1148409

research-article2023
BJO0010.1177/03080226221148409British Journal of Occupational TherapyLarsen et al.

Research Article

British Journal of Occupational Therapy

Occupational therapists’ perspectives on an 1­–9

© The Author(s) 2023
Article reuse guidelines:
evidence-based, client-centered assistive sagepub.com/journals-permissions
DOI: 10.1177/03080226221148409
https://doi.org/10.1177/03080226221148409

technology intervention journals.sagepub.com/home/bjot

Stina Meyer Larsen1,2 , Åse Brandt3 , Lise Hounsgaard4,5,6,

Hanne Kaae Kristensen1,2

Abstract
Introduction: Reviews within the field of assistive technology have shown that a client-centered approach is important
for user satisfaction, and that assistive technology service delivery should be evidence-based, systematic, and structured.
However, client-centered instruments and systematic, structured models are not used consistently. As part of a larger
research project, an evidence-based, client-centered assistive technology service delivery process was developed and piloted.
The purpose of this study was to investigate occupational therapists’ perspectives on this evidence-based, client-centered
assistive technology intervention.
Method: Ten occupational therapists, from two Danish municipalities, participated in focus groups. Data were analyzed based
on a hermeneutic approach.
Results: Three themes emerged from the analysis: a more refined collaboration with clients; advantages of using theoretical
frameworks, structured models and instruments and challenges in using the intervention.
Conclusion: By using the evidence-based, client-centered intervention, the occupational therapists found that the collaboration
with the clients was refined—more emphasis was placed on shared responsibility. They found that the intervention was time-
efficient in the long run; however, there seems to be a particular challenge in designing services that are inclusive of clients
with cognitive limitations.

Keywords
Evidence-based practice, occupational therapy, self-help devices

Received: 22 February 2022; accepted: 5 December 2022

Introduction continuum from mainstream to commercially available to

custom-made ATs. Mainstream technologies are produced for
It is an inherent assumption within occupational therapy that and used by the mass market while those that are made to
occupational engagement is essential for human well-being measure are often custom-built to meet the specific needs of a
and that everyone should have access, and the opportunity
and resources, to engage in occupations that contribute posi-
tively to their well-being (World Federation of Occupational 1Centre for Innovative Medical Technology (CIMT), Department of
Therapists, 2019a). Assistive technology (AT) is used by Clinical Research, University of Southern Denmark, Odense, Denmark
2Health Sciences Research Centre, UCL University College, Odense,
occupational therapists to enable engagement in occupations Denmark
for people with disabilities (World Federation of Occupational 3User Perspectives and Community-based Interventions, Department

Therapists, 2019b). of Public Health, University of Southern Denmark, Odense, Denmark

4Odense Patient data Explorative Network (OPEN), Odense University
In the current study AT is defined as “Any item, piece of
Hospital/Department of Clinical Research, University of Southern
equipment, or product system whether acquired commercially Denmark, Odense Denmark
off the shelf, modified, or customized that is used to increase, 5Centre for Psychiatric Nursing and Health Research, Department of

maintain, or improve functional capabilities of individuals Regional Health Research, University of Southern Denmark
6Institute of Nursing & Health Science, University of Greenland, Nuuk,
with disabilities” (Cook et al., 2020: 4). However, there is no Greenland
universally agreed definition of AT, definitions differ depend-
ing on their purpose and scope (World Health Organization Corresponding author:
Stina Meyer Larsen, Department of Clinical Research, University of
and United Nations Children’s Fund, (UNICEF), 2022). Cook Southern Denmark, J.B. Winsløws Vej 19,3, Odense C 5000, Denmark.
et al. (2020) have argued that ATs can be considered on a Email: smlarsen@health.sdu.dk
2 British Journal of Occupational Therapy 00(0)

