case study research in occupational therapy

Open access
Published: 31 July 2023

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

Leona McQuaid ORCID: orcid.org/0000-0002-6819-8784 1 ,
Katie Thomson 1 &
Katrina Bannigan 1

Systematic Reviews volume 12 , Article number: 132 ( 2023 ) Cite this article

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

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

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

Conclusions

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

Systematic review registration

Open Science Framework 10.17605/OSF.IO/PCFJ6.

Peer Review reports

Developing evidence informed occupational therapy practice is a priority across international practice standards and research agendas [ 1 , 2 ]. The challenge in achieving this, however, is multifaceted. Occupational therapists report a lack of research knowledge, time, resources and organizational support as barriers in the conduct of research [ 3 , 4 , 5 ]. Implementing findings from a research environment to the reality of clinical practice also presents a challenge despite knowledge translation and implementation strategies [ 6 ]. In practice, therapists use reasoning, experience and the client’s perspectives in addition to research [ 7 , 8 ]. This holistic approach to service provision can be difficult to capture, but the need to demonstrate impact and quality outcomes remains.

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

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

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

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

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

Case study research has previously been advocated for in occupational therapy. Ottenbacher [ 26 ] originally described the small ‘N’ study as a tool for practitioners to address their responsibilities of documenting service provision effectiveness. Others have provided support for case study methodology to demonstrate clinical impact, overcome challenges of investigating complex phenomena and develop the occupational therapy evidence base [ 27 , 28 , 29 ]. It is presented as a good ‘fit’ for occupational therapy with untapped potential for contributing to the evidence base [ 11 , 30 ]. Whilst these studies offer a justification for the use of case study research in occupational therapy and call for greater uptake of the method, no extensive review of empirical case study methodology in occupational therapy practice has been conducted. It therefore remains unclear if, and how, the methodology is being utilized, or how feasible it is to contribute to the evidence base. A scoping review was deemed the most appropriate methodology for this review as it has recognized value for researching broader topics [ 31 ]. It will identify all available, eligible evidence and chart key information from the literature to answer the research questions and identify any gaps in the knowledge base.

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

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

Review questions

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

How is ‘case study’ defined as a research methodology in occupational therapy literature?

What are the methodological characteristics of case study research used in occupational therapy practice?

What are the contexts and recorded implications of case study research undertaken in occupational therapy practice?

This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [ 33 ] and, in line with best practice, used the updated Preferred Reporting Items Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR) (See Additional File 1 for PRISMA-ScR checklist) [ 34 , 35 , 36 ]. It was conducted in accordance with an a priori protocol [ 37 ], and any deviations from this are reported and justified.

Inclusion criteria

Participants.

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

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

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

Types of sources

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

Search strategy

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

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

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

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

Study/source of evidence selection

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

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

Data extraction

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

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

Data presentation

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

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

Search results and study selection and inclusion process [ 34 ]

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

Mapping of empirical studies

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

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

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

Study design.

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

Methods of data collection

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

Number of studies per practice setting and data collection approach

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

Outcome measures.

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

Methods of analysis.

Descriptive analysis and visual analysis to compare data graphed over time was used in quantitative experimental designs. Statistical analysis in the form of Rasch and frequency analysis was also employed in some instances [ 66 , 67 , 68 ] but this was largely in conjunction with visual analysis. Both Gustaffson et al. [ 69 ] and Gimeno et al. [ 70 ] suggested in their studies that visual analysis is preferable for single-case designs rather than statistical hypothesis testing due to the small number of participants. Thematic and content analyses were commonly used in qualitative studies in addition to descriptive statistics. For multiple case designs, within and cross case analysis was described [ 59 , 64 , 71 , 72 , 73 , 74 ]. Specifically, Yin’s approach to pattern matching [ 51 , 73 , 75 , 76 ], explanation building [ 45 ] and matrix coding [ 77 ] was used. Two studies referred specifically to Stake’s approach to data analysis [ 59 , 78 ].

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

Practice contexts

Occupational therapy case study research were conducted with various client groups across a range of practice settings (Additional files 8 and 9 ). The majority were based in the community ( n = 48/84; 57%); however, the practice context or setting where the research was carried out was not always clearly reported ( n = 11/84; 13%). Interventions adopting therapeutic use of occupation and activity were apparent, such as feeding [ 80 ], gaming [ 81 , 82 ], gardening [ 83 ] and play [ 84 , 85 , 86 ]. This was more prevalent in outpatient or community settings with inpatient settings adopting more of a compensatory approach [ 87 ] to facilitate engagement in occupations as an end, rather than the therapeutic use of occupation itself as a means. Across all practice settings, the most common occupational therapy interventions were sensory-based interventions ( n = 10/84; 12%) for example Giencke Kimball et al. [ 88 ], Go & Lee [ 89 ] Hejazi-Shirmard et al. [ 90 ], and provision of assistive equipment ( n = 9/88; 11%) for example Cruz et al. [ 91 ], Golisz et al. [ 92 ] and Teixeira & Alves [ 93 ]. In other instances ( n = 4/84; 5%), provision of occupational therapy was described as the intervention, subsequently involving a range of input rather than a single defined intervention, for example Kearns Murphy & Sheil [ 49 ], Haines et al. [ 78 ] and Pretorius [ 79 ].

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

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

Recorded implications for practice.

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

Mapping of non-empirical papers

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

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

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

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

Proposed conceptual model describing case study research in occupational therapy practice

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

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

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

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

Case study research has been shown to be a flexible methodology both in design and purpose. Of particular interest to evidence building is its use to explore the efficacy and feasibility of an intervention in the real-life practice context. These findings support the assertions of previous authors who have suggested that case study research can be used to demonstrate clinical impact of interventions and to investigate complex multifactorial phenomena [ 11 , 27 , 28 , 29 ]. Particularly in areas of innovative or emerging practice, case study research can provide a way to capture impact when participant numbers or resources are not available to conduct larger-scale inquiry. Stickley and Hall [ 47 ], for instance, specifically state that their study is the first known investigation into social enterprise in occupational therapy. As a first step to building evidence, a descriptive or single-case account can therefore provide an important grounding on which to build upon. The need for timely evidence during the Covid-19 pandemic demonstrated an acute awareness of this but it has also been recognized as a process of cumulative evidence building in occupational science [ 103 ] and more broadly across other disciplines [ 104 ]. Of note however is Flyvbjerg’s [ 16 ] argument that the case study holds value beyond pilot or preliminary data. Whilst it may be difficult to generalize from a case study, particularly in terms of process, the outcomes can contribute to knowledge when used to test a theory or data pooled across cases.

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

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

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

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

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

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

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

Strengths and limitations of the scoping review

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

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

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

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

Implications for research and practice

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

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

Availability of data and materials

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

Abbreviations

Assessment of Motor and Processing Skills

Canadian Occupation Performance Model

Goal Attainment Scaling

International Collaborative Network of N-of-1 Trials and Single-Case Designs

Joanna Briggs Institute

Model of Self-Efficacy

Single-case experimental design

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Acknowledgements

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

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Leona McQuaid, Katie Thomson & Katrina Bannigan

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

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Search strategy.

Additional file 3.

Data extraction instrument (Empirical studies).

Additional file 4.

Data extraction instrument (Non-empirical studies).

Additional file 5.

Characteristics of included empirical studies.

Additional file 6.

Characteristics of included non-empirical papers.

Additional file 7.

Studies ineligible following full-text review post 2016.

Additional file 8.

Heat map contrasting interventions and practice contexts. Numbers and shading represent number of studies.

Additional file 9.

Heat map contrasting population characteristics of age and diagnosis categories. Numbers and shading represent number of studies.

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McQuaid, L., Thomson, K. & Bannigan, K. Exploring the contribution of case study research to the evidence base for occupational therapy: a scoping review. Syst Rev 12 , 132 (2023). https://doi.org/10.1186/s13643-023-02292-4

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

McQuaid, Leona 1 ; Thomson, Katie 1 ; Bannigan, Katrina 1,2

1 School of Health and Life Sciences, Department of Occupational Therapy, Human Nutrition and Dietetics, Glasgow Caledonian University, Glasgow, Scotland

2 The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, Plymouth, UK

Correspondence: Leona McQuaid, [email protected]

The authors declare no conflict of interest.

Objective:

This scoping review will explore the range and characteristics of case study research within the occupational therapy evidence base. It will examine how case study research is defined, the methodologies adopted, and the context in which it is applied. Most importantly, it will consider the viability of case study research for contributing to the evidence base for occupation and health.

Introduction:

Occupational therapists report barriers to conducting research due to the complexities of clinical practice, and lack of knowledge, time, and resources. Case study research is generating interest as a potentially manageable and practical solution to increase research engagement. However, it is not clear how this is being utilized by occupational therapists or how feasible it is to contribute to the evidence base.

Inclusion criteria:

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

Methods:

A three-step search following JBI methodology will be conducted across databases and websites for English-language, published peer-reviewed and gray literature from 1990. Study selection will be completed by two independent reviewers. A data extraction table developed and piloted by the authors will be used and data charted to align with the research questions.

Introduction

Evidence-based practice is essential to contemporary health care, and engaging with it is an ethical requirement for occupational therapists. 1 Health care delivery must be informed by accurate, up-to-date research to achieve the best outcomes for those accessing services. 2,3 It is disquieting then, that in occupational therapy, the literature highlights a gap between practice and the evidence base. 4-6 Standardized assessments and outcome measures are not routinely used in practice and the evidence base for effectiveness of many interventions is low. 6-8 This is not solely an issue of research implementation, but also one of research capacity, production, and dissemination. 9 The American Journal of Occupational Therapy , the internationally recognized, highest ranking occupational therapy journal, saw a reduction in manuscript submissions in 2018 and fewer effectiveness studies published in 2019. 10 To meet the requirement of policy drivers, and to ultimately improve clinical outcomes for service users, occupational therapists must increase their evidence base and research engagement. 5 Supporting this, the Occupational Therapy Australia Research Foundation aims to increase the health and well-being of communities through increasing practitioner research capacity and increasing the production of new knowledge. 11 This is mirrored in the Royal College of Occupational Therapists’ (RCOT) research and development strategy. Its strategic aims focus on expanding the evidence base, enhancing knowledge, and supporting implementation of research into practice to improve the experience of individuals, groups, and communities accessing occupational therapy. 12

Reported barriers to conducting research include lack of research knowledge, time, resources, and organizational support. 13,14 In addition, implementation of findings from a research setting into the reality of clinical practice, with its varying cultural, psychosocial, and economic contexts, has been cited as a barrier to research engagement. 5 As a result, in practice settings, service evaluation and audit is often prioritized over empirical research or policy-making activity. 15 The case study research method, however, which focuses on one case with the potential to pool data across cases, may be a feasible way to overcome such barriers for practitioners due to its emphasis on real-world clinical contexts. This research method has become increasingly popular within social sciences to address complex phenomena and is beginning to generate greater interest in occupational therapy. 16,17 It is used to answer “how” and “why” questions, and allows for deep understanding of complex situations or phenomena and considers the context in which they are situated. 18 Drawing on several seminal authors’ definition of “case,” a case under study could be an individual, group, population, organization, or process. 18-20

Case study research, however, is not without its critics. Variations in approach between authors has led to the method becoming somewhat elusive and difficult to define, often confused with “non-research” case histories or educational case studies that do not include data collection or analysis. 21 It has also been criticized for lack of rigor and external validity. 21-23 Whilst data from a single case study may not be generalizable, Yin 18 argues the accumulation of case studies may offer greater rigor, reliability, and external validity of findings. He suggests collating qualitative and quantitative data in a database and viewing a single case as a single experiment. This allows for case replication to create a larger dataset and enhances the understanding of the phenomena through pooling of multiple cases. Using this approach, case study research may provide an achievable and practical means of (and therefore an important role in) engaging practitioners in research.

Case study research is not a new phenomenon in occupational therapy. Colborn 23 presented a rationale for case study research in 1996 in response to pressures to provide evidence of clinical impact and the challenge of achieving this with other research designs in occupational therapy. Almost a decade later, Fisher and Ziviani 24 suggested explanatory case studies provide a rigorous methodology for investigating complex multifactorial phenomena in clinical settings, including occupational therapy. They proposed a model for approaching explanatory case study research in an attempt to support practitioners in understanding how to implement this method in practice. Later, Salminen et al. 16 advocated for case study research to be used more extensively in the profession. They concluded that case study research offers an appropriate scientific methodology that can be used to understand and develop occupational therapy practice but is potentially under-utilized. However, their literature review was based on only one journal published in the occupational therapy field, so does not provide a comprehensive overview of its use in the profession.

Whilst these studies offer a justification for the use of case study research in occupational therapy and a call for greater uptake of the method, they present a narrow view of its use by focusing on a specific case study methodology or a limited literature search. To date, no extensive review of all the empirical case study research in occupational therapy practice has been conducted. It therefore remains unclear if this call for case study research has been taken up in practice, how the methodology is being utilized, or how feasible it is for this methodology to contribute to the evidence base. A scoping review was deemed the most appropriate methodology for this review as it has recognized value for researching broader topics. It will bring together and chart key information from the literature to answer the research questions and identify any gaps in the knowledge base. 25

A preliminary search of PROSPERO, MEDLINE, Open Science Framework, and JBI Evidence Synthesis was conducted and found a similar scoping review published in 2020, but this focused solely on the use of qualitative case studies in occupational therapy, therefore providing a restricted view of case study methodologies. 16 Equally, the literature search was completed in 2017 and interest in this methodology has grown in the social science field since, hence there may have been a change in the use of qualitative case study research methods within occupational therapy in the recent years. 16,17

To address this knowledge gap, the proposed scoping review aims to explore the range and characteristics of case study research methodologies to understand how they are used within the context of occupational therapy research. It will examine how case study research is defined, the methodologies adopted, and the professional context in which it is applied. By reviewing all case study research within the field, it will be possible to assess the extent to which case study research has contributed to the evidence base for occupation and health. The enriched understanding of case study research within occupational therapy could identify areas for future research and strategies to improve evidence-based clinical outcomes for those accessing services.

