Abstract
School-based practitioners have been encouraged to reframe their job-related responsibilities in terms of their workload, rather than their caseload, as a means of enabling more efficient and effective service delivery that aligns with evidence-based practice (American Occupational Therapy Association [AOTA] et al., 2014; Bazyk & Cahill, 2014; Endsley, 2017; Polichino & Jackson, 2014; Rioux & Jackson, 2019). Workload refers to all activities in which a school-based practitioner engages in that support students directly and indirectly, and caseload refers to the number of clients the practitioner treats (Garfinkel & Seruya, 2018; Polichino & Jackson, 2014). This paradigm shift provides more opportunities for occupational therapy practitioners to implement occupation-based interventions in natural environments by expanding the practitioner’s role beyond direct treatment to include engagement in programs that promote positive student outcomes in a larger community, such as participation in curriculum development; literacy programs; public health approaches, such as multitiered systems of support (MTSS); and positive behavioral intervention services (AOTA et al., 2014; AOTA Response to Intervention Workgroup, 2012; Bazyk & Cahill, 2014; Endsley, 2017; Grajo et al., 2018; Handley-More et al., 2013, 2019; Polichino & Jackson, 2014). The use of a population health approach to engage in schoolwide programming allows occupational therapy practitioners to reach a larger group of children earlier and prevent some of them from requiring more intensive services (AOTA et al., 2014; Bazyk & Cahill, 2014; Grajo et al., 2018; Handley-More et al., 2019; Seruya & Garfinkel, 2018). Moreover, adoption of a workload model supports practitioner job satisfaction (AOTA et al., 2014; American Speech-Language-Hearing Association [ASHA], 2016; Endsley, 2017). Although several states have developed guidelines and others have suggested the use of a workload approach, or caseload caps (ASHA, 2016; Ohio Department of Education, 2016; Ray et al., n.d.), no general standards or regulations have been implemented at the national level, and existing guidelines are not enforceable.
Practitioners have reported various barriers that limit their ability to successfully implement or advocate for a workload approach in their setting, such as high caseload numbers, differing perceptions of how therapists’ time should be used, decreased administrative support, scheduling conflicts, and a lack of resources. Despite challenges to successful implementation, therapists have expressed great interest in using a workload-oriented service delivery model, viewing it as a tool that supports best practice (Garfinkel & Seruya, 2018). Exploration of current practice patterns of school-based occupational therapy practitioners is needed to gain a better understanding of the factors that may affect therapists’ ability to successfully implement a workload approach in their practice. Recent exploration of caseload size; service delivery models in elementary, middle, and high school settings (Giordanella et al., 2015; Rodrigues & Seruya, 2018; Seruya & Ellen, 2015); practitioner inclusion in school community service provision (Rodrigues & Seruya, 2018; Seruya & Ellen, 2015); and the use of a workload model in school-based practice (Garfinkel & Seruya, 2018) from a national perspective has provided limited evidence (Spencer et al., 2006).
Therefore, because of the lack of information regarding current practice patterns, including information specific to caseload size, we examined current practice trends of elementary, middle, and high school occupational therapy practitioners across the United States by exploring their caseload size, caseload attributes, workload responsibilities, involvement in whole-school programming, and current service delivery models. We also explored practitioners’ knowledge of state and local policy, attempts to implement other models of practice within their school settings, and job satisfaction.
Method
Design and Instruments
This study used a researcher-designed online survey. The first section of the survey collected demographic data from the participants, including age, gender, and years of practice. The second section of the survey included Likert scales (wording varied on the basis of type of question), multiple-choice questions, and rank-order questions that were designed to ascertain the characteristics and attributes of practitioners’ caseloads and the types of activities they complete during their workday. The survey also included questions related to knowledge of state and local guidelines pertaining to caseloads and workloads, procedural knowledge base to implement a workload model, and questions related to job satisfaction. The survey questions were developed on the basis of information obtained from a qualitative study regarding the perceptions of a workload approach model conducted by Garfinkel and Seruya (2018), an extensive review of current literature, and findings from credible scholarship. Moreover, questions were piloted with content experts, which resulted in revisions to the length of the survey and increased clarity for some of the survey questions.