single individual with disabilities. Increasingly, individuals shown that, although the occupational therapists are aware of
with disability can use mainstream technologies such as com- and prefer a client-centered approach, they still find it diffi-
puter technologies as well as information and communication cult to practice in a client-centered way (Hedberg-Kristensson
technologies to compensate for functional limitations. Along and Iwarsson, 2013). Qualitative research also shows that
the continuum are the commercially available devices, which the clients experience the AT service delivery process to be
are produced to compensate for reduced functioning in indi- multifaceted and complex (Gramstad et al., 2014) and that
viduals with disabilities, and they are often used with few or the experience of participation among clients is variable;
no modifications. The current study focuses on commercially while some clients feel that they participate actively in the
available ATs, such as powered scooters, wheelchairs, shower entire service delivery process, others feel less involved
toilets, grab bars, etc. (Gramstad et al., 2014; Hedberg-Kristensson et al., 2006).
Both in Scandinavia and globally, many occupational The second element to which the reviews point is that a
therapists are engaged in AT service delivery (Ergoterapeut­ structured and systematic process conducted by profession-
foreningen, 2015; World Federation of Occupational als with experience in AT seems to be an important factor in
Therapists, 2019b). In 2015, the Danish Association of an effective AT service delivery and in having satisfied users
Occupational Therapists conducted a survey that showed (Brandt et al., 2014, 2015, 2020; Larsson Ranada and
that approximately two-thirds of all occupational thera- Lidström, 2019; Socialstyrelsen, 2015). Some studies have
pists in Denmark are engaged in AT service delivery suggested that, if service delivery is to be evidence-based,
(Ergoterapeutforeningen, 2015). In Denmark, most ATs are it should rely on systematic and structured procedures that
cost-free for individuals with disabilities and the munici- should be based on guidelines, instruments, or models
palities are obligated by law to offer ATs to people in need. (Bernd et al., 2009; Triccas et al., 2019). Within this field,
Applications are typically evaluated by an occupational models are understood as symbolic representations of con-
therapist, based on a written request, and usually supple- cepts that support and guide the AT service delivery (Bernd
mented with a home visit (Lassen et al., 2019). Despite et al., 2009). Other studies have argued that there seems to be
the fact that AT service delivery is an essential part of a lack of relevant instruments and models within the field
occupational therapy and many occupational therapists (Friederich et al., 2010; Socialstyrelsen, 2015). However,
are involved in it, the evidence-based knowledge concern- Federici et al. (2014) have shown that, although the number