Review questions

How are case study research methodologies used to contribute to the evidence base for occupational therapy?

Specifically, this review will collect and chart data to address the following sub-questions:

i) How is “case study” defined as a research methodology in occupational therapy literature?
ii) What are the methodological characteristics of case studies used in occupational therapy?
iii) What are the contexts and recorded implications of case study research undertaken in occupational therapy?

Inclusion criteria

Participants.

This review will consider studies where occupational therapy input is provided as the object of study or to the “case” within the case study. This will not be limited to an individual, but can include groups and populations that an occupational therapist works with, and the processes and organizations they work within. 26

This review will consider empirical studies using case study research methodology. Papers will be excluded where a case study research design is not explicit; for example, a descriptive case report without data collection and analysis. Literature reviews, text, or opinion pieces that discuss the value of case study research will also be included to ascertain how others have conceptualized the use of case study research to achieve evidence-based practice.

This review will consider studies in any area of occupational therapy practice, which is wide-ranging across health and social care, criminal justice, and education. 26 All geographical locations will be considered; however, as only articles written in English will be included, this may create a geographical restriction through language limitations. Studies will be excluded where the occupational therapy context cannot be clearly defined; for example, multi-disciplinary focused contexts.

Types of sources

This scoping review will only include studies if they have involved empirical quantitative, qualitative, and mixed-method case study designs. This could include single or multiple case study designs, but case studies that are descriptive with no data collection and analysis will be excluded. Opinion, text, or articles that discuss the use of case study research will be included.

The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews, employing a three-step search strategy. 28

Search strategy

As this review will explore the contribution of case study research methods to evidence-based practice in occupational therapy, it is appropriate to align the search strategy to the understanding and emergence of evidence-based practice to ensure a relevant and comprehensive review.

The search strategy will aim to locate both published and unpublished primary studies and reviews. As per the JBI-recommended three-step approach, an initial limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (see Appendix I). It is accepted that the scoping review process may be iterative and the search strategy, including identified keywords and index terms, may need to be adapted as the review evolves and for each included source. 28 The reference lists of articles selected for full-text review will be screened to source additional relevant studies.

Only studies published in English will be included as the resources for translation are not available for this review. Articles published from 1990 to the date of the search will be included as the emergence of evidence-based practice in health care is recognized internationally from the early 1990s. 27

The databases to be searched include MEDLINE (EBSCO), CINAHL (EBSCO), AMED (EBSCO), Embase (Ovid), PsycINFO (ProQuest), Web of Science, and OTSeeker. The search of gray literature will include the SIGLE database and additionally the first 50 hits of Google and Google Scholar will be screened for eligible studies. As case study research may form the methodology of relevant PhD theses, a search for unpublished dissertations will be conducted on EthOS and OADT.

To identify occupational therapy–specific gray literature, a search will be conducted of the RCOT Library, which includes OTDBASE, an index of over 20 international occupational therapy–focused journals. The contents pages of practice publications Occupational Therapy News (UK), Occupational Therapy Now (Canada), and Occupational Therapy Practice (USA) will also be screened to ensure a broad scope of relevant literature is included. If key authors within occupational therapy emerge, an additional author search will be conducted.

Study selection

Following the search, all identified records will be collated and uploaded into Mendeley V1.19.4 (Mendeley Ltd., Elsevier, Netherlands) and duplicates removed. Studies will then be transferred to Rayyan QCRI (Qatar Computing Research Institute [Data Analytics], Doha, Qatar), a systematic review web application to manage the independent review process. Titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). 25,28 The full text of selected citations will then be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text papers that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at any stage of the selection process will be resolved through discussion or with a third reviewer. Studies will not be excluded based on quality, as the purpose of this scoping review is to present an overview of the available existing evidence. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses for scoping reviews (PRISMA-ScR) flow diagram. 29

Data extraction

Data will be extracted from included studies using a tool developed by the reviewers to align with the objectives of this review (see Appendix II). The data extracted will include specific details about the:

citation details: author, year, country, and information source (type, journal title);
case study definition: definition of the term “case study” (quote and page number), justification for case study design, ethics approval (Y/N/NA);
context: study aim, population (age/diagnosis), context of research (practice setting, education, etc), intervention (type), outcome measure(s) used, findings, and implications for practice;
methodological characteristics: case(s) (number and description), data collection (methods), data analysis (methods), and type of case study research (stated or conjected; intrinsic, instrumental, exploratory, explanatory, descriptive).

The data extraction tool will be piloted by two independent reviewers initially on three papers and subsequently modified and revised. However, it is noted that further modifications may be required as the data extraction process progresses to ensure all relevant data is captured. If modifications are required after initial piloting, this will be cross-checked with a second reviewer to ensure consistency. Modifications will be detailed in the full scoping review. Where required, authors of papers will be contacted a maximum of three times to request missing or additional data.

Data presentation

As per JBI methodology for scoping reviews, the extracted data will be presented in diagrammatic or tabular form to align with the objective of this scoping review. 27 Data will be summarized and reported based on emerging patterns from the results of the review; for example, studies of a similar case study type may be charted together. A narrative summary will accompany the charted results and will describe how the results relate to the review questions. This will inform the discussion of the viability of case study research in occupational therapy and provide insight into whether case studies can be used to increase the evidence base for occupation and health.

Appendix I: Search strategy

Medline (ebsco).

Searched conducted 29 May 2020

Appendix II: Data extraction instrument

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

Affiliations.

1 Glasgow Caledonian University, Glasgow, UK. [email protected].
2 Glasgow Caledonian University, Glasgow, UK.
PMID: 37525266
PMCID: PMC10388505
DOI: 10.1186/s13643-023-02292-4

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

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

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

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

Systematic review registration: Open Science Framework 10.17605/OSF.IO/PCFJ6.

Keywords: Case study research; Evidence-based practice; Occupational therapy; Single-case.

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The authors declare that they have no competing interests.

Search results and study selection…

Search results and study selection and inclusion process [34]

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Phrase cloud illustration of study design as self-identified in included empirical studies. Size…

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Number of studies per practice setting and data collection approach

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Proposed conceptual model describing case study research in occupational therapy practice

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The Effectiveness of Community Occupational Therapy Interventions: A Scoping Review

Maria-francesca estrany-munar.

1 ASPAYM Baleares (Association of Spinal Cord Injuries and Other Physical Disabilities), 07006 Mallorca, Spain; moc.liamg@acsixranumynartse

Miguel-Ángel Talavera-Valverde

2 Integra Saúde Research Unit, Department of Health Sciences, Universidade da Coruña, 15001 A. Coruña, Spain

Ana-Isabel Souto-Gómez

3 Integra Saúde Research Unit, University School of Social Work, Universidade Santiago de Compostela, 15704 Santiago de Compostela, Spain

Luis-Javier Márquez-Álvarez

4 Department of Occupational Therapy, Faculty Padre Ossó, Oviedo University, 33008 Oviedo, Spain; se.ossoerdapdatlucaf@reivajsiul

Pedro Moruno-Miralles

5 Department of Nursing, Physiotherapy and Occupational Therapy, Castilla-La Mancha University, 45600 Toledo, Spain; [email protected]

Associated Data

No data availability statement.

Background: This review aims to evaluate the level of scientific evidence for the effectiveness of Community Occupational Therapy interventions. Methods: A systematic review was used to analyze and synthesize the studies collected. The databases of Cochrane, OTseeker, OTCATS, Web of Science, Scielo and Scopus were used in order to collect articles published between 2007 and 2020. PRISMA recommendations were followed. Results: A total of 12 articles comprised part of the study (7 randomized controlled studies, 4 systematic reviews and 1 meta-analysis). The main areas of practice were geriatric gerontology (22.1%) and mental health (19.7%), which were statistically significant (χ 2 ; p < 0.005) compared to the rest. Regarding the studies analyzed, all of them had scores of >7 on the PEDro and AMSTAR scales. Conclusions: Research on Community Occupational Therapy constitutes a consolidated line of research but the objectives and areas of research were limited. Descriptive qualitative methodology predominated and studies on the effectiveness of Community Occupational Therapy interventions showed a medium–low level of evidence.

1. Introduction

According to the Ottawa Charter, health is a positive concept that underlines the importance of social and personal resources in order to achieve an adequate state of physical, mental and social well-being. The promotion of health is focused on populations or communities in order to create the necessary conditions for them to improve their health or exercise greater control over it [ 1 , 2 ].

Today, occupational therapists adhere to this perspective, recognizing that health is supported and maintained when individuals are able to engage and participate in occupations and activities at home, school, the workplace and in their community [ 3 ]. Occupational therapy actively participates in programs and services to promote the health of communities and populations, developing and implementing occupational-based approaches that pursue the involvement and participation of a population in occupations that promote health in the community [ 4 ].

This community perspective of health and its relationship with occupation has given rise to an abundant source of literature in recent years [ 2 , 5 , 6 ] concerning various theoretical concepts that are proposed as a basis for the practice of Community Occupational Therapy [ 7 , 8 ]. All of these concepts have contributed to the emergence of a new approach to the practice of occupational therapy, emphasizing the promotion of community health as the center of the practice [ 9 ]. This approach has been named in various ways: community-based occupational therapy [ 10 ], community-centered occupational therapy [ 9 ] and Community Occupational Therapy [ 7 , 8 ]. It has been echoed by various models of practice and different institutions [ 3 ]. A preliminary review of the scientific literature has allowed us to identify Community Occupational Therapy interventions in different practice settings: primary care [ 11 ], geriatrics and gerontology [ 12 ], mental health [ 13 ], childhood [ 14 ] and hospital [ 15 ] were among the most relevant.

However, a literature review does not allow us to identify studies that rigorously and clearly describe the definition and characteristics of this type of practice. There are also no systematic reviews of the scientific literature that synthesize the scientific evidence regarding Community Occupational Therapy interventions. Accordingly, we believe that a scoping review is fully justified, since it allows us to delimit and describe an area of evidence regarding Community Occupational Therapy interventions. Only in this way can Community Occupational Therapy represent a solid base for occupational therapist practice, thus moving away from isolated interventions that blur its nature, ignoring the emerging reality that makes it such [ 16 ].

Therefore, the research questions guiding this review were: (a) What was the volume, content and characteristics of the research carried out on Community Occupational Therapy? (b) What level of scientific evidence did the analysis of the scientific literature provide on the efficacy of Community Occupational Therapy?

2. Materials and Methods

A scoping review method was used to conduct an exploratory mapping of occupational therapy research at the community level. This type of methodology was selected because it allows the examination of a heterogeneous body of knowledge, both in terms of disciplines and research methods [ 17 , 18 ]. In this way, the aim was to identify and synthesize the lines of research explored and identify possible gaps in this research, as well as to elaborate more precise questions in future studies that have the same focus. The review was carried out in five stages [ 19 , 20 ], following the PRISMA-ScR guidelines [ 17 ].

First, the research questions were identified based on a preliminary review of the literature. In addition, the MESH terms and keywords of the search were selected in order to identify all available included and/or accessible studies on occupational therapy in the community setting.

Second, a search strategy was carried out using six databases (Cochrane, OTseeker, OTCATS, Web of Science, Scielo and Scopus) with an initial result that located 6453 articles. The MESH terms and keywords used were: “occupational therapy”, “community based”, “community service”, “community-based”, “community health”, “community development”, “community”, and “community-based rehabilitation”. The search was carried out between 1 January 2007 and 1 December 2020 by targeting the MESH terms and keywords in the title, abstract, keywords and main text. The strategy of the search used for Web of Science that was subsequently adjusted to the rest of the databases was: (“Community-Based”) OR (“Community Based”) OR (“Community Service”) OR (“Community Based Rehabilitation”) OR (“Community”) OR (“Community Development”) OR (“Community Health”) AND (“Occupational Therapy”). These were refined by: (Excluding) Types of documents: (Editorial OR Case Report OR Report OR Other OR News OR Retracted Publication OR Abstract OR Letter OR Biography OR Retraction OR Meeting OR Correction OR Reference Material OR Art And Literature OR Unspecified OR Data Paper OR Bibliography Or Book).

Third, the screening process was performed by ordering the references using the Mendeley manager (version 1.5.2), eliminating n = 3753 duplicated articles. The following selection criteria were established as inclusion criteria: (a) any study of a quantitative or qualitative nature that looked at occupational therapy in the community setting, (b) all age ranges, (c) studies published in English, Spanish, Portuguese, French and Catalan, (d) any type of population, scope of practice and/or health condition. The exclusion criteria were: those that did not have occupational therapy interventions in the community setting as the main objective of the study. Subsequently, the eligibility process was based on the synthesis of 122 articles.