Data Collection and Analysis
The study was conducted through an online survey using SurveyMonkey (SurveyMonkey, San Mateo, CA). The survey remained open for 3 mo from its initial implementation in December 2018. Convenience sampling was used to solicit the initial participants from state occupational therapy associations and social media sites for pediatric occupational therapists. After this initial solicitation, snowball sampling was used to recruit the rest of the participants. Reminders to participate were sent or posted 2 wk and then again 4 wk after the initial invitation.
Demographics were analyzed using basic descriptive statistics. Questions were initially analyzed to determine frequencies of responses and overall trends within the data. Cross-tabulations explored relationships between variables and a workload model. Statistical analysis was performed using IBM SPSS Statistics (Version 25; IBM Corp., Armonk, NY) and SurveyMonkey data analysis functions.
Results
Five hundred forty-one practitioners from across the United States began the survey, and 371 completed it in its entirety. The majority of participants (88.54%; n = 479) were occupational therapists (OTRs); 8.13% (n = 44) were occupational therapy assistants. Participants who indicated that they were either from outside the United States or were currently not working (3.32%; n = 18) immediately exited from the survey. Overall results indicate that participants were primarily full-time employees (working >30 hr/wk; 86.2%; n = 400), were directly hired by their districts (70%; n = 423), and largely worked in a public elementary school setting (82.46%; n = 423). 1 Regionally, the sample had the greatest representation from the Northeast (33.74%; n = 165), followed by the Midwest (23.72%; n = 116), the West (22.29%; n = 109), and the South (19.43%; n = 109). The largest number of participants (28%; n = 133) had approximately 1–5 yr of employment in school-based practice; however, years of employment varied widely, ranging from 1 yr to >25 yr. There was also great variability in the number of schools that individual practitioners serviced. Many participants (67.02%; n = 315) indicated that they worked in one to four schools, but some participants reported a higher number, including 1 practitioner who serviced more than 10 schools.
Full-time employees reported an average caseload of 41–50 students (21.7%; n = 88; Table 1 provides a more specific breakdown of part-time and full-time practitioners). Many practitioners (60.09%; n = 277) indicated that the current number of students on their caseload was not reasonable and did not always allow them to manage all of their workload responsibilities. Specifically, 55.10% (n = 254) participants reported that they were not always able to provide services mandated by individualized education programs (IEPs) to students on their caseload as a result of their other responsibilities, such as attendance at meetings, screenings and evaluations, school scheduling issues, and larger scheduling conflicts. Respondents reported that they either did not know whether there were (18.26%; n = 84) or believed they did not have (61.30%; n = 282) guidelines or policies that governed the number of students allowed on an individual caseload. Of those participants who indicated that there were guidelines, regulations, or policies regarding caseload size or workload responsibilities, the majority of participants (86.31%; n = 82) reported that they were provided at either the district or the state level.
Number of Students on Caseload for Full-Time and Part-Time Employees
Note. Percentages may not total 100 because of rounding. N/A = not applicable.
≥31 hr/wk.
≤30 hr/wk.
Participants were asked to rank which services they provided in the school setting on an 8-point scale ranging from most frequently used (1) to least frequently used (8). Many practitioners (65.53%; n = 277) ranked nonintegrated pull-out service interventions as their most frequently used model of service delivery, followed by integrated push-in services (23.39%; n = 102; Table 2). Likewise, 56.42% (n = 244) of participants reported primarily providing services in a designated therapy room. Practitioners also indicated that the majority of students receiving services did so via IEP mandates (92.27%; n = 455) and 504 plans (50.76%; n = 235). However, 38.23% (n = 177) of respondents reported that they participate in and provide services through their school’s MTSS programs. Finally, practitioners (64.4%; n = 251) reported feeling that they had a great deal of influence in the decision-making process related to setting service mandates for the students on their caseload.
Ranking of Service Delivery (N = 436)
Note. N = 436 because not all participants responded to this item. Rankings range from most frequently used (1) to least frequently used (8). Percentages may not total 100 because of rounding. N/A = not applicable; OTP = occupational therapy practitioner.
