OTS 207: What Hundreds of School-Based OTPs Revealed About Their Actual Practice
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Welcome to the show notes for Episode 207 of the OT Schoolhouse Podcast.
What's really happening in school-based OT practice across the country? In this episode, Jayson sits down with Hannah Smiles, OTD, OTR/L, to unpack findings from a national survey of 331 school-based occupational therapists across 41 states, published in the open-access Open Journal of Occupational Therapy.
Hannah and her research team examined the entire OT process — from referral through intervention — using the OTPF as a guiding framework, revealing that narrow referral patterns persist (handwriting, sensory, and fine motor still dominate), over two-thirds of OTPs aren't using formal environmental assessments, and most practitioners are operating in a "blended" workload/caseload model. Three major interconnected themes emerged from the data: role confusion, inconsistent leadership opportunities, and an incomplete transition to the workload approach.
Whether you're looking for validation, language to advocate for your role, or a clearer picture of where the profession stands today — this episode is for you.
Press play to discover where school-based OT stands today and what needs to change to move the profession forward.
Listen now to learn the following objectives:
— Learners will identify the most common referral patterns in school-based OT and recognize gaps in scope.
— Learners will recognize the three major themes affecting school-based OT practice.
— Learners will identify the unique value of school-based OT using research evidence.
—Learners will identify practical ways to expand their role, advocate for involvement in MTSS/RTI activities, and move toward more leadership within their schools.
Guest(s) Bio
Hannah Smiles, OTD, OTR/L, is a school-based occupational therapy practitioner in St. Louis. She works with students across a wide age range, from kindergarten through vocational skills programming, supporting their development and independence in the school setting. Hannah is passionate about expanding the role of occupational therapy in schools and empowering OT practitioner leadership on school teams. In addition to her work on Perspectives of School-Based OT Practitioners, she has contributed to publications focused on health literacy and menstrual health management programming in schools.
Quotes
"The role of the OT is misunderstood by the education team, but also by OTs themselves."
— Hannah Smiles, OTD, OTR/L
"Leadership can be getting in on a problem-solving team and advocating for yourself to be in the room."
—Hannah Smiles, OTD, OTR/L
"Some people feel stuck. Some people want to break out."
—Jayson Davies, M.A., OTR/L
Resources
Episode Transcript
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Jayson Davies
As a school-based OT practitioner, there is something uniquely powerful about finding out that your colleague across the district and even across the country is struggling with the exact same things that you are. That referrals feel just as narrow, like sensory and handwriting, and that's it. That the workload feels just as impossible trying to squeeze 50 treatment sessions into a single week, and that the gap between what you know is best practice and what you can actually do feels just as frustrating. There's real comfort in knowing that you're not doing it wrong. That maybe it's not you, but maybe it's the system that is making things so difficult. If hundreds of OT practitioners across 41 states are running into the same barriers. That's not just validation; that is a signal, and that signal deserves a real, honest look. A team of researchers did exactly that. They surveyed 331 school-based OT practitioners nationwide and asked a simple but ambitious question: How are we actually carrying out the OT process within schools, from referral all the way through intervention, and how does that compare to what best practices actually call for? I'm Jayson Davies, and this is episode 207 of the OT Schoolhouse podcast. My guest today is Hannah Smiles, a school-based occupational therapist in the St. Louis area, and the first author of an open access study published in the Open Journal of Occupational Therapy. What makes Hannah's perspective especially compelling in this story is that she didn't just research this. After she conducted her research, she went straight into the schools and watched every finding play out in real time. Today, we're walking through what this data actually shows us, what it means for your daily practice, and why, despite all of it, one quote from a survey respondent just might reframe the way that you think about the value that you bring to your school every single day. Let's dive in.
Amazing Narrator
Hello, and welcome to the OT Schoolhouse Podcast, your source for school-based occupational therapy tips, interviews, and professional development. Now, to get the conversation started, here is your host, Jayson Davies. Class is officially in session.
Jayson Davies
And welcome to the OT Schoolhouse Podcast. How are you doing today?
Hannah Smiles
Good. Thanks for having me.
Jayson Davies
Absolutely. And really quickly, where in the world are you joining us from? It's it's really awesome. I love the podcast. We get to talk to people from all over the country and sometimes even outside the states. But love to hear a little bit about where where you live on this great big earth.
Hannah Smiles
I'm currently in St. Louis, Missouri. So St. Louis from Chicago, but live in St. Louis.
Jayson Davies
Ah, very cool. And that's where you're working as well.