Fourth, two authors of the study independently performed a complete reading of the 122 selected articles by extracting the data from each article in an Excel table (v.11) prepared by the research team, which recorded the following information from each study: author(s), year of publication, journal, study methodology and design, scope of practice, study objectives or research question, sample, intervention, evaluation tools used in the study, statistical analysis and outcome measurements, limitations and conclusions. Subsequently, a third author independently reviewed the analysis of the extracted data. Any differences in the analysis of the documents between the different authors were resolved by consensus between them. Based on data extracted from the 122 selected articles, the first research question: (a) What was the volume, content and characteristics of the research carried out on Community Occupational Therapy? was answered.

Fifth, the strategy included 40 studies that represented a quantitative synthesis. Furthermore, in order to calculate the level of scientific evidence in the 40 studies, we used the SING scale [ 21 ]. With the aim of responding to the second objective of this review—(b) What level of scientific evidence did the analysis of the scientific literature provide on the efficacy of Community Occupational Therapy?—15 studies were selected (randomized clinical trials, systematic reviews, and meta-analysis), due to the fact that these studies were the ones that showed more scientific evidence. Finally, the methodological quality was analyzed in order to determine the extent to which the studies addressed the risk of bias in their designs and analyses. To do this, the PEDro scale [ 22 ] was used for the evaluation of randomized clinical trials, and the AMSTAR scale [ 23 ] was used for meta-analysis and systematic reviews. Studies that did not exceed a score of at least 50% on the PEDro and AMSTAR scales were discarded. Finally, a total of 12 articles were selected in order to analyze their scientific evidence. Furthermore, with these 40 articles, and to calculate the level of evidence, the SING scale [ 21 ] was used.

Finally, a descriptive and inferential statistical analysis of the variables recorded in the study was carried out using IBM SPSS Statistics (version 19) and EPIDAT 3.1. The quantitative variables were expressed by using the mean, frequency and percentage. In the inferential analysis, the Chi-square (χ 2 ) test was applied in order to verify the null hypothesis of equality of proportions, using a confidence interval of 95%. This analysis made it possible to identify the volume, content and characteristics of the research and to summarize the existing scientific evidence on occupational therapy interventions in the community setting [ 19 ].

The search identified 122 relevant documents after a full-text review ( Figure 1 ).

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Flow chart diagram.

3.1. Research synthesis

3.1.1. research volume.

The 122 articles included in the synthesis were published in 49 indexed journals, primarily in English. They were predominantly publications in occupational therapy journals: Australian Occupational Therapy Journal n = 15 (12.3%); American Journal of Occupational Therapy n = 13 (10.7%) and the Scandinavian Journal of Occupational Therapy n = 10 (8.2%). The rest of the journals published less than ten articles that were relevant to the research questions between 2007 and 2020. As shown in Figure 2 , the number of publications fluctuated, although a certain regularity was maintained, with an average of 8.3 annual publications. Furthermore, a gradual and stable increase in published studies was observed in the last ten years ( Figure 2 ).

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Temporal evolution of articles published between 1 January 2007 and 1 December 2020.

The countries that produced the most literature on the objectives of the study were: USA n = 40 (32.8%), Australia n = 25 (20.5%), Canada n = 24 (19.7%) and England n = 10 (8.2%). The rest of the countries had less than ten published articles. Only one study was found in Spanish Puerto Rico n = 1 (0.8%) and one in Portuguese Brazil n = 1 (0.8%).

3.1.2. Content of the Research

The practice areas with the greatest number of investigations were: geriatrics and gerontology n = 27 (22.1%), mental health n = 24 (19.7%), and physical dysfunction ( n = 8; 6.6%). In the rest, the percentage number of studies was less than 6%. In the areas of geriatrics and gerontology, and mental health, a statistically significant difference was identified (χ 2 ; p < 0.005) when compared to the rest of the practice areas. Regarding the research objectives, those related to the assessment of evaluation tools and the application of practice models n = 18 (14.8%), the evaluation of intervention programs to improve health n = 12 (9.8%), and the evaluation of leisure interventions and/or social participation in the community n = 12 (9.8%), were the most frequent. The average duration of the intervention programs evaluated was 2.5 months, and the rest of the research objectives were less than 9.8%.

3.1.3. Characteristics of the Research

Qualitative research predominated in the study. When compared with the rest of the methodological strategies, a statistically significant difference (χ 2 ; p < 0.005) was identified. A total of 58.2% of the studies used a qualitative design: 20(16.4%) phenomenological, 18 (14.8%) participatory action research (PAR), 15 (12.3%) ethnographic, 12 (9.8%) narrative, and 6 (4.9%) meta-ethnographies. A total of 32.7% of the studies used a quantitative design: 7 (5.7%) RCT, 7 (5.7%) systematic reviews, 1 (0.8%) meta-analysis, 3 (2.5%) pilot studies, 7 (5.7%) case–control studies and 15 (12.3%) cohort studies.

3.1.4. Quality of the Evidence

Quality analysis of the randomized controlled studies, systematic reviews and meta-analyses revealed a mean and mode score of 6, median of 6.9 and a range of 5.9–8.

Of the 15 studies initially identified, only three [ 24 , 25 , 26 ] did not exceed 50% of the scores on the PEDro or AMSTAR scales ( Table 1 ). According to the items of the different checklists used, the following were assessed: the source of the evidence and its characteristics, the nature of the findings reported, statistical analysis, the internal and external validity of the designs, the strength of association between the variables, the risk of bias across the studies, the measurement tools across the studies, and the checklist results.

Methodological quality.

Reference	Journal and Country	Scale

Randomized Controlled Studies		PEDro
Garvey et al. [ ]	BMC Fam Pract (UK)	✔	✔	✔					✔	✔	✔
Clark et al. [ ]	J Epidemiol Community Health (UK)	✔		✔			✔		✔	✔	✔
Graff et al. [ ]	BMJ (UK)	✔	✔	✔			✔	✔	✔	✔	✔
Lam et al. [ ]	Int J Geriatr Psychiatry (UK)	✔	✔	✔			✔	✔	✔	✔	✔
Graff et al. [ ]	J Gerontol A Biol Sci Med Sci (USA)	✔	✔	✔			✔			✔	✔
Hirsch [ ]	BMJ Evid Based Med (UK)	✔					✔		✔	✔	✔
Ciaschini et al. [ ]	Age Ageing (UK)	✔		✔				✔	✔	✔	✔
Systematic review		AMSTAR
De Coninck et al. [ ]	J Am Geriatr Soc (USA)	✔	✔	✔	✔		✔	✔	✔	✔	✔
Hall and Skelton [ ]	Br J Occup Ther (UK)		✔	✔	✔	✔	✔	✔
Tate et al. [ ]	Brain Impair (Australia)		✔	✔	✔	✔	✔	✔			✔
Parente et al. [ ]	Occup Ther Int (UK)	✔		✔	✔	✔	✔
Meta-analysis		AMSTAR
Clemson et al. [ ]	J Aging Health (USA)	✔	✔	✔	✔	✔	✔	✔	✔	✔	✔

✔: Meets the criteria; ✕ : Does not meet the criteria. PEDro—1: The selection criteria were specified; 2: subjects were randomized in groups (in a crossover study, subjects were randomized as they received treatments); 3: allocation was hidden; 4: the groups were similar at the beginning in relation to the most important prognostic indicators; 5: all subjects were blinded; 6. all therapists who administered the therapy were blinded; 7: all raters who measured at least one key outcome were blinded; 8: measurements for at least one of the key outcomes were obtained from more than 85% of the subjects initially assigned to the groups; 9: results were presented for all subjects who received treatment or were assigned to the control group, or where this could not be, data for at least one key outcome were analyzed by “intention to treat”; 10. results from statistical comparisons between groups were presented for at least one key outcome. AMSTAR (Assessing the Methodological Quality of Systematic Reviews)—1: Was the design provided a priori?; 2: was there a selection of duplicate studies and data extraction?; 3: was an exhaustive search of the literature carried out?; 4: was publication status (i.e., gray literature) used as an inclusion criterion?; 5: was a list of studies (included and excluded) provided?; 6: were the characteristics of the included studies provided?; 7: was the scientific quality of the included studies assessed and documented?; 8: was the scientific quality of the included studies used appropriately to formulate conclusions?; 9: were the methods used to combine the results of the studies appropriate?; 10: was the probability of publication bias assessed?

Concerning the quantitative aspects of the scientific evidence, the studies scored with 1- and 2- predominated, compared to 1++ and 1+ ( Table 2 ).

Levels of evidence and grades of recommendation according to SIGN.

	1++	1+	1-	2++	2+	2-	3	4
Cohort studies					8	7
Case–control studies					2	5
Pilot studies		1	2
Meta-analysis	1
Systematic review	1	2	4
RCT		2	5
Total	2	5	11	0	10	12	0	0

RCT: randomized controlled studies; 1++: meta-analysis, systematic reviews of clinical trials or high-quality clinical trials with very little risk of bias; 1+: meta-analysis, systematic reviews of clinical trials or well conducted clinical trials with little risk of bias. 1-: meta-analysis, systematic reviews of clinical trials or clinical trials with high risk of bias; 2++: systematic reviews of cohort or case–control studies or high-quality diagnostic test studies, cohort or case–control studies of high-quality diagnostic tests with very low risk of bias and with a high probability of establishing a causal relationship; 2+: cohort or case–control studies or well-conducted diagnostic test studies with low risk of bias and with a moderate probability of establishing a causal relationship; 2-: cohort or case–control studies with; 3: Non-analytic studies, e.g. case reports, case series; 4: expert opinion.

It should be noted that due to the heterogeneity and methodological limitations of the studies, it was not possible to perform a meta-analysis with the research results, nor perform detailed comparisons between studies. Table 3 provides a summary of the studies included. In the presentation of this summary, the following have been detailed: thematic areas, objectives, characteristics (duration of the study, population profile, number of participants or number of articles included in the reviews), results, and conclusions of the investigations carried out on the efficacy of Community Occupational Therapy interventions that exceeded the minimum criteria of rigor and scientific quality (scores ≥7 on the PEDro and AMSTAR scales).

Synopsis of findings for randomized controlled studies, systematic reviews and meta-analyses.