In relation to workload, most participants indicated that they use a blended workload–caseload approach (45.62%; n = 172), allotting some time to engage in workload responsibilities but not enough time to manage all of them; 33.69% (n = 127) indicated that they used only a caseload approach, and 20.69% (n = 78) indicated that they used only a workload approach. Practitioners reported that their typical workload consisted of a variety of activities; documentation, direct student intervention, consultation and collaboration, report writing, scheduling, and evaluations and reevaluations were cited as the most common activities (a complete list of responsibilities is provided in Table 3). A majority of participants (75.86%; n = 377) reported a desire to use a workload approach. Barriers to implementing a workload approach included lack of administrative support (51.46%; n = 194), high caseload numbers (48.54%; n = 183), lack of time (38.99%; n = 147), and uncertainty over how to make the transition (35.81%; n = 135). Although respondents indicated that they had made efforts to advocate for a transition to a workload approach, many participants (61.33%; n = 230) indicated that they were unsuccessful. The most widely used methods for advocacy included talking to (65.87%; n = 247) and providing evidence to (41.60%; n = 156) administrators and other stakeholders.
Workload Responsibilities, by Frequency of Reporting (N = 386)
Note. Survey respondents were able to select multiple responses.
The final section of the survey queried practitioners on job satisfaction. The majority of participants (77.09%; n = 286) were either very satisfied or somewhat satisfied with their current job. The top five factors ranked as most related to job satisfaction, from highest impact to lowest, were salary and benefits (48.79%; n = 181), relationships with stakeholders (46.36%; n = 172), hours worked (45.01%; n = 167), population of students (26.68%; n = 99), and caseload numbers (25.61%; n = 95). When asked which factors would increase their job satisfaction, participants ranked the top five factors, from highest to lowest frequency, as lower caseload numbers (54.99%; n = 204), better salary and benefits (50.13%; n = 186), more resources (35.85%; n = 133), fewer workload responsibilities (28.84%; n = 107), and more opportunities for professional development (22.91%; n = 85).
Cross-tabulations were performed to explore potential relationships between use of the workload model and variables such as number of years in practice, region of the country, and employment model (district employee vs. contracted employee). Statistical analysis did not yield statistically significant findings for these variables in relation to use of a workload model.
Discussion
On the basis of survey responses, school-based practitioners appear to have a high level of interest in moving to a workload approach. The findings support those of previous studies indicating that barriers include a lack of administrative support and the time needed to implement a workload approach (ASHA, 2016; Garfinkel & Seruya, 2018). The findings suggest, interestingly, that although some practitioners have advocated for a workload approach, they continue to feel that they do not know how to implement a workload model in their practice setting; this result indicates that more resources and training are needed to assist practitioners in moving to this model of service delivery.
Moreover, practitioners reported perceiving that they had a great deal of influence on the recommendations for service delivery models and goals stated on IEPs for students on their caseload. Nevertheless, they felt largely unsuccessful in advocating for varied workload models. The results suggest that although practitioners may have influence on IEP recommendations, their influence exists only in the context of the current, accepted systems and does not reflect an ability to influence systemic changes.
Results indicate high caseload numbers are strongly tied to job satisfaction. Because 19.9% of occupational therapy practitioners are employed in school-based practice (AOTA, 2015), seeking ways in which policy can support job satisfaction would benefit all stakeholders, in addition to improving student outcomes and aligning with best practices (AOTA Response to Intervention Workgroup, 2012, Bazyk & Cahill, 2014; Polichino & Jackson, 2014; Rioux & Jackson, 2019). It may also be prudent to advocate for a workload approach at the state and federal policy-making levels rather than the district or building level because practitioners have reported poor results from advocating at the local level. Schools appear to be highly influenced by federal and state policy; therefore, policy directives targeted at these levels may be more effective in facilitating and creating change in service delivery provision. In addition, the use of a workload model supports a public health model and MTSS for at-risk students and may therefore qualify for distinct funding through the Individuals With Disabilities Education Improvement Act of 2004 (Pub. L. 108-446; Bazyk & Cahill, 2014; Endsley, 2017).