ing the delivery process is still sparse (Brandt et al., of models has increased, the same growth has not been
2014, 2015, 2020; Larsson Ranada and Lidström, 2019; observed in service quality. This argument is supported by
Socialstyrelsen, 2015). other studies and reports that suggest that instruments and
systematic, structured models are not routinely used within
the AT field (Brandt et al., 2014; Larsson Ranada and
Literature review Lidström, 2019; Socialstyrelsen, 2015). There seems to be a
In recent years, a number of literature reviews and system- lack of studies focusing on the application of an evidence-
atic reviews have been published within the area (Brandt based, client-centered AT service delivery within occupa-
et al., 2014, 2015, 2020; Larsson Ranada and Lidström, tional therapy practice.
2019; Socialstyrelsen, 2015). These reviews have diverse
study populations and foci, ranging from studying the effects
An evidence-based, client-centered AT
of various AT service delivery processes (Brandt et al., 2020)
to an exploration of the impact of the delivery on satisfaction
intervention
with AT in relation to daily occupations (Larsson Ranada and The current study is part of a larger project, in which an
Lidström, 2019). Notwithstanding the diverse study popula- evidence-based, client-centered AT service delivery process
tions and foci, the reviews point to two elements. One ele- that relied on structured models and instruments was devel-
ment that all the reviews suggest is that a client-centered oped and piloted in close cooperation with two Danish
approach in the service delivery process seems to positively municipalities. The term AT service delivery process is in the
impact user satisfaction with the AT itself and with the ser- current study defined as an intervention that “directly assists
vice delivery (Brandt et al., 2014, 2015, 2020; Larsson an individual with disability in the selection, acquisition, or
Ranada and Lidström, 2019; Socialstyrelsen, 2015). In the use of an assistive technology” (Cook et al., 2020: 4). The
current study, the term “client” is defined broadly as both the AT service delivery process developed in the current study
person applying for ATs and the client constellation, which is is hereafter referred to as the AT intervention.
others who live with, work with, or are closely connected to The developed AT intervention was based on evidence-
the person applying for the AT. However only those who based practice—understood as the integration of the “best
experience issues with occupational performance in relation available research evidence,” “clinical experience,” and
to interaction with the person applying are considered to be “knowledge and experiences of the clients” (Harvey and
part of the client constellation (Fisher and Jones, 2017). Kitson, 2015). These three elements of evidence-based prac-
Nevertheless, qualitative studies within the field of AT have tice were used as the basis for the development of the AT
Larsen et al. 3