Population and Sample	D *		Objective		Intervention Type	Assessment Tools and Results	MQ **
Geriatrics and Gerontology
Randomized Controlled Studies
Graff et al. (2006) [ ]. Netherlands							8/10
135 people ≥ 65 years old with mild-moderate dementia.	12		To evaluate the efficacy of community-based occupational therapy intervention in improving the daily functioning of patients.		Ten occupational therapy sessions (cognitive and behavioral) to train patients (use of aids, compensate for cognitive impairment) and caregivers (coping and supervisory behaviors).	Assessment of Motor and Process Skills (AMPS), and Daily Activities in Dementia (IDDD). Sense of Competence Questionnaire (SCQ). There was a significant pre- and post-improvement in patients and caregivers in the intervention group compared to the control group (the differences were 1.5 (95% confidence interval 1.3 to 1.7) for the AMPS; −11.7 (−13.6 to −9.7) for the IDDD and (11.0; 9.2 to 12.8) for SCQ. The number of patients needed to treat in order to achieve a clinically relevant improvement in motor skills score was 1.3 (1.2 to 1.4) at six weeks, whereas those who received occupational therapy performed significantly better. In ADL those compared to those who did not at 12 weeks showed this improvement was still significant (effect sizes 2.7, 2.4 and 0.8).
Lam et al. (2010) [ ]. Hong Kong							8/10
102 people ≥ 65 years old with mild dementia, residents in the community.	16		To evaluate whether occupational therapy interventions focused on case management alleviated the burden on the caregiver and improved the quality of life for people with dementia.		Case Management.	Primary outcome: Zarit Burden Scale (ZBI). General Health Questionnaire (GHQ). Personal Well-Being Index for Adults (PWI-A). Secondary outcome: Mini Mental State Examination (MMSE). Neuropsychiatric Inventory (NPI). Cornell Scale for Depression in Dementia (CSDD). Personal Well-Being Index for the Intellectually Disabled (PWI-ID). The use of day centers and home assistants was higher in the case management group, both in the fourth and twelfth month of follow-up ( < 0.005). The study showed significant effects in reducing the burden on the caregiver.
Graff et al. (2007) [ ]. Netherlands							6/10
135 couples of patients older than 65 years with mild or moderate dementia and their caregivers.	5		To evaluate the effectiveness of a multidisciplinary community program aimed at optimizing the management of cases with risk of fractures related to falls.		Ten sessions of cognitive and behavioral occupational therapy.	Diabetes Quality of Life (DQOL). Cornell Scale for Depression (CSD). Center for Epidemiologic Studies Depression Scale (CES-D). General Health Questionnaire (GHQ-12). This study was a replica of the study by Graff et al. [ ], which corroborated the results of the previous study. The improvement in the COD of patients in general (0.8, 95% confidence interval (CI) 0.6–0.1, effect size 1.3) and the COD of the caregivers in general (0.7, 95% CI 0.5–0.9, effect size 1.2) was significantly better in the intervention group compared to controls. Scores on other assessment instrument measurements and their outcome also improved ( < 0.007 with Bonferroni correction). Improvement also obtained at 12 weeks. Community occupational therapy improved mood, quality of life, health status and caregivers’ sense of control, and was recommended for patients with dementia and caregivers.
Hirsch (2007) [ ]. Netherlands							6/10
135 people ≥ 65 years old (56% women) with mild-moderate dementia and residents of the community.	5		To evaluate the efficacy of community-based occupational therapy interventions in the daily functioning of older patients with dementia and in the competence of caregivers.		Ten occupational therapy sessions using client-centered guidance to modify the patient environment, ADL performance, and training of caregivers in maintaining patient autonomy and their own social participation.	Ten one-hour sessions of occupational therapy were conducted in homes ( = 68) together with the same number of sessions without occupational therapy intervention ( = 67). The study showed a statistically significant improvement ( = 0.005) in daily functioning in patients and in the competence of their caregivers in the group that received the occupational therapy intervention.
Ciaschini et al. (2009) [ ]. USA							6/10
201 people ≥ 55 years old at risk of hip fracture due to falls.	48		To evaluate the effectiveness of a multidisciplinary community program to optimize the management of cases with risk of fractures.		Components of the intervention included assessment of risk of falls, functional status and family environment, and patient education.	Compared with usual care, the intervention increased the number of referrals to physical therapy (21% (21/101) vs. 6.0% (6/100); relative risk (RR) 3.47, confidence interval (CI) 95% 1.46–8.22) and occupational therapy (15% (15/101) vs. 0%; RR 30.7, 95% CI 1.86 to >500), but it did not reduce the risk of falls since at 12 months, those in the intervention group were higher than in the usual care group (23% (23/101) vs. 11% (11/100); RR 2.07, 95% CI 1.07–4.02).
Clark et al. (2011) [ ]. USA							6/10
460 people (60-95 years old) in the Los Angeles metropolitan area (USA).	24		To determine the efficacy and economic profitability of occupational therapy and health promotion intervention in community-residing elderly people.		Monthly outings to the community were programmed to facilitate direct experience with the content of the intervention, such as the use of public transport.	The participants of the intervention, in relation to the control group, showed improvement in scores of vitality indices, social functioning, mental health, compound mental functioning, and satisfaction with life, as well as a decrease in depressive symptoms and body pain ( < 0.005). Furthermore, it was economically profitable when comparing occupational therapy intervention costs with other alternative interventions.
Systematic review
De Coninck et al. (2017) [ ]. Netherlands							9/10
Nine studies up to 2015 with a population of 3163 people ≥ 60 years of age with chronic disabilities residing in the community.	-		To evaluate the efficacy of Community Occupational Therapy interventions in improving performance of activities of daily living.		-	A significant increase in performance improvement was identified, with a standardized mean difference of 0.30 in the case of activities of daily living (95% CI 0.50 to 0.11; = 0.002); 0.44 in the case of social participation activities (95% CI 0.69 to 0.19; = 0.007) and 0.45 in the case of mobility in the community (95% CI 0.78 to 0.12; = 0.007).
Hall and Skelton (2012) [ ]. United Kingdom							6/10
17 studies published between 1999 and 2010 with 586 people with dementia and their caregivers.	-		To identify the efficacy of occupational therapist interventions to increase support for caregivers of people with dementia.		-	There was an increase in all variables related to the support perceived by the caregiver, except for one related to knowledge of the disease.
Meta-analysis
Clemson et al. (2008) [ ]. Australia							10/10
3298 people ≥ 65 years old who resided in the community.	-		To determine the efficacy of occupational therapy interventions in local community services for reducing the risk of falls in older people.		-	The collected analysis of the six clinical trials ( = 3298) showed a total reduction of 21% in the risk of falls (RR = 0.79, 95% CI = 0.65 to 0.97). Pooled analysis of four clinical trials with participants having a high risk of falls ( = 570) showed an absolute risk difference of falling of 26% and a clinically significant reduction of 39% in falls (RR = 0.61, 95% CI 0. 47 to 0.79).
Physical dysfunction
Systematic review
Tate et al. (2014) [ ]. Australia							7/10
Articles: Medline (since 1946), PsycINFO (since 1806), and PsycBITE (since 1806), to 2014. Nine studies and a population of 132 adults with traumatic brain injury, residents in the community.		-		To identify and evaluate the efficacy of community-based occupational therapy interventions for the improvement of leisure/social activity after suffering a head injury.	-	A total of 58 statistical comparisons were made, but only 25 (43%) were significant. The effect size for improvement in the experimental group was small.
Primary care
Randomized controlled studies
Garvey et al. (2015) [ ]. Ireland							6/10
50 people with problems associated with the management of multimorbidity and chronic conditions.	-		To evaluate efficacy, increased frequency of participation in community activities, improvement of quality of life and independence of ADL.		OPTIMAL. Occupational Therapy Led Self-Management Support Programme (six weeks).	There was an increase in the frequency of participation in activities within the community ( < 0.001), in the subjective perception of performance and personal satisfaction.
Natural disasters
Systematic review
Parente et al. (2017) [ ]. Italy.							5/10
Ten studies published between 2005 and 2015	-		To evaluate the available evidence on the efficacy of occupational therapist interventions in disaster situations.		Articles on rehabilitation and occupational therapy interventions in disaster management (after earthquakes) were included.	Insufficient scientific evidence and scarcity of studies in the literature. The importance of access to rehabilitation interventions, including a rehabilitation team and providing methods to address difficult evacuations.

D *: Duration in weeks; MQ: Methodological quality. ** The systematic review and meta-analysis were evaluated with AMSTAR. The randomized controlled studies were evaluated with PEDro.

4. Discussion

Regarding the first question of this study, from 2007 to the present, the number of studies on Community Occupational Therapy experienced a gradual increase, which may indicate growing interest in this area of research. Principally, this fact may be related to an aging population, and that there needs to be more outcome studies in order to evaluate the effectiveness of such an intervention [ 37 , 38 , 39 ]. In relation to this fact, we could confirm that research on Community Occupational Therapy currently constituted a consolidated line of research during the period studied.

According to the data obtained, it appeared that research in areas of geriatrics and mental health concentrated most of the research (exceeding 50% of the articles selected). In addition, the main objective of a quarter of the research in these areas focused on the evaluation of the effectiveness of different intervention programs. In geriatrics, such programs had the main objectives of improving the functionality and quality of life, reducing the risk of falls and overloading caregivers, increasing autonomy in the performance of activities of daily living and independence in the home, and promoting the health and well-being of healthy older people residing in the community.

In the case of mental health, the main objective of intervention programs is to improve the performance of basic activities of daily life, provide independence in the community, social participation, quality of life, mood and general health, as well as reducing addiction relapse and caregiver burden. However, the average duration of such programs was short, with an average of 2.5 months, which considering the objectives, is usually achievable in the medium- or long-term once such programs are established [ 40 ]. In addition, the focus is on individual interventions within the community, to the detriment of actions aimed at promoting the health of communities and populations, distancing itself from the guidelines that direct the practice of occupational therapy in the community [ 3 ]. Surprisingly, the little research undertaken on interventions for health promotion and disability prevention has traditionally been linked to community health.

Therefore, in light of the results of this study, we advocate increased research on health promotion and prevention of disability in the community, with the aim of expanding the scientific evidence on the efficacy of Community Occupational Therapy related to these spheres.

Regarding the methodological characteristics of the research, on the one hand, we considered that the range of research objectives was limited. This circumstance could be related to the meagre experience and poor tradition of the practice of Community Occupational Therapy, which implies a significant lack of tools and intervention strategies, as well as the necessary skills for the implementation of distinctive actions and proven effectiveness [ 4 , 41 ]. In this regard, we fully agree with the numerous authors [ 41 , 42 , 43 ] who have advocated the diversification of study objectives and the development of lines of research that make it possible to gather scientific evidence on the efficacy of the practice of Community Occupational Therapy.

On the other hand, it should be noted that the qualitative methodology of a descriptive nature predominated, since the percentage of quantitative studies (32.79%) was significantly lower than the percentage of qualitative studies (58.20%). This fact could be related to the suitability of this methodology, in relation to the objectives usually proposed in Community Occupational Therapy studies, which seek to apprehend the subjective experience of the health of members of the community. Considering the data obtained in this review, it appeared that research on Community Occupational Therapy has reached a period of consolidation, adopting a variety of both qualitative and quantitative approaches, although qualitative studies still predominated. However, we believe that it would be advisable to increase quantitative research in order to provide scientific evidence [ 44 , 45 , 46 ].

Nevertheless, it should also be noted that, according to the data analyzed in this scoping review, some of the studies identified had low methodological quality. Therefore, we consider it necessary to improve such quality. These findings seemed to indicate the need to improve the quality of evidence from the effects of Community Occupational Therapy programs in specific areas, in order to reduce the variability of the practice and improve its efficacy [ 47 , 48 ]. It should also be noted that research on Community Occupational Therapy has been carried out mainly in Anglo-Saxon countries. This circumstance could generate a possible bias in research on the selection procedure of the study population [ 49 , 50 , 51 , 52 ]. Therefore, we advocate increasing the number of countries in which this study objective is investigated, in order to collect information on the social and cultural particularities of the practice of Community Occupational Therapy.

Regarding the second question of this review, despite the fact that in recent years there has been a significant increase in evidence-based research as a fundamental basis for the best choice of occupational therapy practice in the community, the quality of evidence of efficacy for this practice is inconclusive or sparse. A high percentage of studies based on the efficacy of Community Occupational Therapy interventions showed a medium–low level of evidence. Therefore, not all the scientific studies analyzed had the same value with regard to decision making in choosing the best available practice. In fact, studies classified as 1- and 2- should not be used in the recommendation-making process due to their high potential for bias. However, it should be considered that the studies included were too small to detect this effect. It is possible that methodological limitations and the heterogeneity of the studies included meant that the effect was not detected.

In this same sense, it should be noted that, in the field of mental health, despite the high percentage of studies identified in the review, no randomized controlled studies, meta-analyses or systematic reviews have been carried out. Therefore, the scientific evidence gathered regarding the efficacy of occupational therapy interventions in this setting is sparse.

Along the same lines, due to the analysis carried out in this scoping review, we should consider the apparent contradiction between the characteristics of interventions considered as Community Occupational Therapy and the definition of this area in the specialized literature on occupational therapy.

In recent years, occupational therapy has suggested a profound transformation of the perspective toward the concept of health that changes from the individual to the community [ 53 , 54 , 55 ], which has been echoed by various models of practice [ 56 ] and diverse institutions [ 3 ]. From this new perspective, according to Wilcock and Townsend [ 42 ]: “[…] it is not only about reducing illness and disability in individuals […] but about promoting a broad notion of health, understood as the ability and opportunity to live, work and play in safe communities that provide support”. In accordance with these guiding principles, Community Occupational Therapy stands as a paradigm of this change in a health perspective [ 7 , 57 , 58 ].

However, the results of this review show that scientific research on Community Occupational Therapy focuses on specific groups (mainly geriatrics and mental health), with time-limited interventions, which are fundamentally based on an individual concept of health. This circumstance could be related to the absence of a clear and precise definition of the notion and scope of Community Occupational Therapy [ 41 ].

From our point of view, the absence of this precise definition, as well as the health exegesis that accompanies it, can lead to the practice of Community Occupational Therapy based on short-term interventions, centered on individuals residing “within” the community, as the results of this scoping review seemed to show.

Therefore, we advocate for the practice of Community Occupational Therapy that implies a profound change in the intervention perspective, based on occupational justice and empowerment, which requires medium- and long-term interventions “in, with and from” the community. In other words, Community Occupational Therapy should understand the community as a unit of analysis and independent intervention [ 58 , 59 ]. Only in this way will we be able to modify the conditions that allow the community to carry out and engage in occupations that ultimately promote the health and well-being of its members.

In short, we defend a greater precision and clarity in the definition of the notion of Community Occupational Therapy, the ultimate support for a real change in the practice of our profession in this area.

4.1. Limitations of the Research

A detailed analysis of the methods used to assess the risk of bias in the studies included in this review was beyond the scope of this study. Therefore, the absence of this information can be considered as a limitation of the study.

4.2. Recommendations for Future Research

Improving the methodological quality of research in this area is a basic recommendation for increasing the scientific evidence on the efficacy of Community Occupational Therapy interventions [ 50 , 51 ].

It is advisable to develop research projects that allow scientific evidence to be gathered on the efficacy of Community Occupational Therapy interventions in the field of mental health.

5. Conclusions

The efficacy of occupational therapy practice in the community is not entirely clear, but these interventions appear promising and deserve further investigation. The quality of evidence on the effects of Community Occupational Therapy programs is inconclusive or sparse. The Community Occupational Therapy interventions to reduce the risk of falls and enhance the performance of activities of daily life in older people seem to be the most effective strategies. Research on Community Occupational Therapy must heighten the methodological quality of research in order to reduce the variability of the practice and improve its efficacy.

Acknowledgments

No acknowledgements.

Author Contributions

Conceptualization, M.-F.E.-M. and P.M.-M.; methodology, M.-F.E.-M., P.M.-M. and M.-Á.T.-V.; software, M.-F.E.-M. and M.-Á.T.-V.; validation, formal analysis, investigation, resources, data curation, writing—original draft preparation, writing—review and editing, visualization, M.-F.E.-M., M.-Á.T.-V., A.-I.S.-G., L.-J.M.-Á. and P.M.-M.; supervision, P.M.-M. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Research article
Open access
Published: 16 May 2013

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

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

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

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

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

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

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

Peer Review reports

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

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

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

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

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

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

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

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

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

Site identification

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

Participants

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

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

Data collection

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

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

Data analyses

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

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

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

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

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

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

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

Case 1: Very large rural community family health team

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

Case 2: Small urban community family health team

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

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

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

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

Case 4: Urban academic family health team

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

Cross case analysis

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

Themes and Subthemes.

