered model and previous pull-out model). Several occupational therapists were being asked to continue carrying a caseload from the previous pull-out model including taking new students off the waiting list, while at the same time providing tiered services to the whole school. Participant #10 stated: I cannot do all of this in a day while I am still maintaining and trying to figure out this waitlist and…then also getting into classrooms and doing universal because our managerial team and admin staff is saying the universal is important because then you are getting in earlier and you are able to address more, yet we still have this waitlist…we still have a massive waitlist that we are trying to get through and this model was created without a waitlist…You are supposed to be able to do it and then meet the demands as they come in whereas we are trying to navigate and it was put on us to go through that entire waitlist and figure out how to prioritize between waitlist and this P4C model and needs that are coming up right away and universal strategies, but you also have this massive waitlist to manage and don’t forget about them.
Discussion
This research advances knowledge and understanding regarding the ethical tensions experienced by school-based occupational therapists in transitioning to tiered models of SBOT by answering the question—What are the perceived ethical tensions experienced by occupational therapists in transitioning to tiered models of service delivery in SBOT? Eleven school-based occupational therapists participated in the study and findings indicated that ethical tensions were experienced around five inter-related ethical principles: fidelity, veracity, autonomy, confidentiality, and distributive justice.
There appear to be several findings that are consistent with ethical tensions experienced in SBOT broadly that may not be exclusive to the transition to tiered models. A recently published study explored the ethical issues of SBOT practice in Quebec, Canada not focused on, but including tiered models (Renaud et al., 2024). Findings highlighted some similar inter-related ethical tensions including concerns regarding compliance with practice standards resulting from cultural and policy differences between healthcare and education, and limited resources. Similar to participants in our study, the participants in the study by Renaud et al. (2024) expressed concern regarding maintaining occupational therapy regulatory standards within the school setting particularly related to confidentiality and consent. Participants similarly identified that differing norms and values in education as compared to the standards for regulated health professionals exacerbated ethical tensions. Participants in the Renaud et al. (2024) study also noted that limited resources (e.g., shortage of occupational therapists, limited time, and limited financial allocations) negatively impacted their ability to deliver effective occupational therapy services. A scoping review of tensions in school-based collaborations between occupational therapists and teachers also noted time constraints as a tension (i.e., occupational therapists not having enough time to spend in the classroom and not enough time to collaborate with teachers) (Wintle et al., 2017). While some of the ethical tensions noted in our study may be consistent with those reported elsewhere, existing ethical tensions appear to be exacerbated by the transition to tiered models. For example, as noted in our findings, the nature of the occupational therapist being embedded in the school in tiered models seemed to exacerbate issues with confidentiality. Occupational therapists being expected to provide services in two systems (i.e., tiered model while addressing previous waiting list from traditional pull-out model) seemed to exacerbate issues with distributive justice regarding time and resource allocation.
In a realist review of the literature regarding tiered models of rehabilitation service delivery in education settings, VanderKaay et al. (2021) identified several macro-, meso-, and micro-level contextual circumstances for the successful delivery of tiered services. Providing education to relevant collaborators (e.g., school boards, health care organizations, principals, etc.) about tiered models and how they differ from traditional school-based practice was reported to be imperative to success. Our findings are consistent and suggest that additional education about tiered models may be beneficial for all relevant collaborators in mitigating ethical tensions in the Ontario context. VanderKaay et al. (2021) also found that sufficient resources must be allocated so that a workload orientation associated with tiered models can be adopted rather than a caseload orientation focused solely on direct activities for individual students. Administrative support, including leaders who understand tiered models and documentation processes and materials that are relevant to tiered models were also noted to be integral to successful delivery of services (VanderKaay et al., 2021). To address ethical tensions related to fidelity, veracity, autonomy, and confidentiality, policymakers and managers are encouraged to prioritize deep understanding of tiered models and to create policies and processes that are aligned with tiered models of service delivery.
Findings of our study indicated that occupational therapists were being asked to carry traditional caseloads (i.e., services delivered in the previous 1:1 pull-out model) while also responsible for implementing a tiered model without clear implementation guidelines. Shifting practice in occupational therapy “is a time consuming and complex process” (Pollock et al., 2017, p. 250). Typically, large-scale shifts in practice are most successful when guided by thoroughly developed evidence-informed implementation plans and iterative analyses of implementation (Nuckols, 2024). Ethical tensions could be lessened by considering best practices in implementation science as well as increased utilization of implementation resources directly related to tiered models. Pollock et al. (2017) outlined several recommendations for implementing P4C including allocating sufficient time and resources and providing mentorship and support. In response to the latter, members of our research team developed freely accessible training materials that can support rehabilitation professionals in successfully transitioning to tiered models of SBOT, including the FIRST Course, FIRST KIT and FIRST FAQs (Campbell et al., 2020). More recently, the P4C team has developed a Professional Development Program specifically for occupational therapists delivering P4C. While not specifically designed to address the findings of this study, the content of the program is relevant to addressing the ethical tensions reported. Lastly, the P4C team recently issued a comprehensive and step-by-step P4C implementation guide at How to Implement P4C that is based on their realist evaluation findings and which describes a new P4C implementation theory detailing key ingredients for success (https://p4cguide.com/). Those involved in the delivery of tiered models of SBOT may benefit from leveraging the freely available resources to support implementation.
There are two main limitations to this study that should be noted. First, participants were self-nominated. Self-nomination promotes inclusivity in research (Government of Canada, 2018) but may have favored participants who were willing to come forward to speak about ethical tensions. Second, only front-line occupational therapists were included. Triangulation of data sources (e.g., study participants possibly including occupational therapy managers) may have enriched findings (Carter et al., 2014).
Conclusion
This interpretive description study advances knowledge and understanding regarding the ethical tensions experienced by school-based occupational therapists in transitioning to tiered models of SBOT in Ontario, Canada by articulating ethical tensions experienced around five inter-related ethical principles—fidelity, veracity, autonomy, confidentiality, and distributive justice. Although several of the ethical tensions identified reflect those previously documented within the broader SBOT literature, the transition to tiered models—undertaken within the context of insufficient implementation plans—appeared to amplify existing ethical tensions while simultaneously introducing new tensions. Our findings underscore the importance of cultivating a comprehensive understanding of tiered models prior to implementation. Such foundational knowledge could meaningfully inform the design of implementation plans, policies, and processes that are well-aligned with tiered models and therefore more likely to elicit their documented benefits and desired outcomes while mitigating the experience of ethical tensions. To extend knowledge and address noted limitations, future research could focus on the perspectives of other collaborators including school-based collaborators (e.g., principals/teachers), occupational therapy managers, and caregivers/families, and could explore additional knowledge dissemination interventions to support implementation.
Key Messages
Occupational therapists faced significant ethical tensions while shifting to tiered models of school-based occupational therapy (SBOT).
While some of these ethical tensions align with those previously reported in the literature, the shift in service delivery models intensified these tensions, and other new tensions emerged related specifically to the new tiered model, likely exacerbated by the limited implementation support.
Organizational leaders, managers, educators, and occupational therapists can harness existing evidence and practical resources, like those available at
Footnotes
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by an Ontario Society of Occupational Therapists (OSOT) Strategic Priorities Grant.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