Hannah Smiles
Yep, I'm a school-based OT in a school in St. Louis.
Jayson Davies
Awesome, perfect. And now every few years, there seems to be an article that comes along talking about the perspectives of school-based OT practitioners. I don't know if this is unique to school-based OT. Obviously, I only look at really school-based OT stuff to see if there's perspectives to school-based OTs. I don't know if this happens outside, like in general outpatient Peds or in the adults world, but it seems to happen within the school-based OT world. And so, to kind of get us going here, I just want to know kind of like the why behind that. Why did you, Steve and Charlie and Lauren, who also worked on this article with you, say to ourselves, like, or say to yourselves, we need to look at the perspectives of school-based OT practitioners.
Hannah Smiles
Yeah, so we were kind of exploring the literature within school-based scholarship, and we were kind of seeing a lot of different literature surrounding different parts of the OT process, and there was a lot of information about best practice suggestions for OTs in schools, and we were kind of came up with the question of like, what is actually happening now? What are OT practitioners? How are they completing the OT process, and how does that compare to all of this literature in best practice? And we really couldn't find anything current that was the entire OT process and what that looked like in comparison to best practice to kind of see what it in our minds we were like in order to have actionable steps to move forward towards best practice we needed to know kind of where we stood, and so that's kind of how this this survey and this piece came about.
Jayson Davies
Interesting, because yeah, when I was talking about those perspectives of school-based OT practitioner research in the past, I know several of them have kind of been around the realms of caseload and workload. I know from Syria and Garfinkel, and I think that did come up in your paper eventually, but that isn't exactly what you necessarily wanted to look at, correct?
Hannah Smiles
No, yeah, we were looking at the OT process as a whole rather than individual pieces of intervention or evaluation or caseload with versus workload, for example. We wanted to get kind of a snapshot of how current practice trends are aligning with those best practice standards to kind of see because there's so much variation across the country and across school-based practice. We kind of wanted to see where we kind of stood in relation to all of these suggestions that come out for best practice to kind of start that ball towards moving us a little bit closer towards those best practice standards.
Jayson Davies
Yeah, yeah. And you mentioned that you're a school based OT yourself, right, in the St. Louis area. How did that impact? Kind of, I mean, was this something that you were wondering as a practicing therapist? Like, hey, best practices? Am I doing best practices? Am I not? Is that like why? What kind of led you down this road, or how did your actual practice lead into this?
Hannah Smiles
Yeah, so this we completed this kind of study while I was on Capstone, and I was working within a charter school actually, and we were kind of introducing OT as a more like population level work into this charter school, and so that's kind of how we got led down into this realm. As we were introducing kind of these best practice, and we were talking about how this is not how OT is being done in a lot of other district schools around the country. So that was kind of where that comparison started, was because we were kind of starting from the ground up for my capstone project and another person before me's capstone project. So we were talking kind of from the roots up of best practice standards, if that makes sense. And now, as I'm working kind of full time in in a in a different district, I'm seeing the realities of what our research kind of has presented, and I'm understanding a little bit more where everybody's coming from, and knowing where my focus and intentionality needs to lie based on kind of how how the respondents and all the themes and trends that kind of came out of this study.
Jayson Davies
Gotcha. You mentioned that this, I think, if I heard correctly, that this was kind of like a follow up to a previous project before. Is that correct?
Hannah Smiles
Well, there was another capstone student that was starting in before me in the charter school, and she introduced kind of the OT into the population level OT into the school, and then I kind of took like what she was seeing, and we talked about it together, and then we kind of took the project and ran with it. So, gotcha, yeah. So it it takes kind of building upon people upon people, you know.
Jayson Davies
Oh yeah, I've been there. I have advised master thesis students, and it's like a little mini capstone. And I've gone through that process with multiple groups of students, and yeah, like each time we built a little bit more on top of the previous project, and sometimes it's a project, and then the next one's a research to look at to see if the project was effective, and yeah, so it kind of goes back and forth a little bit. So totally get that. All right, well, every research, every article that gets published, especially within the OT world. Before you actually get into the the nitty gritty of doing your work, you've got to look backwards and you've got to see what's out there. and And you mentioned, you know, that there wasn't necessarily a research space that kind of looked at the best practices within the school based OT process. What were some of the themes, though, that you recall kind of coming out that that you were finding, and how did that influence where you eventually went?