1. Understanding occupational therapy

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

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

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

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

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

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

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

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

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

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

Educating the team

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

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

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

Engaging physicians: a physician champion

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

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

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

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

Enhancing understanding through research and teaching

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

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

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

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

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

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

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

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

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

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

2. A culture of collaboration

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Program based care

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

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

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

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

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

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

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

Collaborating with each other

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

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

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

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

3. Communication and trust

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

Facilitating communication: the electronic medical record

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

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

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

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

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

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

Building trust: co-location

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

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

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

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

Interprofessional meetings and gatherings

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions

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

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

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

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

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

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

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

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

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Acknowledgements

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

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

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

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Research Article

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

Leona McQuaid, Katie Thomson, Katrina Bannigan

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https://doi.org/ 10.21203/rs.3.rs-1600747/v1

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

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

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

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

Scoping review registration: Open Science Framework 10.17605/OSF.IO/PCFJ6

Case study research

Evidence based practice

Occupational therapy

Single-case

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

Arguably, the challenge in evidencing the value of occupational therapy reflects the complexity of practice where the ‘the active ingredient’ is difficult to stipulate ( 9 ). This is comparable to the ‘complexity turn’ of wider health and social care which acknowledges that interventions are not always linear processes with predictable outcomes ( 10 ). In recognition of this, debate exists in occupational therapy about how best to develop the evidence base ( 11 ). Whilst the need for large scale inquiry and randomized controlled trials is evident, there is also a growing perception that this may not be appropriate to answer the full spectrum of practice-based questions ( 10 ). A shift to a pluralistic approach which best serves the decision-making needs of practitioners may be more appropriate ( 12 , 13 ).

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

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

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

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

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

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

This scoping review explores the range and characteristics of case study research methodologies to understand how they are used within the context of occupational therapy practice. It will examine how case study research is defined, the methodologies adopted and the professional context in which it is applied. By reviewing case study research within the field, it will be possible to assess the viability of case study research for contributing to the evidence base for occupation and health. The enriched understanding of case study research within occupational therapy could identify areas for future research and strategies to improve evidence based clinical outcomes for those accessing services.

Review Questions

How is ‘case study’ defined as a research methodology in occupational therapy literature?

What are the methodological characteristics of case studies used in occupational therapy practice.

What are the contexts and recorded implications of case study research undertaken in occupational therapy practice?

Inclusion Criteria

Participants.

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

Any area of occupational therapy practice was considered which spans health and social care, criminal justice, education and other diverse areas ( 33 ). An a priori decision was made to exclude studies where the occupational therapy context could not be clearly defined, for example, multi-disciplinary input or where practice was not the focus of the study, for example, describing an occupation only. All geographical locations were considered, however, as only articles written in English language were included, this may have created a geographical restriction through language limitations.

Types of sources

This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews ( 34 ) and in line with best practice, follows the updated Preferred Reporting Items Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) (See Additional File 1 for Prisma-ScR checklist) ( 35 – 37 ). It was conducted in accordance with an a priori protocol ( 38 ) and any deviations from this are reported and justified.

Search strategy

The search strategy aimed to locate both published and unpublished primary studies, reviews, and text and opinion papers. As per the JBI recommended three-step approach, an initial limited search of MEDLINE (EBSCO) and CINAHL (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy. The scoping review process is iterative ( 34 ) so it was noted in the protocol that the search strategy may need to be adapted as the review evolved. As a result of the preliminary searches, a change was required through the addition of the search term ‘occupational science’. Without its inclusion, a valuable review on the use of case study research in occupational science which also included occupational therapy practice was missed ( 39 ). Therefore, the addition of this term ensured a thorough search, recognizing the influence of occupational science on occupational therapy practice.

The search strategy, including all identified keywords and index terms was adapted for each included information source and a second search was undertaken in June 2020 and updated on 7th July 2021. The full search strategies are provided in Appendix I. The reference lists of articles included in the review were screened for additional papers plus a key author search to ensure all relevant studies were identified ( 34 ). Studies published in English were included as the resources for translation were not available within the scope of this review.

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

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

Study/Source of evidence selection

Following the search, all identified records were collated and uploaded into Mendeley V1.19.4 (Mendeley Ltd., Elsevier, Netherlands) and duplicates removed. A decision was made not to use the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Adelaide, Australia) as JBI SUMARI does not offer modifiable data extraction templates which was needed for this review ( 34 ). Instead studies were transferred to Rayyan QCRI (Qatar Computing Research Institute [Data Analytics], Doha, Qatar), a systematic review web application to manage the independent relevance checking process ( 42 ).

A screening tool was developed and piloted on a sample of studies by all three reviewers (initials anonymised for peer review) and adjusted until consensus reached to enhance clarity before continuing the full screening process. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria (initials anonymised for peer review). Due to the broad nature of the question and a lack of clarity in reporting case study research methodology in the title or abstract, where there was doubt, articles were included for full text review to be as inclusive as possible. Potentially relevant papers were retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers (initials anonymised for peer review). Full-text studies that did not meet the inclusion criteria were excluded, and reasons for their exclusion recorded. Any disagreements that arose between reviewers were resolved through discussion or with a third reviewer. Studies were not quality assessed, as per scoping review guidance ( 34 ), as the purpose of this scoping review was to map available existing evidence rather than consider methodological quality.

Data extraction

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

Data extraction was completed by the first author and a 10% sample checked by a second reviewer. As recommended in the data extraction process ( 35 ), multiple reports from the same study were linked. The data extracted for empirical studies included specific details about the definitions, justification and citations of case study research, the methodological characteristics, the context in terms of practice setting and population, and key findings and implications relevant to the review question ( 38 ). Authors of papers were contacted to request missing or additional data, where required.

Data presentation

Study inclusion

In total, database and secondary searching returned 8,382 studies (Fig. 1 ). After duplicates were removed, 5280 underwent title and abstract screening and 1200 were eligible for full text screening. After applying the updated 2016 date parameters, and full text screening, 92 were eligible for inclusion. This included seven reports linked to three studies which were subsequently combined ( 43 ) and four non-empirical review papers. Three of these reviewed the use of case studies in occupational therapy and/or occupational science prior to 2016, further justifying the decision to provide a more contemporary review. Therefore 88 records were included in the review in total; 84 empirical studies, and four non-empirical papers.

The majority of studies were excluded due to not having an occupational therapy practice focus, for example, multidisciplinary or a description of the meaning of an occupation rather than in a practice context (see Additional File 2 for more detail). Studies were also excluded if they could not be identified as case study research or in one occasion, the full text was in a foreign language. Studies where the full text could not be sourced were also excluded. Website and referencing list screening returned no additional results to those identified through database searching.

Characteristics of included studies

The characteristics of included studies (N = 88) are presented in Appendix IV and V and a summary in Table 1 . Although papers such as opinion and literature reviews were eligible for inclusion, the majority were empirical studies adopting a case study research design (n = 84/88; 95%). The remaining papers (n = 4/88; 5%) were a literature review (n = 3/4; 75%) or discussion (n = 1/4; 25%) focused on case study research within the context of occupational therapy practice. The majority of studies were published in journal articles (n = 77/88; 87%) but empirical research was also identified in theses (n = 6/88; 7%), abstracts (n = 4/88; 5%) and a book chapter (n = 1/88; 1%). After an initial dip from 2016, publication of empirical case study research shows a consistent trend from 2017 onwards; the lower number in 2021 is attributed to the search stopping mid-way through the year (July 2021). There is greater representation of the Global North, consistent with wider trends in occupational therapy and reflecting a need for decolonisation of education and practice ( 44 ). The top five countries of publication were USA (n = 24/88; 27%), Canada (12/88; 14%), UK (n = 11/88; 13%), Australia (n = 9/88; 10%) and Sweden (n = 7/88; 8%). However, this is likely also reflective of the western dominant databases searched and the English language inclusion criterion.

Studies were published across 36 journals (Table 2 ), with the majority published in occupational therapy specific journals (n = 56/88; 63%). The American Journal of Occupational Therapy had published the most case study research in this five-year time frame (n = 13/88; 15%) followed by the British Journal of Occupational Therapy (n = 5;/88 6%), Occupational Therapy in Mental Health (n = 5/88; 6%), Occupational Therapy International (n = 5/88; 6%), OTJR: Occupation Participation and Health (n = 5/88; 6%) and Brazilian Journal of Occupational Therapy (n = 5/88; 6%).


Study Characteristics	Empirical (N = 84)	Non-empirical (N = 4)
Publication Year 2016 2017 2018 2019 2020 2021 (July)	24 15 11 15 14 5	1 1 2
Publication Type Journal article Thesis Abstract Book chapter	73 6 4 1	4
Geographical context USA Canada UK Australia Sweden Brazil Iran South Africa Ireland Korea Japan Portugal New Zealand	23 11 10 8 7 6 5 4 1 4 2 2 1	1 1 1 1


Journal	N = 88	Journal	N = 88
American Journal of occupational Therapy	13	Frontiers in Pediatrics	1
British Journal of Occupational Therapy	5	Healthcare	1
Occupational Therapy in Mental Health	5	Hong Kong Journal of Occupational Therapy	1
Occupational Therapy International	5	Human Movement Science	1
OTJR: Occupation Participation and Health	5	International Journal of Environmental Research and Public Health	1
Brazilian Journal of Occupational Therapy	5	Journal of Occupational Therapy, Schools and Early Intervention	1
Canadian Journal of Occupational Therapy	4	Journal of physical therapy science	1
Scandinavian Journal of Occupational Therapy	4	Journal of policy and practice in intellectual disabilities	1
International journal of Therapy and Rehabilitation	3	Journal of Occupational Science	1
The Open Journal of Occupational Therapy	2	Mental Health and Social Inclusion	1
Australian Occupational Therapy Journal	2	Neurology	1
Disability and Rehabilitation	2	Neuro Rehabilitation	1
Disability and Rehabilitation: Assistive Technology	2	Occupation, Participation and Health	1
Physical & Occupational Therapy in Geriatrics	2	Occupational Therapy in Health Care	1
Archives of physical medicine and rehabilitation	1	Research in Developmental Disabilities	1
Archives of rehabilitation	1	Science and Collective Health	1
Asia-Pacific Journal of Oncology	1	Somatosensory & Motor Research	1
Early Intervention in Psychiatry	1	The Journal of Physical Therapy Science	1
		NA	7

Mapping of empirical studies

Of the 84 empirical studies, 57% (n = 48/84) provided a definition or justification for the chosen case study research methodology. The most common cited explanations for adopting case study methodology were; (i) to gain a deep understanding of the case (n = 28/84; 33%); (ii) to achieve this using multiple data sources, perspectives or baseline measures (n = 21/84; 25%) and (iii) to study the case in the real-world environment or context (n = 17/84; 20%). A need for comprehensive understanding was linked to the complexity of the phenomena or case under study, such as a social interaction or human behaviour e.g. Carrol ( 45 ) and Soeker & Pape ( 46 ). Adopting case study methodology was justified as being more suitable or practical when the phenomena was too complex or too little was already known for other data collection approaches, such as experiments or surveys to be used e.g. Nilsson et al ( 47 ) Stickley & Hall ( 48 ). Consequently, 10 studies specifically justified case study research as appropriate for early efficacy and feasibility studies e.g. Peters et al ( 49 ). In particular, Peny-Dahlstand et al ( 50 ) provided a clear description of how multiple data collection across multiple viewpoints (patient, therapist and organization) can provide intervention feasibility analysis in terms of acceptability, efficacy, adaptation and expansion. Case study methodology was described as a form of empirical enquiry or research by a small number of studies (n = 13/84; 15%) and in some instances, this was justified as being closely aligned to the principles of occupational therapy practice or a way to provide clinically relevant information e.g. Kearns Murphy & Sheil ( 51 ) and Verikios et al ( 52 ). To a lesser extent (n = 6/84; 7%), case study methodology was described as a way to test theory.

Less than half of studies (n = 41/84; 48%) referred to seminal authors or included relevant case study methodological citations. Yin’s work was most commonly cited followed by Stake and Merriam whom were more associated, but not limited to, qualitative case studies. Dibsdall ( 53 ) and Hurst ( 54 ) justified their choice of Yin’s approach to case study methodology because it provided a clearer structure to follow. Other authors cited, to a lesser extent for case study methodology include; Flyvberg ( 16 ), Hamel, Dufour and Fortin, ( 55 ), Thorne ( 56 ) and Blatter and Haverland ( 57 ). Ottenbacher ( 26 ) was cited with particular reference to single case experimental designs in addition to Salminen et al ( 29 ) when discussing the relevance of case study or n-of-1 methodology specifically to occupational therapy. Table 3 provides a summary of cited authors explanation of case study research.