intervention (Harvey and Kitson, 2015). The “best available the process, for example, offering the clients verbal and
research evidence” was sourced through updated systematic written information about the AT intervention to enable
reviews and literature reviews within the field (Brandt them to understand the predictable aspects of the process,
et al., 2014, 2015; Larsson Ranada and Lidström, 2019; and explore and compare their expectations with their occu-
Socialstyrelsen, 2015). “Knowledge and experiences of the pational therapists.
clients” was obtained through a systematic review (Larsen The evidence-based, client-centered AT intervention was
et al., 2018) and a qualitative longitudinal study (Larsen developed and piloted in two Danish municipalities over a
et al., 2019, 2020)—both conducted as part of the larger period of 10 months. As the current study focuses on the
project. Finally, the element of “clinical experience” was municipal occupational therapists’ perspectives on the AT
gained by the participation of practitioners, lecturers, experts, intervention, the purpose is therefore to investigate the
and researchers in the development of the AT intervention. occupational therapists’ perspectives on the evidence-based,
Evidence-based practice has been criticized for focusing too client-centered AT intervention.
much on experimental evidence, thereby overlooking indi-
vidual needs, circumstances, and preferences (Greenhalgh
et al., 2014; Rycroft-Malone et al., 2004). It has therefore Method
been argued that the success of evidence-based practice A hermeneutical approach informed the study, inspired
depends on informed, shared decision making with clients by Gadamer’s thinking on interpretation. This approach
and on the acceptability and fit of the intervention to the involved focusing on the participants’ generation of mean-
local context (Greenhalgh et al., 2014). Thus, these elements ing and perspectives as revealed through the participants’
informed and inspired the understanding of evidence-based stories (Vandermause and Fleming, 2011), and understand-
practice applied to the current study. ing interpretation as a collaborative process between the
The Occupational Therapy Intervention Process Model reader and the text—a process of horizontal fusion (Dahlager
(OTIPM) was used as theoretical framework for the devel- and Fredslund, 2008). To gain insight into the occupational
opment of the AT intervention (Fisher, 2009). The model therapists’ generation of meaning and perspectives on the
was chosen because the OTIPM has been used previously AT intervention, focus groups were used (Halkier, 2012).
within the field of AT (Kassberg and Skär, 2008; Linden The focus group method was chosen because the occupa-
et al., 2010), and because studies have shown that the model tional therapists’ comparisons, reflections, and discussions
can be used to guide an improvement process and lead to an of experiences were expected to provide valuable insight
integration of evidence-based knowledge in practice, with into their stories concerning the evidence-based, client-
long-lasting achievements (Sirkka et al., 2014a, 2014b). In centered AT intervention (Halkier, 2012).
line with the OTIPM, the AT intervention entails the follow-
ing three phases: evaluation and goal setting, intervention,
and re-evaluation. Each phase comprises a number of steps,
Study context
and each step contains a detailed explanation of: how the The study was conducted in cooperation with two Danish
occupational therapists are to perform throughout this step, municipalities during the period 2015–2018. To ensure
including descriptions of instruments and methods, along that the knowledge generated would be relevant in diverse
with questions to support the professional reasoning; what settings, the selected municipalities varied according to,
is to be achieved during this step; what is the result of this for example, number of inhabitants—one municipality had
step; and lastly, how this step is documented (Fisher, 2009). fewer than 25,000 inhabitants, while the other municipality
During the evaluation and goalsetting phase, the focus was had more than 100,000 inhabitants; size—one municipality
on establishing collaborative relationships between clients was larger than 300 square kilometers while the other one
and therapists, and on the clients’ expressed need to engage was under 200 square kilometers; and type of district—one
in occupations with positive personal value. Structured municipality was a rural district while the other was an urban
instruments, such as Individually Prioritised Problem district (Patton, 2015).
Assessment (IPPA) (Wessels et al., 2002) and non-standard-
ized performance analysis (Fisher, 2009) were employed in
this phase. During the intervention phase, emphasis was
Participants
placed on enabling the clients to participate actively in The participants in the focus groups were the occupational
choosing, modifying, and implementing of the AT into their therapists who had participated in the overall project and in
valued occupations. Finally, in the re-evaluation, the focus the pilot of the evidence-based, client-centered AT interven-
was on the clients’ needs for further training, adjustment, or tion; each had piloted 2–3 cases. The occupational therapists
follow-up. were selected for the overall project based on the criteria of
During the entire AT intervention, importance was placed having an interest in and a motivation for engaging in devel-
on increasing the clients’ competence to participate in the opmental work. Eleven occupational therapists had partici-
process. This was done by enhancing the predictability of pated in the overall project and conducted the piloting.
4 British Journal of Occupational Therapy 00(0)