Hannah Smiles
Yeah. So again, kind of like we touched base on, there's a huge growing body about workload versus caseload management styles and like approaches. So that was a big one, and then also there was we were looking at some information on MTSS and how research is beginning to arise on OTs role in MTSS, and we did a big kind of background on the legislation and how IDEA and ESSA all came into about and how this influences OT practice. So that's kind of all things that we touch on in our introduction because they're things that you can't leave out when you're talking about school-based OT. And then we continue to look at different intervention types. There's lots of research about specific interventions and maybe specific referrals as well that we were kind of finding, and we were kind of wanting to put it all together and see if, as a process, where people were kind of landing. So
Jayson Davies
pretty ambitious.
Hannah Smiles
Again, lots of bits and bits and pieces, and we kind of wanted to see the process as a whole.
Jayson Davies
Yeah, anything related to like the scope of school-based OT. I mean, right? There's this constant. What is our scope as school-based, as opposed to outpatient pediatric? And some OT practitioners really, really like being. In that, I do handwriting and sensory and fine motor, and then there's other OT practitioners who are really wanting to break out and do other things. And some people feel stuck. Some people want to break out, and some people are very happy with with where we're at. Any of that come out in that that research part, or maybe not?
Hannah Smiles
We didn't find a lot of like that perspective base. There was more quantitative research on like caseload size and service delivery type, and like implementation of implementation of workload. But there's less information regarding the OTs' role in like referral or evaluation and things like that. So we have found like that there's a couple bits and pieces, but not a ton of like the OTs like specific voice giving voice to their perspective on these things either.
Jayson Davies
Gotcha, gotcha. Okay. So as you kind of look back at the lit review, was do you feel like that there was one like one or two key things? I mean, you mentioned caseload workload. You mentioned MTSS. You mentioned IDA, ESSA, and and some of the other pieces. Was there anything that just like really shocked you and kind of led the direction a little bit, or was everything pretty much kind of you know things that you already knew as as even as a capstone student.
Hannah Smiles
I think none of it was super surprising. Okay, I think that there was like there's focus on maybe an OT referral or an OT collaboration with other team members in the school or even OT intervention, but there's also like a missing piece of that like larger contextual perspective of education and working within the system of education, and so it felt like there was like a missing piece in all this evidence of like how the OT process as a whole is implemented, if that makes sense, so we were seeing things that really like made sense of like okay, there's mostly this type of referral, and there's all like there's minimal collaboration, and once people are educated on what an OT can do, they feel like like they want the OT to be more involved, and that's that like collaboration piece, and all of that's like super important. And I think it's not something that we should discount. It was important. It's important for our lit review and for our study as well. But the seeing it as a whole towards like the OT process towards best practice as a whole is kind of where we wanted to kind of fit into that gap.
Jayson Davies
Interesting. Okay, so you've talked, you said the the phrase a few times, right? Like the OT process. That's what we wanted to look into the OT process. I want to give you a moment to kind of break that down a little bit. I'll kind of I think cue up a little bit here. Like, is that from the referral to going from the referral process to the evaluation process to the intervention treatment plan, and eventually, you know, exiting a student-is that what you mean by the process, or how do you define that?
Hannah Smiles
Yeah, that's exactly kind of what we were going with. We wanted to have basically questions from pre-referral, so before the referral, their involvement, so that's your MTSS, and then questions about referral, evaluation, intervention, and then kind of scope as a whole and things like that as well, kind of the larger picture as well. But yes, we kind of followed the OT PF and we followed the OT process and how we created the survey as well to kind of hit all of the pieces of what a school-based OT would be kind of working within, if that makes sense.
Jayson Davies
Yeah, you mentioned just there really quickly. You use like the OTPF to kind of guide this. I think within the process, we actually did an episode about this not too long ago, with where the OTPF requires an occupational profile, it basically requires the the assessment piece, the observation, the assessments if you're going to do tools or whatnot, and then a synthesis. Is that kind of what you're referring to here when you're talking about you use the OTPF to kind of define that process?
Hannah Smiles
Yep, exactly.
Jayson Davies
Gotcha. Okay, very cool. All right. Of course, now if we're talking about any research article, right? Starts with the the little abstract, goes through the lit review, and the next kind of comes the next parts that that methodology piece. Before we start talking about exactly what you did, you already mentioned survey or question. So obviously this was a survey, but break down the population a little bit here for us. I'm surprised you guys actually had a pretty decent number of people fill this out. But tell us a little bit about who it was and what your your requirements were.