Author cited	Explanation of case study research
Yin (14,p.15)	Investigates a contemporary phenomenon (the ‘case’) in depth and within its real-world context, especially when the boundaries between phenomenon and context may not be clearly evident
Stake (20, p.xi)	Case study is the study of the particularity and complexity of a single case, coming to understand its activity within important circumstances
Merriam (21, p.37)	An in-depth description and analysis of a bounded system
Flyvberg (16, p.241)	The main strength of case studies is depth – detail, richness, completeness and within case variance. It is a necessary and sufficient method for certain research tasks in the social sciences
Hamel, Dufour and Fortin (55, p.2)	An in-depth study of the cases under consideration employing various methods
Thorne (56, p.281)	The case study or case in point, is a fundamental component of knowledge development within an applied practice field
Blatter and Haverland (57, p.19)	A non-experimental research approach that differs from large-N studies in the following four characteristics; a small number of cases, a large number of empirical observations per case, a huge diversity of empirical observations and an intensive reflection on the relationship between concrete empirical observations and abstract theoretical concepts
Ottenbacher (26, p.647)	The single system model of evaluation research provides a method for incorporating empirical procedures into clinical practice not available in traditional research methods
Salminen et al (29, p.3)	Case study research seeks out rich, in-depth information. It aims to investigate a particular topic in its context from multiple viewpoints and it uses multiple methods and multiple data sources for its data collection. For occupational therapists, case study research offers a research approach that can be used to advance professional practice.

There did not appear to be a consistent approach adopted across the studies to define case study methodology or the specific design adopted. Design could, but not unanimously, be defined by number of cases (i.e., single or multiple), methods adopted (e.g. qualitative, quantitative or mixed methods) or by purpose (e.g. exploratory, experimental, descriptive). Figure 2 captures the various ways studies self-reported their methodological design (the more prominent the text, the more a word or phrase was featured in the data).

Study design

The majority of case study research adopted a multiple case design (n = 64/84; 76%), however single case designs were also published (n = 19/84; 23%). In one instance the study design could not be determined as it was not reported in the protocol abstract ( 58 ). Congruence between description of study design and the methods undertaken was not always consistent. Kassberg et al ( 59 ) self defined as a qualitative descriptive exploratory multiple case study. However, it’s collection of outcome measure data in addition to interview and field note data with Rasch descriptive analysis would suggest it is a mixed methods design ( 60 ). Two studies classified as case reports by the American Journal of Occupational Therapy ( 61 , 62 ) include a methods section with data collection, analysis and have received ethical approval which would be more consistent with case study research methodology rather than a descriptive, non-research case report ( 14 ). Similarly, three studies self defined as case series ( 63 – 65 ) but were included in line with the inclusion criteria as they reported data collection and analysis akin to quantitative and mixed methods multiple case study methodology ( 14 ).

Reliance on reported ethical approval to determine a study as research was not always reliable. The majority of studies (n = 75/84; 89%) documented that ethical approval was gained, suggesting that the design is of a research nature. However, 12 studies did not report on ethics and one study ( 66 ) documented that, after seeking guidance from three university review boards, ethics was not required for a case study approach. Whilst the word research is not used in this study, the authors provide appropriate citation when justifying the choice of case study to gain in depth understanding. It also has a methods section with data collection (interview and documents review) and analysis suggesting it is research.

Methods of data collection

Case studies in this review utilized a variety of data collection methods and appeared to represent different research paradigms, although the authors positioning is only stated in two studies; critical realism ( 53 ) and constructivism ( 67 ). Quantitative data collection methods accounted for the majority of methods used across all studies (n = 42/84; 50%), but particularly dominant in inpatient and outpatient settings (Fig. 3 ). Mixed methods (n = 22/84; 26%) and qualitative (n = 20/84; 24%) data were also utilized across studies although to a lesser extent. Case study data collected in community settings presents a spread of quantitative qualitative and mixed methods (Fig. 3 ). All except one study used two or more methods to collect and triangulate data. The one exception was Lorenzo et al ( 68 ) who conducted only focus groups. However, data was triangulated across focus group sites to provide an in depth understanding and cross case analysis.

Quantitative outcome measure data was collected and triangulated by using different instruments or repeated measurements taken at different time points. This data was used to evaluate effectiveness with testing pre and post intervention and as such, they adopted explanatory, N-of-1, single case experimental or observational designs. The exceptions are Provancha-Romeo et al ( 69 ) and Teixeira and Alves ( 70 ) who state an exploratory and descriptive explanatory design was adopted respectively. Both however, collect outcome data pre and post intervention. Mixed methods case study research included a range of designs such as the single case experimental design ( 71 ), multiple case study ( 72 ) and descriptive case study ( 73 ).

Qualitative designs were used in studies with an exploratory or descriptive purpose. Here, qualitative data added further understanding of the effects or acceptability of an intervention from a variety of perspectives. For instance, Joyce and Warren ( 74 ) use qualitative case study methodology to explore how participation in an allotment group facilitated by a mental health occupational therapy service influences wellbeing. Data collection methods across qualitative studies included the use of semi structured interviews, observation, document review and field diaries. Observation was also evident in quantitative methods but for the purpose of gathering performance data and applying objective measures rather than descriptive or thematic purposes. Focus groups were also used in exploratory or descriptive study designs but where an intervention or area of practice was discussed rather than delivered (n = 4/84; 5%). For example, Ribeiro et al ( 75 ) used focus groups to gather perceptions of occupational therapists, team members and individuals with substance misuse experience to better understand the intervention of occupational therapy in this area. The resulting output is a detailed outline of the scope of occupational therapy intervention including areas of functional deficit to address and how this role differs to other professions’ input.

Outcome measures

The Canadian Occupational Performance Measure (COPM) was the most commonly used occupation-based outcome measure (n = 20/84; 23%) and to a lesser extent, the Assessment of Motor and Process Skills (AMPS) was used (n = 3/84; 4%). The Goal Attainment Scale (GAS) was also used (n = 5/84; 6%) and Kearns Murphy and Sheil ( 51 ) in particular advocated for its use in occupational therapy case study research, particularly in mental health settings. They provided guidance to support the use and interpretation of GAS results and examples of this in practice. Non-occupation specific measures of function were also used such as Range of Movement, Fugl-Meyer assessment, Sensory profiles and other condition specific measures e.g. Hospital Anxiety Depression Scale ( 76 ), Stroke Impact Scale( 77 ), Modified Checklist for Autism in Toddlers ( 78 ).

Methods of analysis

Descriptive analysis and visual analysis to compare data graphed over time was used in quantitative experimental designs. Statistical analysis in the form of Rasch and frequency analysis was also employed in some instances ( 79 – 81 ) but this was largely in conjunction with visual analysis. Both Gustaffson et al ( 82 ) and Gimeno et al ( 83 ) suggested in their studies that visual analysis is preferable for single case designs rather than statistical hypothesis testing due to the small number of participants. Thematic and content analysis were commonly used in qualitative studies in addition to descriptive statistics. For multiple case designs, within and cross case analysis was described ( 67 , 68 , 77 , 84 – 86 ). Specifically, Yin’s approach to pattern matching ( 53 , 59 , 84 , 87 ), explanation building ( 46 ) and matrix coding ( 88 ) was used. Two studies referred specifically to Stake’s approach to data analysis ( 67 , 89 ).

Few studies (n = 10/84; 11%) made the case explicit in terms of description, selection or boundaries. In particular, quantitative case study designs appear not to define the case, therefore, the participant receiving occupational therapy was assumed to be the case. In these studies, the inclusion criteria, time and location of intervention appear to be the boundary. Alternatively, the provision of occupational therapy input as a process could be the case of interest. Fields( 90 ) and Pretorious( 91 ) exemplify a clearly defined case as an individual and both were bounded by the context of time and location. Haines et al( 89 ) and Hyett et al( 67 ) demonstrate a defined case as a process; occupational therapy provision and a social network respectively. Across the studies, the case, either stated or conjected, was predominately an individual (n = 72/84; 85%). Groups, namely families (n = 5/84; 6%) and organizations were also identified as the case (n = 4; 5%). The case was stated as a process in a small number of studies (n = 3/84; 4%) however, without a clear description of the case and boundary, it is challenging to accurately identify this within the included studies.

Occupational therapy case studies were conducted with various client groups across a range of practice settings, as illustrated in Figs. 4 and 5. The majority were based in the community (n = 48/84; 57%) however the practice context or setting where the research was carried out was not always clearly reported (n = 11/84; 13%). Interventions adopting therapeutic use of occupation and activity were apparent, such as feeding ( 92 ), gaming ( 93 , 94 ), gardening ( 74 ) and play ( 95 – 97 ). This was more prevalent in outpatient or community settings with in-patient settings adopting more of a compensatory approach ( 98 ) to facilitate engagement in occupations as an end, rather than the therapeutic use of occupation itself as a means. As such, compression bandaging and electrical stimulation interventions were only researched in this setting. Across all practice settings, the most common occupational therapy interventions were sensory based interventions (n = 10/84; 12%) for example Giencke Kimball et al ( 99 ), Go & Lee ( 100 ) Hejazi-Shirmard et al ( 101 ), and provision of assistive equipment (n = 9/88; 11%) for example Cruz et al ( 102 ), Golisz et al ( 103 ) and Teixeira & Alves ( 70 ). In other instances (n = 4/84; 5%), provision of occupational therapy was described as the intervention, subsequently involving a range of input rather than a single defined intervention, for example Kearns Murphy & Sheil ( 51 ), Haines et al ( 89 ) and Pretorius ( 91 ).

Although all studies had a practice focus, not all were intervention specific but investigated a broader aspect of practice and so did not always include participants (n = 11/84; 13%). For example, Carey et al ( 104 ) conducted an instrumental case study on the case of occupational therapy practice in the broad context of mental health services in Saskatchewan, Canada. This involved reviewing documentation and records from practice rather than including a population group or specific intervention. Others focused on particular assessments used in practice ( 105 , 106 ) using conceptual frameworks in practice ( 54 , 67 ) and practice at the organisation or community level ( 48 , 68 , 75 , 107 ).

For studies that included a population group, case study methodology was used across the life span; adults (n = 27/84; 32%) children (24/84; 29%) and to a lesser extent, older adults (n = 6/84; 7%). It was also used with mixed age populations (n = 21/84; 25%) for instance, with families. Across all age groups, case study research was conducted largely with populations experiencing neurodevelopmental disorder (n = 32/84; 38%), stroke (n = 14/84; 17%) and ill-mental health (n = 9/84; 11%) but was not always diagnosis specific (n = 13/84; 15%) (See Fig. 5). For example, in Dibsdall’s ( 53 ) case study of a reablement service, occupational therapists provided a service to individuals with a range of diagnoses. Similarly, Fischl et al ( 84 ) supported older adults with digital technology mediated occupations irrelevant to a particular diagnosis.

Recorded implications for practice

As the majority of studies had an intervention focus (n = 73/84; 87%), they were able to draw conclusions and identify implications for practice in terms of how and why an intervention works. A mixture of exploratory, experimental and descriptive designs were used to explore the potential feasibility and efficacy of an intervention. However, implications for practice in terms of intervention efficacy were often presented as preliminary or pilot with recommendations for further research including larger sample size studies. Through multiple data collection methods, some studies incorporated participant, family or therapist views to triangulate data and draw conclusions about the acceptability of an intervention ( 50 , 52 , 73 ). As an example, Peny-Dahlstand et al ( 50 ) includes a clear diagram illustrating how multiple data sources are collected from the patient, the therapist and the organizational perspective to analyze feasibility in terms of acceptability, efficacy, adaptation and expansion. Details of the Cognitive Orientation to daily Occupational Performance intervention are aligned to a protocol giving the reader a sense of how this can be implemented in practice.

The remaining studies (n = 11/84; 13%) added to the understanding of non-intervention aspects of practice such as the use of models, frameworks and assessment tools within the practice context or recommended policy changes. For example, Soeker and Pape ( 46 ) explored the experiences of individuals with a brain injury of the Model of Self Efficacy (MOOSE) as it was used by occupational therapists to support their return to work journey. Using an exploratory multiple case design, the authors were able to conclude that the MOOSE is a useful model in this area of practice as well as increasing understanding of how and why it supported work retraining. McCourt & Casey ( 108 ) concluded that the Northern Ireland powered wheelchair criteria may need reviewed towards a more person-centered assessment after they discovered children, excluded by the current policy because of age restrictions, were able to pass the organisations’ powered wheelchair competency test. Stickley and Hall ( 48 ) concluded that occupational therapy social entrepreneurs have positive outcomes both for service users and occupational therapists. As such they recommended further government funding support for social enterprise which tackle health inequalities and injustices.

A detailed description of the participant and/or intervention is characteristic across case studies as necessitated by the ‘in-depth’ inquiry. For instance, in Carlsedt et al’s ( 77 ) mixed methods case study, a detailed overview of the BUS TRIPS intervention is provided including a session plan noting the duration, targeted skills, content and homework for individuals. A narrative accompanies the results to understand how each case progressed during the interventions including how contextual factors of individual circumstances and capabilities impacted implementation and outcome. As an example of this in the SCED, Cruz et al ( 102 ) described how each participant acquired their brain injury including presenting symptoms and impact on occupational participation. Targeted activities to test the text message memory intervention were co-constructed and person-centered and therefore varied between cases. Subsequently, different adjustments to the intervention needed for each individual are described and the results analyzed taking this into account. In contrast, Gustafsson et al ( 109 ) provides only basic demographic data about the participants but does provide sufficient detail on the intervention administration. The detailed description was therefore not always consistent, particularly where the case of interest and boundary had not been adequately defined. Whilst studies were able to draw conclusions about intervention effectiveness and noted how the uniqueness and context of a case (or client) can impact these outcomes, an accompanying detailed description and narrative aids transferability ( 14 ).

