If you’re working in schools right now, you’ve likely noticed the push towards tiered models of service delivery. Whilst these approaches promise benefits like earlier identification and better outcomes, this qualitative study by VanderKaay and colleges explores the ethical tensions occupational therapists face during this transition.

To give context, tiered models involve three levels: tier one provides universal services beneficial for all students at classroom or school level, tier two offers targeted support for some students with specific issues, and tier three delivers individualised services for a few students who need them. One well-known example is Partnering for Change.

Methods

The researchers used interpretive description methodology, particularly suited to addressing complex clinical practice issues. They recruited eleven self-nominated occupational therapists. All were registered in Ontario, working in contexts transitioning to or having transitioned to tiered models. Data was collected via in-depth online interviews between January – Mach 2023. Their research question was: What are the perceived ethical tensions experienced by occupational therapists in transitioning to tiered models of service delivery in school-based occupational therapy?

The Results

Theme 1 Fidelity: Implementing as Designed

Occupational therapists struggled to be faithful to tiered model tenets. Many reported not actually delivering tiered services despite organisations labelling them as such. As one participant stated, “I actually take P4C out of my notes because I do not think what we are doing is P4C.”

Resource limitations precluded genuine transition—adequate time wasn’t allocated for universal services, and funding wasn’t provided for whole-school interventions. Limited capacity in schools following COVID-19, including teacher shortages and limited educational assistant support, created additional barriers. Limited understanding of tiered models themselves posed challenges, some therapists said they didn’t fully understand the models or how to explain them to others. Knowledge gaps existed amongst managers and school personnel too.

Crucially, implementation processes weren’t fully in place. Intake, time-tracking, documentation, and discharge processes still reflected traditional pull-out services. Productivity reporting methods only counted one-to-one intervention, leaving therapists feeling their tier one work didn’t matter despite being told it was important.

Theme 2 Veracity: Being Truthful

Concerns about truthfulness emerged at all three tier levels. Therapists were asked to indicate they were delivering tiered services whilst knowing this wasn’t feasible given caseload sizes. One participant described it as “we overpromised and underdelivered.”

At tier one, letters went to all families announcing universal services when these weren’t actually viable. At tier two, services were sometimes utilised to bypass consent that would ordinarily be needed to work with a child individually, whereby the therapists were asked to create resources for groups but were targeting one child. At tier three, therapists were asked to clear waiting lists by providing traditional pull-out services rather than working within the tiered model.

Documentation practices raised truthfulness challenges too. To track productivity, some therapists were still being asked to tie universal services to individual students. As such, the specific tier of intervention was not correctly recorded.

Autonomy: Prioritising Self-Determination

Professional autonomy was significantly limited. Many therapists were required to follow rotational schedules visiting schools approximately once every three to four weeks rather than determining frequency based on each school’s or child’s needs. Therapists were also told which services to provide and at which tier, making service delivery prescriptive rather than needs based.

Student and family autonomy was also compromised around informed consent. There was lack of clarity about when consent was required, and therapists were asked to deliver interventions circumventing consent requirements.

Confidentiality: Safeguarding Entrusted Information

Confidentiality represented a “grey zone.” Teachers can discuss student concerns quite freely without informed consent, whilst occupational therapists as regulated health professionals cannot. This created particular challenges in tiered models where therapists aim to become embedded as school team members. Even when therapists explicitly stated they couldn’t discuss student information without consent, teachers continued sharing confidential details. I think this issue is less of a concern if the therapist is employed by the school, however for those of us in independent practice or working for the NHS it can be a challenge.

Distributive Justice: Allocating Resources and Services Fairly and Equitably

Approximately one day per school every three to four weeks wasn’t enough time to adequately deliver tiered services. Intervention time often went to one classroom whilst others received very little.

A significant concern arose from therapists straddling two systems—the new tiered model and previous pull-out model. Many were asked to continue carrying traditional caseloads whilst simultaneously providing tiered services to whole schools.

Practical Takeaways

If you’re experiencing these tensions yourself, this research validates that you’re not alone and these challenges aren’t due to individual failings.

For managers and organisational leaders, these findings highlight the critical need for deep understanding of tiered models before implementation. Policies, processes, and documentation systems must align with tiered service delivery rather than forcing new models into old systems.

The study reveals that large-scale practice shifts require thoroughly developed implementation plans. It highlights that we still don’t have clear processes for documenting input or ensuring that provision is delivered based off clinical need, rather than a prescriptive allocation. I also think we often forget that a tiered model is actually designed for the whole population. So, within the whole population, the majority of children could benefit from universal support, some need more targeted help and a smaller proportion need specialist help. The reality is, if the child has been referred to an OT service, they are likely in need of tier two or three input. I personally cannot remember the last time I received a referral for a child that only needed universal provision. Whilst universal supports, especially environmental modifications and knowledge translation are important, I do think our services need to acknowledge that there are still children who need extra support and teams need to be adequately resourced to deliver this.

This mixed-methods study by Salazar Rivera and colleagues examined service delivery models and barriers to inclusion in occupational therapy practice in Chilean schools. The research explored how occupational therapists are working to promote inclusion within the Chilean educational system and identified systemic barriers that impede inclusive practice. Data was collected from 241 questionnaires and focus groups with 18 OTs. Tier 1 direct pull-out support consisting of weekly 45 minute sessions was the approach used by 68% of participants. Factors that influenced service delivery included, institutional constraints, the educational community’s perspectives on OTs, characteristics of students, and a persistent structural demand for a deficit-based approach. Understanding these contextual factors and service delivery challenges provides insights relevant to occupational therapists working within diverse educational systems internationally.

This study by Grandisson and colleagues evaluated a capacity building initiative designed to enhance occupational therapists’ skills in working with autistic students. The research examined the effectiveness of professional development focused on autism-informed, neurodiversity-affirming practice with twelve OTs. Results demonstrated improvements in therapists’ knowledge, confidence, and practice approaches following participation in the capacity building programme. This highlights the value of ongoing professional development in supporting quality service delivery.

This study by Pratte and colleagues. Factors that influenced the success included strong collaborations, open-mindedness, knowledge and interpersonal skills, and ability to personalise services. Barriers reported were limited follow-up by the OT, shortage of human resources, and limited availability of staff, which negatively influenced the ability to meet regularly and implement strategies.