They were therefore invited to participate; one occupational (Cott, 2004; Fisher, 2009; Gupta and Taff, 2015; Hammell,
therapist was unavoidably prevented from attending on the 2013; Mroz et al., 2015; Sumsion and Law, 2006). However,
day of the interview. Thus, 10 occupational therapists from an awareness that the pre-understanding also defines the
the two municipalities participated in the focus groups; five boundaries of the researchers’ horizon of understanding also
from each. Two were men and eight women; they were shaped the study, in that the methodological principle of
between 27 and 61 years of age; their professional work becoming aware of one’s pre-understanding and placing it at
experience ranged between four and 35 years; and their risk during the interviews was also sought. As an example,
experience within the field of AT service delivery ranged before the focus groups, the first author engaged in a reflec-
between 2.5 and 24 years. tive process with the other authors where the experiential,
empirical, and theoretical pre-understandings on which the
questions were based were discussed. Furthermore, during
Ethical considerations
interactions with the focus groups, both first and last authors
The participants were orally informed about the research were aware of and willing to adopt and pursue perspectives
study and were told that participation was voluntary and that and themes that were brought up by the participants. The
they could opt out at any time without any adverse conse- focus groups were carried out with an openness and sensitiv-
quences for their employment. Written informed consent ity toward the participants’ situations and horizons and a
was obtained from the participants. flexibility to adapt the interview structure to reach a new
understanding.
The interactions with focus groups were audio-recorded
Data collection
and transcribed verbatim by an experienced transcriber.
The data collection was carried out within 2 weeks of the end As the transcribing process involves both interpretive
of the pilot. Interactions with the focus groups were held and technical decisions, the transcriptions were based on a
separately for the two municipalities to ensure situated written guideline, including decisions on how to handle,
knowledge generation (Harvey and Kitson, 2015). They for example, anonymity, breaks, overlapping speech, emo-
were conducted in municipal settings and lasted approxi- tional outbursts, and intonations (Kvale and Brinkmann,
mately 2 hours each. The first author functioned as modera- 2015). The guideline was developed by the first author, and
tor, while the last author observed the dynamic interactions presented and discussed with the transcriber prior to the
and took notes. A funnel-based approach with less structure transcription.
in the beginning and more structure toward the end was used
to investigate the participants’ perspectives on the AT inter-
vention (Halkier, 2012). In accordance with focus group
Data analysis
methodology, both focus groups opened with an introduc- The analysis was conducted as a process of decontextual-
tion, explaining the purpose, and giving information about ization and recontextualization, inspired by Dahlager and
the focus group, the moderator role, and ethical issues Fredslund (2008), and carried out in four steps: general
(Halkier, 2012). Consistent with the funnel-based approach, impression; identifying meaning-bearing units; operationali-
the moderator started out by asking mainly descriptive ques- zation; and, recontextualization and hermeneutic interpreta-
tions (Spradley, 1979), with the purpose of gaining insight tion. In the first step: general impression, the whole text was
into the participants’ experiences of using the evidence- read several times to get a preliminary understanding of the
based, client-centered AT intervention in specific situations. text. In the second step: identifying meaning-bearing units,
Later, the descriptive questions were followed by structured the focus was on “what” the text says; this is described as a
and contrast questions, where the participants were encour- meaning categorization process. In this process, the mean-
aged to discuss the revealed perspectives and opinions ing-bearing units were each assigned a theme. During the
(Halkier, 2012; Morgan, 1997; Spradley, 1979). All types of third step: operationalization, the themes identified at step
questions were combined with various exercises (Halkier, two were ordered and operationalized, to determine whether
2012). As an example of an exercise, the participants were some themes should be incorporated into one, or be divided
asked to write down some notes about how, in cases where into sub-themes. At the fourth step: recontextualization and
the AT intervention was used, it impacted on delivery, and hermeneutic interpretation, the focus was on how the text
then share these stories and perspectives with the rest of the could be understood in relation to the study aim and relevant
participants. theory. During this step, the attention moved from the parts
A moderator guide was used to structure the focus groups. to the whole, from the individual to the general and from text
In accordance with Gadamer’s hermeneutics, it was acknowl- to context. Thus, at this final step, the preliminary analysis
edged in the current study that the researcher’s pre-under- became subject to a further analysis (Dahlager and Fredslund,
standing influenced the study. The researchers’ theoretically 2008). The analysis was conducted by the first author and
based pre-understanding, in the form of literature on client- discussed with the other authors after the first step and again
centered practice, was used to inform the moderator guide after the fourth and final step.
Larsen et al. 5