Mapping of non-empirical papers

Four non-empirical papers that reviewed the use of case study research related to occupational therapy were included in this review. These were integrative reviews of case study research in occupational therapy ( 110 ), occupational science( 39 ) and a scoping review of qualitative case study research( 32 ) together with a discussion of the applicability of single case experimental designs to occupational therapy ( 111 ). The literature review searches were conducted in either 2016 or 2017 and identified 32 ( 110 ), 27 ( 32 ), and 18 studies ( 39 ). Results suggest a global uptake of case study research in occupational therapy across a diversity of practice settings. Case study research has been adopted to address exploratory and explanatory aims, to answer ‘how’ and ‘why’ questions about a process, or ‘what’ questions to understand the case. As such, it has been used to understand the outcomes of interventions, to explore elements of practice such as clinical reasoning and theoretical models, and to understand occupation and occupational science concepts to inform practice. Multiple data collection methods had also been used including interviews, observation and outcome data.

Defining features of case study methodology identified by the reviews are that it investigates a phenomenon i) in depth, ii) in its real-life natural context, and iii) uses multiple sources of data for triangulation. Jonasdittor et al ( 39 ) and Carey ( 110 ) both suggest case study methodology can cross research paradigms and therefore can be qualitative, quantitative or mixed methods in nature. Lane ( 111 ) somewhat contradicts this stating that case studies are a form of descriptive qualitative inquiry and therefore described the quantitative single case experimental design (SCED) as distinct and separate from case study research. However, Lane ( 111 ) also acknowledged that multiple sources of data may be used including narrative records but this should be considered secondary to observing trends in data because the primary focus is to determine the effect of the intervention. In the SCED, multiple data collection points are used for in-depth understanding to measure change and make appropriate intervention responses. Hercegovac et al ( 32 ) did not make a distinction about data collection methods but sought only qualitative case study research. Reflective of this, the majority of studies identified by Carey ( 110 ) were mixed methods and qualitative in Jonasdottir et al’s ( 39 ) and Hercegovac et al’s ( 32 ) reviews. Quantitative studies were less common.

All four papers comment that generalisations cannot be made from a single case. Instead, providing a thick description of characteristics and information about the case was deemed necessary to help the reader understand the context and determine transferability of the case. Collecting and comparing across cases was also noted to provide greater validity ( 111 ). Despite this, Hercegovac et al ( 32 ) identified only 18% of studies that had adequately defined the case. All review and discussion papers conclude that case study or single case experimental designs are appropriate in the study of occupation and health. They support the wider adoption of this methodology to advance the occupational therapy evidence base because it offers a rigorous but flexible approach to study complexity in the real-world practice environment. It is presented as a ‘familiar, appropriate tool’ (110; p.1293) to develop evidence informed practice.

The findings of this review, in conjunction with the wider literature knowledge base, are integrated in Fig. 6 as a proposed conceptual model to illustrate how case study research can be applied in occupational therapy practice. It highlights the three important elements of the methodology as the ‘Case’ of interest, the ‘Study’ purpose and that it is a ‘Research’ method. Central to the application of this methodology is the aim to achieve an in-depth understanding of a phenomenon within the occupational therapy practice context. To compliment Fig. 6 , a description of case study research within occupational therapy is proposed as;

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

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

A key issue highlighted was the lack of consistent or easily identifiable terms used to describe the methodology. Some studies defined the design by number of cases (e.g. single/multiple), by purpose (e.g. exploratory, descriptive, experimental) or by data collection (e.g. quantitative, qualitative, mixed). Other terms were also used such as ‘almost experimental’, ‘case series’, ‘changing criterion’ and ‘case report’. Hyett ( 17 ) suggested case study, as a research approach, has been confused with the non-research based case report and this is supported by the findings of the current review. Self-identified ‘case studies’ were excluded, in line with the inclusion criteria, if they did not report data collection or analysis. In addition, journal classification of study type was at times incongruent with the methodology taken e.g. Proffitt et al ( 62 ). Alpi & Evans ( 112 ) highlight this lack of distinction not only in journal classification but also in database indexing. They propose that case study is a rigorous qualitative research methodology and case report is a patient or event description. Based on this, the Journal of Medical Library Association updated classification of descriptive manuscripts previously known as case studies to case reports and case studies as a research methodology are now identified as original investigations. Despite this effort at clarification, there is still room for debate. Where Alpi & Evans ( 112 ) suggest N-of-1 single subject studies fit the case report label, Paparini et al ( 10 ) aligns this to the explanatory case study. Therefore, this review adopted Yin’s ( 14 ) term ‘case study research’ as a common language that can be used by occupational therapists in the conduct and reporting of this methodology. It is suggested this will make the distinction clear from case report or non-research.

The issues highlighted in this review reflect current debate about case study research methodology. A key issue identified with empirical case study research was the inadequate description of the case and boundary so that it could be easily identified by the reader. Other reviews of case study research in occupational therapy included in this review ( 32 , 39 , 110 ) also identified this as a concern pre-2016 and Hyett ( 17 ) identified this more broadly in the literature, but particularly a concern for health and social science case studies. A clearly identifiable case, with detailed description including the boundary and context is necessary for practitioners to understand how it may translate to their own practice. A case is not synonymous with participant and, whilst it can be an individual of interest, it can also take a more intangible form of a process such as intervention delivery, practice networks or other practice areas of interest such as theory.

As a form of inquiry, case study research provides context specific, practice-based evidence, so the practice context must be understood. This in-depth, contextual understanding provides an alternative to studies seeking breadth of knowledge or generalizations and is thus the unique characteristic of case study research ( 11 ). For this reason, ‘in-depth’ inquiry and ‘occupational therapy practice context’ are positioned at the core of the proposed descriptive model, encapsulated by the ‘case and context boundary’ as essential elements to case study research methodology (Fig. 6 ).

Case study research has been shown to be a flexible methodology both in design and purpose. Of particular interest to evidence building, is its use to explore the efficacy and feasibility of an intervention in the real-life practice context. These findings support the assertions of previous authors who have suggested that case study research can be used to demonstrate clinical impact of interventions and to investigate complex multifactorial phenomena ( 11 , 27 – 29 ). Particularly in areas of innovative or emerging practice, case study research can provide a way to capture impact when participant numbers or resources are not available to conduct larger scale inquiry. Stickley and Hall ( 48 ) for instance, specifically state that their study is the first known investigation into social enterprise in occupational therapy. As a first step to building evidence, a descriptive or single case account can therefore provide an important grounding on which to build upon. The need for timely evidence during the Covid-19 pandemic demonstrated an acute awareness of this but it has also been recognized as a process of cumulative evidence building in occupational science ( 113 ) and more broadly across other disciplines ( 114 ). Of note however is Flyvbjerg’s ( 16 ) argument that the case study holds value beyond pilot or preliminary data. Whilst it may be difficult to generalize from a case study, particularly in terms of process, the outcomes can contribute to knowledge when used to test a theory or data pooled across cases.

By mapping the findings of this review, case study research appears to mirror the broad and varying nature of occupational therapy. It reflects occupational therapy as a direct service provided to individuals or groups, but also to others on a client’s behalf ( 115 ). Organization, population and system level practice is also recognized as an important aspect of occupational therapy practice ( 33 ) and was reflected in the included cases ( 68 , 75 ). Case study research therefore not only has the potential to evidence impact through intervention outcomes, but also has wider health and wellbeing impact potential by exploring and advocating for occupational therapy across the full spectrum of practice including diverse areas.

Occupational therapy was provided in a range of settings including hospital, community and industry sectors. Interventions adopted illustrate the global variation in occupational therapy practice. For instance, compression bandaging ( 82 , 109 ) and electrical stimulation ( 64 , 65 , 116 ) are not aspects of standard practice in the UK but reflect other international practice standards ( 117 , 118 ). Interventions were wide ranging and reflective of those described in the American Occupational Therapy Process and Domain Framework ( 33 ). This included therapeutic use of occupation ( 74 ), interventions to support occupation ( 119 ), education and training based ( 120 ) advocacy based ( 87 ) group based ( 121 ) and virtual interventions ( 122 ). Narrowing the intervention to a single entity was not always possible or appropriate reflecting the complexity of occupational therapy practice and several authors, for example Kearns Murphy & Sheil ( 51 ) and Pretorious ( 91 ) instead reported occupational therapy as the intervention involving a range of activities and approaches that were meaningful and goal directed for the client.

A suggested strength of case study research identified by the findings, is the similarity between the research process and clinical practice. Fleming ( 123 ) had suggested that practitioners generate hypothesis in clinical practice to test theory and problem solve elements of the therapy process for example, why an intervention may not be working as expected. Similarly, case study research has been used to test theory in evaluative or explanatory designs. Methods of data collection (e.g. observation, outcome measurement, document review, interview, client feedback) and analysis (e.g. descriptive, visual, pattern-matching outcomes) bear resemblance to how evidence is collected in practice to inform the intervention process ( 124 ). The term ‘pattern-matching’ is an analytic strategy adopted by Yin ( 14 ) in case study research to compare patterns in collected data to theory. However, pattern matching is also evident in occupational therapy clinical reasoning literature, particularly in relation to how practitioners utilize tacit knowledge to inform decision making ( 125 , 126 ). This insight into case study research supports the perspective that it may be a more familiar and therefore achievable approach to evidence building for practitioners.

The challenge of capturing the complexity of practice has previously been cited as a barrier to research engagement and evidence-based practice in occupational therapy ( 38 ). In contrast to this, case study research was largely justified as the chosen methodology because it allowed for individual tailoring of the intervention to the case and context ( 59 , 84 , 86 ). The ability to provide a narrative description of the case, context, intervention and how it was implemented or adapted was seen across case study research, including single case experimental designs (SCED). This idea of ‘individualization’ of treatment is also noted by Fleming( 127 ) to differentiate occupational therapy clinical reasoning from medical procedural reasoning. The effectiveness of occupational therapy is not solely based on a prescriptive treatment, but is also influenced by the interactions between the therapist and service user and the particulars of that context. Therefore, if thinking on clinical reasoning has evolved to capture the important nuances of interactive reasoning( 123 ) and furthermore embodied practice( 126 ) then it would seem appropriate that the research approach to building evidence should also. A pluralistic approach whereby there is a valued position for both case study research and larger scale inquiry to capture both the depth and breadth of practice would seem fitting. Collecting and pooling case study research data from practice can capture these important elements and allow for pattern matching or synthesis. In this way, case study research can hold value for evidence building, just as the randomized controlled trial, or other larger scale inquiry, does for generalizability with the potential to inform policy and practice.

Based on the findings from this review, collecting case studies from practice to develop an evidence base is potentially viable given its uptake across practice areas and relatively consistent publication. In psychotherapy, Fishman ( 23 ) advocated for a database of cases which follow a systematic structure so they can be easily understood, recognized and data compared. Journals dedicated to publishing case data using a methodical format have since evolved in psychotherapy ( 128 ). In occupational therapy, the Japanese Association of Occupational Therapists ( 129 ) collects practical case reports from members using dedicated computer software to host a collective description of occupational therapy practice. There is potential then to adopt this even on an international basis, where occupational therapy practice can be shared and measured. The challenge however, is in achieving a systematic approach to how case study research data is collected and recorded to allow for meaningful comparisons and conclusions to be drawn.

In this review, quantitative and mixed method designs used a range of different outcome measures which is not conducive to pooling cross case data. Goal Attainment Scaling (GAS) is an outcome measure that defines individualized goals and relative outcomes to determine therapeutic effectiveness ( 130 ). It is a measure advocated for its applicability across areas of practice but also for research, both large scale inquiry and case study research ( 131 ). In this review, it was used across age groups, in the community, outpatient settings and schools and in the areas of neurodevelopmental disorder, stroke, brain injury and ill mental health.

Kearns-Murphy & Sheil ( 51 , 131 , 132 ) adopted Goal Attainment Scaling in their longitudinal case study and explored the different methods of analysis of the measure. They concluded that charting GAS scores at multiple timepoints is beneficial to case study research as it adds to the ‘in-depth’ analysis providing insight into the fluctuations of therapy and outcomes in the real-life context. Visual analysis of charted scores is then an appropriate analytic technique for intervention-based case study research. Two time points, before and after, is more suited to large scale inquiry for generalization but in the case study, only the performance of an individual on a particular day is highlighted which may be influenced by several contextual factors. Given these assertions, adopting a consistent outcome measure across practice such as GAS, would allow for in depth, case and context specific understanding that could also be comparable and pooled across cases.

Strengths and limitations of the scoping review

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

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

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

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

Implications for research and practice

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

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

Abbreviations

AMPS – Assessment of Motor and Processing Skills

COPM – Canadian Occupation Performance Model

GAS – Goal Attainment Scaling

ICN - International Collaborative Network of N-of-1 Trials and Single-Case Designs (ICN)

JBI – Joanna Briggs Institute

MOOSE - Model of Self Efficacy

SCED – Single Case Experimental Design

Declarations

Ethics approval and consent to participate.

Not applicable

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and analysed during the current study are available in the UK Data Service ReShare repository, [Awaiting persistent web link to datasets – under review by ReShare]

Competing interests

The authors declare no conflict of interest.

No grant funding has been provided for this review.