Hannah Smiles
Yeah, so we were trying to get a wide span of OT practitioners to respond to our survey. We had. 331 responses from 41 states. So that was OTs across the country, and we were just snowball recruiting through social media survey boards. We emailed state associations to pass on to their members. We tried our best to get our hands on OTs in whatever way that we could, and that's OT practitioners. So we included OTAs as well as OTs, and I believe it was at least one year of experience was our our limit, and was our start. So we and yeah, 331 responses. We were very excited about that. We felt like that was a good like a representation of
Jayson Davies
yeah
Hannah Smiles
of different OTs across the country.
Jayson Davies
Yeah, definitely 41 different states. I I almost want to guess the nine states, but I'm not going to even try that. And it looks like I'm looking at the research study right now in front of me. It looks like you're at about 29 OTAs and 302 OTRLs. So yeah, I mean, I know how difficult. Like I said, I've done research before. I know how difficult this is. I mean, even when we send out an email to the list of 14,000 plus school-based OT practitioners that are on the OT schoolhouse list, it's still hard to get you know even a few, and so kudos to to all of you that were able to get 331 responses. That is just amazing. I'm kind of looking at this. By the way, everyone listening, you need to say thank you really quickly to Hannah and the team because they actually got this published on the Open Journal of OT keyword there open, and so this research is completely accessible. We will be sure to link to it in the show notes. But yeah, you can look it up right now for free. Don't need any subscription. Easy to access, and I'm looking at table one here where it just kind of breaks down and everything. Yeah, very very diverse, right? You you've got education level, you got years of experience. It looks like you did have some practitioners with zero to 12 months, so it might not quite have been one year. And
Hannah Smiles
yeah, it was. I guess it must have been less than one year.
Jayson Davies
Yeah, which which is totally fine. I mean, because you're breaking this down, which is which is great. Ooh, and I like that you also looked at the current practice setting, and you've got public school here, public charter school, private school, religious day school. So all the different types of school, and again, very diverse. I mean, it looks like 302. Surprising, that's the same exact number of OTRls, but that's just the way the cookie cookie crumbles. I guess we're in public school, but then you've got you've got a several that were in others, so oh, you know what? Did I just realize that? No. Yeah, it was
Hannah Smiles
a select all that applied, so you could yeah select like multiple schools if you were maybe working within different kinds of schools yeah as well.
Jayson Davies
Yeah, well, very cool, and and congrats on getting such a such a again on getting such a large number because that is that's not easy, and I will applaud you for for and thank you.
Hannah Smiles
Anyone's listening who took the survey, thank you. Right, we appreciate that, and I mean it was really important for us to make this accessible accessible to especially school based OTs because we are in it and we know that it's frustrating when things aren't accessible within the public schools. So that was something that was important to us as well.
Jayson Davies
Fantastic, fantastic. So okay, so we've got our population set. Let's talk about some. How did you go about developing the survey? And before I ask you those specific questions, was there like some key things in your mind? You're like, our survey needs to fit this criteria. Doesn't matter what the questions are; it needs to fit this criteria.
Hannah Smiles
We wanted it to be holistic. That was kind of our main driving point. Again, we wanted to kind of create a snapshot of what OTs at that time, were kind of doing, and we wanted it to be comprehensive so that OTs felt like their voice was heard. And I think through that, we ended up wanting to do both quantitative and qualitative data, so that we gave OTs the chance to add anything that was important to them that we didn't have specifically on a multiple choice question, so that was really important to us, and I feel like it was really definitely worth the coding and the effort that it takes for scoring kind of a qualitative type of responses. But we got to we got to hear from the OTs themselves in their own words, which was also really important to
Jayson Davies
us. Oh yeah, yeah, definitely. I appreciate that. And so, when we get into your your methodology a little bit further, it looks like you actually broke it down by referral, evaluation, and then intervention, which kind of makes sense in in line with what we've already talked a little bit about. Was the survey kind of broken down in that manner as well?
Hannah Smiles
Yep, exactly. So the questions flowed in that order, so that it would be the most it would make the most sense to the survey taker of okay, we're starting in our minds at like where we would start with a new student in the referral process, and then kind of go forward because that's the natural way that OTs think. So
Jayson Davies
yep, absolutely. That's that's exactly how I develop my course in the same exact system. Because yeah, you need to know the basics before you move on to pre-referral, referral. Yeah, it's just the way it works. Okay, so then, and I think it makes it a little bit
Hannah Smiles
less daunting. I think it makes it a little bit less daunting to someone who wants to maybe get involved in something like research. Like you don't have to reinvent the wheel, like it's OT already. Kind of has so much mapped out for you that even if it's scary to approach, like look what we did. We just went right through the OT process, and we use the OT PF as a guide. So it's also encouragement to anyone who doesn't know where to start.