Results Advantages of using theoretical

Through the hermeneutic analysis, three themes emerged: a
frameworks, structured models,
more refined collaboration with clients; advantages of and instruments
using theoretical frameworks and structured models and By using the theoretical framework and structured methods,
instruments; and challenges in using the AT intervention. In some of occupational therapists felt that they attained a more
the following section, the themes will be presented. The thorough evaluation of the clients’ situation and occupational
abbreviation (I) refers to interview, the numbers (1) and (2) performance problems. “It started with a height-adjustable
to the two different municipalities, and the letters (A-E) toilet seat and, in many cases, it would have just been ordered
refer to the letters assigned to the participants from the two for them. And then a request would come again, fourteen days
municipalities. later, and then again three weeks after, one month after, and
three months after, about all the other small ATs. I think it
would have been like that. Because it turned out there were a
A more refined collaboration with
lot of other problems. I don’t think that this would have been
clients
picked up on the phone. (I, 1, C).” The quotation shows that
The analysis of the text showed that, in providing the AT the occupational therapists found that conducting the evalua-
intervention, some of the occupational therapists found that tions in a holistic way was time-efficient, as they were able to
their collaboration with clients changed. “They (the clients) provide the clients at once with all the AT they needed, instead
are given some responsibility, in that they have to help of on multiple occasions over a longer period. Time consump-
define what they really want to be able to do again. I think tion was an important issue for the occupational therapists.
that makes the interaction different (I, 1, B).” The quotation In the short term, the AT intervention was time consuming;
seems to indicate that, by involving the clients in the however, some of the occupational therapists considered it an
process, some of the occupational therapists felt that the investment in saving time and money in the long run.
collaboration was refined. They no longer considered Many of the occupational therapists found that the AT inter-
themselves as experts in charge of the entire process; vention enhanced their professional competences, which they
instead, the responsibility was shared between the occupa- experienced as satisfying. A participant gave the following
tional therapists and the clients. This led to enhanced col- example of enhancement of professional competences: “The
laboration, with the purpose of identifying strengths and scientific terms and ways to set things up as an occupational
problems regarding occupational performance and clarify- therapist, it isn’t usual practice, not for me, at least. So, in that
ing the clients’ motivation. “It is the clients that contribute way, I think you need to recall it again, but I think that it gives
to the formulation of (.  .  .) the occupational challenges that a boost to my professional competencies (I, 1, C).” The quota-
are most important for them and that we therefore must tion shows that, previously, some of the procedures had been
concentrate on (I, 2, C).” It was the impression of some of based on tacit knowledge, but by using theoretical frameworks,
the occupational therapists that the use of client-centered such as the OTIPM and non-standardized occupational per-
instruments, such as the IPPA, refined the collaboration and formance analysis, the occupational therapists found that their
facilitated a client-centered approach, in which the clients’ professional assessment and reporting was strengthened.
needs and desires were in focus: “I believe that the clients Instead of writing two lines about an observation, which would
feel that they are heard and seen in a different way than in typically describe walking distance and breaks, the occupa-
the traditional way. It has something to do with the IPPA tional therapists conducted an occupational performance
form (I, 1, A).” analysis that focused on the quality of the performance. “The
By using the client-centered and occupation-based quality of walking (. . .) normally we would write two lines
models and instruments, some occupational therapists about how the client can walk hundred meters with four breaks
found that they gained a more nuanced understanding of and blah blah blah. Now we write more about quality and
the clients, and thereby a different side to, or some new effort and safety and all that. If we reject the application and
aspects of, the clients that they had previously not noticed the client complains. Then I also think it gives a good descrip-
to the same extent: “In some cases, they (the clients) tion for the National Board of Appeal (I, 2, C).” By strengthen-
almost become the disease itself. We move away from that, ing the professional assessment and reporting, some of the
because you become more aware of their resources (. . .) occupational therapists felt more comfortable and competent
You get a much broader picture of them (. . .) a better when discussing issues such as rejections of applications with
insight into them as individuals and their abilities (I, 2, other healthcare professionals, clients, or the appeal board.
A).” The quotation seems to illustrate that it was the occu-
pational therapists’ impression that, by applying the cli-
ent-centered AT intervention, some of them felt that they
Challenges in using the AT intervention
gained a more nuanced picture of the clients and their eve- Overall, the occupational therapists experienced positive
ryday life. elements of working in an evidence-based, client-centered
6 British Journal of Occupational Therapy 00(0)