Our findings indicate that practitioners continue to widely use nonintegrated, pull-out models of service delivery, which supports the findings of previous studies regarding practice patterns in school settings (Garfinkel & Seruya, 2018; Handley-More et al., 2013; Seruya & Garfinkel, 2018; Spencer et al., 2006). Best practice guidelines have indicated that providing services in contextually based settings such as classrooms is more efficacious for children (Bazyk & Cahill, 2014; Rioux & Jackson, 2019; Seruya & Garfinkel, 2018). In addition, according to survey responses, practitioners indicated that one of the primary factors related to their professional job satisfaction was relationships with stakeholders, supporting current scholarship (ASHA, 2016; Rose & Seruya, 2019). On the basis of these factors, it would seem prudent for practitioners to increase their presence in classrooms and other contextually relevant settings because not only is it beneficial for students, but it also facilitates a practitioner’s ability to be part of the school community and develop relationships. Moreover, providing services in the classroom setting enables staff and professionals working with students to have the opportunity to actively collaborate and develop stronger interprofessional relationships. Although we acknowledge that it can be difficult for practitioners to integrate into a school’s community and culture given high caseloads and travel between schools, working to provide contextually based services provides an opportunity for practitioners to demonstrate their distinct value in school settings and become more integral members of the school community. Many respondents to our survey also indicated that telehealth, workload service delivery models that align with a workload approach (i.e., 3:1 model and block scheduling model), and coteaching were not applicable in their settings, indicating that other types of service delivery models require further exploration.
Finally, the survey responses revealed that practitioners continue to require resources not only to develop advocacy skills but also to enhance their access to and use of research. Only 18% of practitioners indicated that research activities were part of their workload. However, whether participants interpreted this category as engaging in research or exploring existing research is unclear; therefore, further exploration is needed.
Limitations and Future Research
Limitations of this study include potential issues with survey validity and reliability. The survey was researcher designed, which may have skewed the results because whether practitioners understood and answered questions similarly is unclear. The survey was posted on several internet-based platforms. Practitioners who do not use such platforms may not have had the opportunity to participate.
Future studies should continue to explore implementation of various service delivery models and seek to determine the efficacy of models currently being implemented in practice that support a workload approach and best practices. In addition, assessing the perceptions of all stakeholders, including parents, school district administrators, and state and federal policy makers, is suggested.
Survey questions also did not lend themselves to specific statistical analysis such as cluster or multivariate analysis. Future studies should address question development to allow for further assessment of relationships among variables.
Implications for Occupational Therapy Practice
Survey results revealed that school-based practitioners would like to move to a workload model in their practice settings. Despite this, however, practitioners also report a lack of resources and decreased knowledge of strategies that could support advocacy for this approach to practice, such as the use of time studies. Practitioners continue to primarily use nonintegrated, pull-out models of service delivery and provide intervention in therapy rooms. This finding is consistent with other research in this area. The findings suggest that changes to federal and state policy may promote a more consistent use of a workload model.
The findings of this study have the following implications for practitioners working in school-based settings:
Practitioners need more resources and training in advocacy and evidence-based practice.
Efforts need to be directed toward state and federal policy-making agencies to promote changes in practice to align with best practices.
Further research needs to demonstrate improved student and practitioner outcomes through the use of both workload and contextually based service delivery models.
Conclusion
This study explored workload and practice patterns of school-based occupational therapy practitioners across the United States. The findings support that practitioners would like to implement a workload model approach in their school-based practice. The primary barriers to implementing such an approach were identified as lack of administrative support, high caseload numbers, and lack of time. This is consistent with the findings of previous studies. Also consistent is the primary use of service delivery outside of classrooms or contextually based settings, although more practitioners are using integrated service delivery than has been noted as previous studies. Practitioners also indicated that they lacked information regarding their state guidelines and the use of strategies aimed at quantifying caseload and workload information, such as the use of data-gathering measures to capture how practitioners use their time, as in time studies. In addition to practice pattern data, participants reported the need for practical resources to facilitate their ability to advocate with administrators and other stakeholders.
Footnotes
Acknowledgments
We acknowledge Marc Campo for his statistical support.
The number of individual responses to survey items varied; therefore, percentages may not be based on the total sample size.