Authors contributions

All authors, (initials anonymised for peer review) were involved in the conceptualization of the idea for this review. Initials anonymized for peer review supporting the development of the search strategy and (initials anonymized for peer review) conducted database searching. All authors contributed to the screening and selection of studies and piloted the data extraction tool. (Initials anonymised for peer review) completed data extraction and (initials anonymised for peer review) cross checked a 10% sample of these. (Initials anonymysed for peer review) charted the results and completed the first draft of the paper with input from the author authors. (Initials anonymised for peer review) critically revised the draft paper and all authors read and approved the final draft before submission.

Acknowledgements

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

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Supplementary Files

Additional File 1: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist

Additional File 2: Studies ineligible following full-text review post 2016

Appendix.docx

Editorial decision: Major revision

25 Nov, 2022

Reviewers agreed at journal

23 Jul, 2022

Reviewers invited by journal

Editor assigned by journal

05 Jul, 2022

First submitted to journal

27 Apr, 2022

Occupational therapy students’ reflections on ethical tensions experienced during fieldwork

August 2024
South African Journal of Occupational Therapy 54(2)
CC BY-NC-ND 4.0

University of the Western Cape
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Stacey L. Schepens Niemiec, PhD, OTR/L, DipACLM is Associate Professor of Research at the University of Southern California Chan Division of Occupational Science and Occupational Therapy. In this presentation, Dr. Schepens Niemiec will overview two approaches to intervention development: the NIH Stage Model for Behavioral Intervention Development and the Multiphase Optimization Strategy (MOST) framework. She will situate her own gerontechnological intervention research within these approaches to demonstrate how the various stages of systematic intervention development can unfold as research teams strive toward implementing effective and sustainable programs that aim to improve the health and quality of life of the community.

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South african occupational therapy students' reflections on ethical tensions experienced during fieldwork, aaqil de vries.

Jo-Celene de Jongh

Lisa wegner.

Introduction: Ethical tensions are routinely encountered by occupational therapists and students in fieldwork and may impact patient care and team morale, and lead to practitioner burnout. Ethics education is a means to reduce ethical tensions in fieldwork. Despite this, however, limited research exists regarding ethical tensions and ethics education amongst students in the South African context.

Methods: The study was conducted to explore South African occupational therapy students' reflections on ethical tensions experienced in fieldwork practice. A qualitative, descriptive design was used to review thirty-five ethics reflective journals by fourth-year occupational therapy students at a university in South Africa. Students identified ethical tensions, reflected on these using Sokol’s decision-making framework and Kolb’s Cycle of Experiential Learning, and incorporated their learning into practice. Data were analysed thematically. Trustworthiness was ensured through triangulation of researchers, multiple data sources, and an audit trail.

Findings: Three central themes emerged: (1) Ethics from the perspective of the student, (2) Ethical tensions experienced during fieldwork, and (3) How students navigated ethical tensions.

Conclusion: This study provides an insight into the ethical tensions and reflections of fourth-year occupational therapy students during fieldwork. Findings inform healthcare educators and clinicians regarding students’ perceptions about ethics education and the tensions experienced during fieldwork.

Implications for practice

Students experienced ethical tensions during fieldwork and navigated these ethical tensions by following institutional procedures, acquiring knowledge through research, drawing from the “well” of experience, and reflective practice.
The study offers a narrative for encountering and resolving ethical tension during
The main distinction between the two classifications persists when reviewing the support given to the participant who has been empowered to resolve the ethical tension whilst receiving consultation from their site clinician and the institution.
Findings inform healthcare educators and clinicians regarding students’ perceptions about ethics education and the tensions experienced during fieldwork.

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IMAGES

(PDF) An integrative review of case study methodologies in occupational
(PDF) Occupational therapy and return to work: A systematic literature
The Occupational Therapy Process : A Case Study by Vicky Holmes on Prezi
(PDF) A Case Study of Occupational Therapy in Acute Myocardial
Occupational Therapy Case Study
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COMMENTS

How Qualitative Case Study Methodology Informs Occupational Therapy
The strength of case study methodology is its flexibility to capture the complexity of the phenomenon under study and take into account the context in which it is situated (Hyett et al., 2014; Stake, 1995).As a result, case studies are well suited to exploring a variety of complex research questions such as the development and evaluation of programs, interventions, and theories (Baxter & Jack ...
Exploring the contribution of case study research to the evidence base
Background Case study research is generating interest to evaluate complex interventions. However, it is not clear how this is being utilized by occupational therapists or how feasible it is to contribute to the evidence base. This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data ...
Exploring the contribution of case study research to the evidence base
Other reviews of case study research in occupational therapy included in this review [32, 39, 100] also identified this as a concern pre-2016 and Hyett identified this more broadly in the literature, but particularly a concern for health and social science case studies. A clearly identifiable case, with detailed description including the ...
How Qualitative Case Study Methodology Informs Occupational Therapy
In all, 27 publications met the inclusion criteria and were included in the scoping review. Case studies in the occupational therapy literature have explored phenomena relating to the delivery of intervention, theoretical concepts, clinical reasoning, and education and research methods and were situated in a range of different practice areas ...
Exploring the contribution of case study research to the... : JBI
This scoping review will explore the range and characteristics of case study research within the occupational therapy evidence base. It will examine how case study research is defined, the methodologies adopted, and the context in which it is applied. Most importantly, it will consider the viability of case study research for contributing to ...
Case study research: Building the occupational therapy evidence base
Results: Case study research can capture the context and complexity of occupational therapy practice. Cases can then be pooled to make a substantial contribution to the evidence base. Conclusions: Occupational therapists should consider the use of case study research to produce practice related, meaningful research.
Exploring the contribution of case study research to the evidence base
Objective: This scoping review will explore the range and characteristics of case study research within the occupational therapy evidence base. It will examine how case study research is defined, the methodologies adopted, and the context in which it is applied. Most importantly, it will consider the viability of case study research for contributing to the evidence base for occupation and health.
Case study research: Building the occupational therapy evidence base
Occupational therapists should consider the use of case study research to produce practice related, meaningful research. Journal editorial boards need to be mindful of the value of high-quality case study research when considering publication priorities in occupational therapy literature.
Exploring the contribution of case study research to the evidence base
We consider the viability of case study research for contributing to our evidence base. Methods: Opinion, text and empirical studies within an occupational therapy practice context were included. A three-step extensive search following Joanna Briggs Institute methodology was conducted in June 2020 and updated in July 2021 across ten databases ...
Case study research: Building the occupational therapy evidence base
Studies will be excluded where the occupational therapy context cannot be clearly defined, for example, where they are multi-disciplinary focused or where a case study research design is not ...
Conducting case study research in occupational therapy
Results: Case study research offers occupational therapists a scientific methodology that can be used to understand and develop occupational therapy practice. Conclusion: This paper argues that case study research should be used more extensively by occupational therapists as the method respects the basic principles of occupational therapy.
Thinking in Stories: Narrative Reasoning of an Occupational Therapist
This qualitative case study research (Thomas, Citation 2015) supported construction of a case that is both exemplary - as a good example of occupational therapy - and instrumental in facilitating readers' in depth understanding (Simons, Citation 2009) with the aim of bringing the case to life.
An integrative review of case study methodologies in occupational
This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and ...
PDF Case study research: building the occupational therapy evidence base
Case study research: A good fit for occupational therapy Case study research is an in-depth investigation of a phenomena within its real-world context, often when boundaries between phenomena and context are unclear (69). This consideration of context or 'real life' illustrates why case study research has been
Multiple-Case Study Exploration of an Occupational Perspective in a
Case study research: Design and methods (5th ed.). SAGE. Google Scholar. Cite article Cite article. Cite article ... Occupational Therapy Journal of Research. VIEW ALL JOURNAL METRICS. Article usage * Total views and downloads: 321 * Article usage tracking started in December 2016.
Full article: How context influences person-centred practice: A
How context influences person-centred practice: A critical-creative case study examining the use of research evidence in occupational therapy with people living with dementia Niamh Kinsella a Division of Occupational Therapy and Arts Therapies, Queen Margaret University, Musselburgh, Edinburgh, UK Correspondence [email protected]
The Effectiveness of Community Occupational Therapy Interventions: A
A scoping review method was used to conduct an exploratory mapping of occupational therapy research at the community level. ... 2++: systematic reviews of cohort or case-control studies or high-quality diagnostic test studies, cohort or case-control studies of high-quality diagnostic tests with very low risk of bias and with a high ...
Occupational Therapy Case Study
Occupational Therapy Case Study. A 55-year-old man with rheumatoid arthritis is referred to you for occupational therapy to help decrease pain in his wrists to help regain function. You have been utilizing wrist splints for quite some time in treating rheumatoid arthritis patients, but wonder if there are other occupational therapy ...
A Case for Case Study Research
A Case for Case Study Research Ann Pas Colborn Anne Pas Colborn, EdD, OTR/L, is an independent contractor to the National Institutes of Health, Rehabilitation Medicine Department, Occupational Therapy Section, Bethesda, Maryland (Mailing address: 7612 Denton Road, Bethesda, Maryland 20894-2414.)
The integration of occupational therapy into primary care: a multiple
The objective of the study was to examine how occupational therapy services are being integrated into primary care teams and understand the structures supporting the integration. ... Case study research seeks to investigate real life experiences within the context in which it occurs and involves the collection of detailed information using a ...
Occupational Therapy Using a Sensory Integrative Approach: A Case Study
Abstract. OBJECTIVE. This article presents a case report of a child with poor sensory processing and describes the disorder's impact on the child's occupational behavior and the changes in occupational performance during 10 months of occupational therapy using a sensory integrative approach (OT-SI).METHOD. Retrospective chart review of assessment data and analysis of parent interview data ...
Exploring the contribution of case study research to the evidence base
Other reviews of case study research in occupational therapy included in this review (32, 39, 110) also identified this as a concern pre-2016 and Hyett (17) identified this more broadly in the literature, but particularly a concern for health and social science case studies. A clearly identifiable case, with detailed description including the ...
Occupational therapy students' reflections on ethical tensions
Methods: An exploratory-descriptive qualitative study was used to explore occupational therapy educators' and students' perceptions regarding spirituality in the community fieldwork process ...
Developing Self-Management in Type 1 Diabetes at Secondary Schools: Who
Importance: Occupational therapists have the proven capacity to improve outcomes for young adults who are self-managing Type 1 diabetes (T1D). There is insufficient understanding of adolescents' experiences of developing responsibility for diabetes self-management (DSM). Objective: To investigate adolescents' perceptions of sharing responsibility for T1D management at school.
South African Journal of Occupational Therapy
Aim: This study explores the perceptions of occupational therapists of a school-to-work transition programme at the school for learners with special needs. Methods: This study was a descriptive qualitative study. The researchers conducted semi-structured interviews with six occupational therapists involved in delivering the programme at the school.
Three Case Studies of Community Occupational Therapy for Individuals
Three case studies illustrate the complexities and opportunities in providing community-based occupational therapy services to persons with HIV. An infectious disease physician recommended three clients for therapy sessions in both the home and community.
NYU Occupational Therapy Scholar Talk Series: Dr. Stacey L. Schepens
Stacey L. Schepens Niemiec, PhD, OTR/L, DipACLM is Associate Professor of Research at the University of Southern California Chan Division of Occupational Science and Occupational Therapy. In this presentation, Dr. Schepens Niemiec will overview two approaches to intervention development: the NIH Stage Model for Behavioral Intervention ...
South African occupational therapy students' reflections on ethical
Despite this, however, limited research exists regarding ethical tensions and ethics education amongst students in the South African context. Methods: The study was conducted to explore South African occupational therapy students' reflections on ethical tensions experienced in fieldwork practice. A qualitative, descriptive design was used to ...
Occupational therapy students' and educators' perspectives and
However, these occupational therapists had already created a foundation for their clinical identity and could understand their role in a developing area contrary to the occupational therapy students within this study, who are at the early stages of exploring clinical identity and understanding the differences and similarities between the ...
2024 Research Symposium
A Comprehensive Study of Duckweed for NASA/Hudson Alpha Proposal . Author: Natania Birnbaum, Biotechnology Entrepreneurship Faculty Mentor: Robert Friedman, MBA Industry Mentor: John McShane, Katz School M.S. '22, Growmics A analysis of the biology, genetics, cultivation methods and market potential of duckweed, a small water plant that is nutrient-dense, resilient, easily modified ...

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

Conclusions

Systematic review registration

Review questions

Inclusion criteria

Types of sources

Search strategy

Study/source of evidence selection

Data extraction

Data presentation

Mapping of empirical studies

Mapping of non-empirical papers

Strengths and limitations of the scoping review

Implications for research and practice

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Additional information

Supplementary Information

Additional file 2.

Additional file 3.

Additional file 4.

Additional file 5.

Additional file 6.

Additional file 7.

Additional file 8.

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

Objective:

Introduction:

Inclusion criteria:

Methods:

Introduction

Review questions

Inclusion criteria

Types of sources

Search strategy

Study selection

Data extraction

Data presentation

Appendix I: Search strategy

Appendix II: Data extraction instrument

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Miguel-Ángel Talavera-Valverde

Ana-Isabel Souto-Gómez

Luis-Javier Márquez-Álvarez

Pedro Moruno-Miralles

Associated Data

1. Introduction

2. Materials and Methods

3.1. Research synthesis

3.1.2. Content of the Research

3.1.3. Characteristics of the Research

3.1.4. Quality of the Evidence

4. Discussion

4.1. Limitations of the Research

4.2. Recommendations for Future Research

5. Conclusions

Acknowledgments

Author Contributions

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