manner; however, they could also foresee some challenges, study by Kjellberg et al. (2012), which shows that 87% of the
if it were to be implemented in the two municipalities. Some participating occupational therapists considered a client-cen-
occupational therapists found that it was difficult to involve tered approach to be very important. However, other studies
experienced clients in the process: “After all, some clients have shown that occupational therapists experience barriers
are trained in this system. They think: this person is from the when trying to comply with a client-centered approach
municipality, so now I have to tell about this, that and the (Hedberg-Kristensson and Iwarsson, 2013; Mortenson et al.,
other (I, 2, C).” As expressed by the quotation, according to 2013). In the present study, the occupational therapists found
the occupational therapists, the difficulties arose mostly that the use of client-centered instruments and models facili-
because some clients had specific expectations of the occu- tated a client-centered approach and enhanced the collabora-
pational therapists, as representatives of the municipalities, tion with the clients in the delivery process. However, a
based on their previous experiences of municipal healthcare previous study within the field of AT has shown that the
professionals. occupational therapists considered functional limitations,
Even though the occupational therapists found that their such as visual or hearing impairments or loss of speech, as
language changed to a more professional language, they also significant barriers to involving clients in the service deliv-
considered the terms used in the non-standardized perfor- ery process (Hedberg-Kristensson and Iwarsson, 2013). In
mance analysis to be challenging. As expressed by the fol- the current study, the occupational therapists also found that
lowing quotation: “E: I’ve thought, when I’ve read the things it was challenging to use the AT intervention in cases where
I’ve written, well this makes sense. B: I thought the concepts the clients were not able to express themselves. However,
used were very unfamiliar and they weren’t so descriptive (I, they also experienced that obstacles arose when the clients
2, E and B).” They were unsure if their colleagues who were had specific expectations of the occupational therapists,
not part of the project would be able to understand their doc- based on their previous experiences with healthcare profes-
umentation of the non-standardized performance analysis. sionals. This finding is also supported by other studies within
Regarding the various elements of the AT intervention the field that argue that maybe challenges with involvement
and the target group, it was the occupational therapists’ expe- in the service delivery process sometimes can be explained
rience that some of the elements, such as enhancing the pre- by tacit expectations and implicit assumptions on the part of
dictability of the process, should be used on all applications, the clients (Gramstad et al., 2014; Hedberg-Kristensson
while others could be used when relevant: “It makes good et al., 2006).
sense if they are new clients, because then you make an It is well known that improvement or implementation
assessment of their everyday lives in a different way, than if work is time consuming (Harvey and Kitson, 2015); how-
you just focused on the AT they have applied for (I, 2, B).” As ever, the current study’s findings support the study by Sirkka
shown by the quotation above, the occupational therapists et al. (2014), in that both studies emphasize that improve-
considered that relevant cases would all be new cases. They ment work saves time in the long run, in that all of the cli-
also argued that it would be relevant in complex cases and ent’s needs are ascertained and addressed the first time,
ones where there had been an immense change in the client’s instead of on multiple occasions over a longer period of time.
situation. However, they also found it difficult to use the AT In addition, the occupational therapists in the current study
intervention in some cases: “I think it should be individuals, also considered the time spent to be an investment in saving
who can participate actively (. . .). They must be cognitively time and money in the long run. Some of the occupational
well-functioning (I, 1, D).” The occupational therapists therapists in the current study found that, by offering the
emphasized that it was challenging to use the AT interven- evidence-based, client-centered AT intervention, they gained
tion in cases where the client’s cognitive functioning was a broader and more nuanced picture of the clients and their
reduced or when the clients were not able to express situation. By using theoretical frameworks and structured
themselves. methods and instruments, some of them perceived their pro-
fessional assessment and reporting to be strengthened, which
led them to feel more competent when discussing issues with
Discussion
other healthcare professionals or clients. Our findings are in
By using the evidence-based, client-centered AT interven- accordance with the study by Sirkka et al. (2014). Although
tion, the current pilot study found that the occupational ther- it is not within the AT field, it focuses on occupational thera-
apists perceived the collaboration with the clients to be pists’ experiences of participating in long-term improvement
refined. They no longer considered themselves to be the work based on the OTIPM. The current study also found that
experts in charge; instead, the responsibility was shared with the occupational therapists’ focus on occupational therapy
the clients. Studies within occupational therapy have shown and occupations was strengthened through the intervention.
that occupational therapists consider client-centered practice Given that occupation creates the foundation or the core base
to be of great importance for occupational therapy (Hedberg- of occupational therapy (Fisher, 2009), Fisher (2013) has
Kristensson and Iwarsson, 2013; Kjellberg et al., 2012; argued that it should also be the foundation of both occupa-
Mortenson et al., 2013). It is exemplified by the Swedish tional therapy services and professional reasoning. To allow
Larsen et al. 7