Jayson Davies
Yep, yep. So then, when it came to questions, how did you? You said you use qualitative and quantitative. How did you all start to lay that out? And if you can, just kind of a few examples, maybe under each of the three areas of of what you wanted to to ask OT practitioners.
Hannah Smiles
Sure. So we started with referrals, and we had not only multiple choice but ranking questions and things like that, so that we could get a sense of what the most common referrals were. For example, so it was like rank your top three referrals, and so then we kind of got to see a wider span instead of just what's your most common referral. So that's an example of that, and then we kind of went into evaluation, and we were looking at the evaluation of the environment, the individual, and occupation. So we had questions related to all of of those. We also use PEOP as kind of a guiding like theory to help us remind us to hit on all of the different areas as well. So we, for example, had a question on evaluation of the environment. We had a question on individual evaluation, and then we had a question on occupation-based evaluation. And those kind of looked like what, which of these environmental assessments do you perform? And then there was an option to, like, we didn't perform any of these any environmental based evaluation. So that's kind of how the evaluation portion looked. And then an intervention. We again were kind of having people rank where they most commonly delivered interventions, and there was also like frequency of which six like intervention service delivery types, things like that. So intervention, it was like what intervention, but also like where and how you're intervening and things like that. Yeah, and we had we had some a question about kind of those formal intervention types like handwriting without tears or zones of regulation, like what the role of published intervention programs are in in school based OT as well.
Jayson Davies
Interesting. I am excited to learn a little bit about that because I do have this like whole conflicting notion in my head all the time about individualized type of I'm with that student I'm going to do what I know versus should we implement a 10 week design program of handwriting without tears or size matters or you know one of Kelly Mahler's program like do we just stick to what's being designed as a quote unquote fixed curriculum. So I'm excited to hear that, and we are going to start to dive into those results right after a quick break. All right, we're back, and we're going to dive into the results now of the survey, and especially I'm really, like I said, I'm really excited to see what you found about people using curriculums. But first, I want to ask: Looking back at this, right? Your this research is all done, written up, all of that. Was there any question that you felt like, man? I wish we would have asked that after you looked at all the data.
Hannah Smiles
Oh, that's a good question. I mean, I think there's there's many like looking, knowing what I know now, like yeah, like there's there's an infinite amount of more information you want from from your therapists. I think, I mean, we would love to have more information about like different comparisons of varying years of experience and things like that, and how that specifically can influence someone's how they intervene and how they evaluate and things like that. So that's just one. And I think, I mean, I personally would want to know more about like health literacy and. Management in that specific area because that's an interest of mine, but but yeah. So I mean, those are two off the top of my head. But when you're in such like a holistic like mindset, I think there's so many that we could have, so many different directions we could have gone, and that's why we needed those like structuring different items like within the OT process and the OTPF, and then PEOP, kind of to keep us on track and not and give us that holistic picture, rather than kind of getting segwayed off in different
Jayson Davies
oh yeah in
Hannah Smiles
different directions.
Jayson Davies
Plus, you've got to keep it short, otherwise you're going to lose people halfway through exactly through the survey. And so, yeah, no, totally get that. Yeah, I was just wondering. I mean, because you know, we live, we learn, and we we like you said, right? Like now you're into health literacy, and you would love to maybe go get your PhD in it. No, I'm kidding. Um, right, go that route. But no, you know, it's it's I don't know. There have been sometimes where we've done research. I'm like, man, it'd be cool if we had this. Now, you said that when you guys tallied up everything and looked at the results, you didn't do any like cross-sectional stuff. You just basically looked at basic statistics. You weren't looking at hey, the people who have been practicing from five to 10 years did more of this versus that, right? It doesn't seem like you went that detail,
Hannah Smiles
right? Yeah, no, we were kind of doing an overall snapshot picture. We didn't do that cross examination there, and again, that's something else that it would have been like cool to have that data and kind of see those two comparisons of like how different aspects of practitioners' demographics affected their OT process and how they execute the OT process.
Jayson Davies
Did you guys use Google Forms or like Microsoft Forms type thing, or did you use more of a specialized software?
Hannah Smiles
We were using Qualtrics, so that was the form the form base that we were working out of.
Jayson Davies
Okay, and then when it came to actually finding the results, did everything just kind of in a spreadsheet get averages and compare? Okay.