the profession’s unique focus on occupations to guide our basis of the criterion of having an interest in engaging in
participants’ professional reasoning, we used the conceptual developmental work (Harvey and Kitson, 2015). The limita-
model OTIPM as inspiration for the development of the tion in this decision could be that these occupational thera-
intervention (Fisher, 2009). pists were more positive toward changes than the other
In the current study, the occupational therapists found it occupational therapists employed in the two municipalities.
challenging to use the evidence-based, client-centered inter- Despite the fact that qualitative research is not preoccupied
vention in cases where the client’s cognitive functioning was with generalizability, a variation in the participants’ back-
reduced. This finding is in accordance with previous studies ground is nevertheless often favored (Patton, 2015).
that show that healthcare professionals find it challenging to The first author, who moderated the focus groups, was
develop services that involve people with cognitive impair- also involved in the overall project and pilot of the AT inter-
ments (Hedberg-Kristensson and Iwarsson, 2013; Kjellberg vention. In order to increase the trustworthiness of the
et al., 2012; Larsson Ranada and Lidström, 2019). In the findings, the moderator guide was discussed among all the
study by Kjellberg et al. (2012), it was found that 39% of the authors and, during the focus groups, both first and last
participating occupational therapists referred to the client’s authors sought both positive and negative experiences.
ability, such as cognitive functioning, as the primary reason However, it is important to be aware of the possibility that
for not applying a client-centered approach. However, hav- some of the occupational therapists may have felt hindered
ing cognitive impairments does not exclude clients from the in expressing negative experiences, due to the presence of
right to be actively involved in decisions about the services the first author. On the other hand, it could be argued that the
that they are offered, and the right to receive services that first author’s insight into the field and process could have
meet their needs and wishes. It could be argued that one of augmented the quality of the questions and facilitated
the limitations of client-centered practice is that some clients nuanced discussions among the participants. The partici-
are not interested in or able to engage in collaborative pants were also colleagues in the two municipalities, which
partnerships with healthcare professionals. Some of the could have influenced their perspectives—both negatively
frameworks within occupational therapy have therefore and positively. During the interactions with the focus group,
emphasized that the term “client” should be understood they were all asked to consider the question and write down
broadly as including individuals, families, organizations some remarks before discussing the question in plenum.
or communities (Fisher and Jones, 2017; Townsend and However, it is still possible that some participants might
Polatajko, 2007). However, Fisher and Jones (2017) still have withheld perspectives and experiences.
argue that, despite the fact that people may be unable to com- Member checking was not employed, as it is acknowl-
municate or express needs, they are nevertheless the client. edged within hermeneutical research that participants’ gen-
Relatives and others close to the client can offer valuable eration of meaning and perspectives, as revealed through the
information about the client’s situation; yet, it is still the cli- participants’ stories, may change with time and situation
ent who is at the center of the occupational therapy interven- (Goldblatt et al., 2011). However, to increase the credibility
tion. This is in line with a meta-aggregation by Kristensen of the findings, questions with the intention of clarifying
and Peoples (2020), albeit conducted within a different field. understandings and perspectives were raised during the
They argue that people with cognitive impairments due to interview (Vandermause and Fleming, 2011).
dementia want to be offered opportunities to make decisions
in their everyday lives and to practice self-determination. A
Conclusion
literature review conducted by the Swedish National Board of
Social Services (2015) argues that, if the AT service delivery The current study revealed that, by using the evidence-based,
follows a systematic and structured service delivery process, client-centered AT intervention, occupational therapists
and if information, evaluation, training, and follow-up are found that the collaboration with clients was refined—more
adapted to the client’s conditions, then this seems to facili- emphasis was put on shared responsibility. Some of the
tate and enable participation in the process for people with occupational therapists also found that, by using the theoreti-
cognitive limitations. However, although in the current study cal framework and structured methods, they attained a more
client-centered models and instruments were used through- nuanced evaluation of the client’s situation. In the short term,
out, to meet clients’ needs for adaptations, descriptions of the AT intervention was time consuming; however, some of
how the evidence-based, client-centered AT intervention can the occupational therapists found it time-efficient in the long
be adapted to meet the needs of clients with cognitive impair- run. The occupational therapists also found that focus on
ments should be further developed. occupational therapy and occupations was enhanced through
the evidence-based, client-centered AT intervention, thereby
strengthening their professional assessment and reporting,
Methodological considerations and making them feel more competent. However, there
This study was limited to a group of 10 occupational thera- seems to be a particular challenge in designing services that
pists. The participants were as stated earlier, selected on the are inclusive of clients with cognitive limitations.
8 British Journal of Occupational Therapy 00(0)

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