Hannah Smiles
Yeah, we were we were comparing like just basic statistics of what we were getting out of it, and not specifically through any sort of like statistician or anything. Yeah, we didn't have any access to that. Yeah,
Jayson Davies
yeah. I bring that up only. I mean, you guys published this, and you all published this in 2025 April. You know, I'm assuming the actual research itself was done 2024, late 2023.
Hannah Smiles
Yeah,
Jayson Davies
2024. Yeah. So, and things have changed. Like I, I don't know. I just think of right now the way that if you a still have the data and if you b ethically can use that data based upon what is said in the IRB and all that fun stuff, it would be interesting. Of course, you know it's all de-identified to ask ChatGPT to actually do some of that stats for you because, like, it probably. I mean, again, we have to be careful with AI, but I do think that I would want to see that. I would definitely want to see how it compares someone who's you know brand new versus someone who's been working for five years versus 15 years. You know, who's using the curriculum? Is it the newer therapist or the the more experienced therapist? Like all of that would be amazing. So, for those of you out there thinking about a project,
Hannah Smiles
exactly. And there's so many places they could go. And yeah, you're right. I feel like when we did this in 2022 or 2023, like
Jayson Davies
okay,
Hannah Smiles
even AI has come so far since then. You know. Oh yeah. And the use of it has dramatically changed since then. So yeah, yeah, it's that's super interesting, yeah, for sure.
Jayson Davies
Yeah, and and I've worked with a statistician, and it is not like the easiest thing. And like now that we have access to a statistician on our computers with with AI to a degree, and at least a good an initial synopsis, you know, and and kind of of course you have to overlook it and make sure things actually line up and make sense. But but yeah, it'd be really interesting. All right, I got sidetracked. Let's talk about results now. You already we've already talked about how you broke it down: referral versus the intervention piece, the PEO, and then or sorry, the evaluation piece, and then the intervention piece. Let's talk about the referrals. What were some of the things that really stood out?
Hannah Smiles
Not surprisingly, the most commonly received referrals were handwriting, sensory processing, and fine motor.
Jayson Davies
Hey, I just wrote an email about that. All right, continue.
Hannah Smiles
Yeah, exactly. So that wasn't really a big surprise to us, and kind of showing us that the we're getting referrals for only a quarter of our scope. We only only two respondents reported that mental health, any sort of relation to mental health and wellness, were their top referral. So were their top
Jayson Davies
okay.
Hannah Smiles
Whether it was their as their top referral, or even within. Top three, and we also found that the majority of respondents like never or rarely received referrals for non-academic, extracurricular, technological, or vocational activities, and that stood out to us. Thinking about how all the things that happen on a daily basis in school, so that are non-academic and how OTs can have a role in that, and over half never or rarely receive any referrals for or in are involved in that at all. So
Jayson Davies
yeah, yeah, that was
Hannah Smiles
interesting to us.
Jayson Davies
Ah, shucks moment when you saw that.
Hannah Smiles
Yeah, I mean, I think, I mean, the other thing is that unless OTs are being are involved in this not formally, as an OT, I can say like I don't maybe even if I don't receive referrals for it, maybe someone's picking my brain or trying to get me involved in like a non formal way. I guess so. I guess that's where the hope could lie is like we could be woven in differently, but in specifics for referrals themselves, if someone's taking that as formal, maybe that's kind of how that could fall.
Jayson Davies
I of those ones that you've got here, we've got non-academic, extracurricular, technological, or vocational activities were the four that you were just talking about there, non-academic. I feel like that can definitely fit. I feel like there are people that get referrals for like feeding, and I feel that that's non-academic, and I think that there are some referrals for that. Extracurricular. I don't think it's happening, and that's frustrating. I also think that that is a very big access problem because I think if again not looking at any research here, but I'm going to assume that if you look at the population of those involved in extracurricular, you're going to see a big gap between those with a disability or an IEP versus those without an IEP in extracurricular activities. I mean, I worked at a high school, and I can only remember one kid who, you know, was on the special or with an IEP that was playing baseball, and it was very adapted and and whatnot. But at least he was doing it. He had access to it, and and that was awesome. So I would love to see that more technological. Like we do a lot of assistive technology. I don't know if that falls into the case of technological, but I mean, we're using technology. I don't know if that's the the reason for the referral, though. But but yeah. And then the one that I really want to see more of is vocational, like especially as we talk about transition planning and the impact that we can have on transition planning, that would be wonderful to to get more referrals for that. So, just my few cents, but yeah, anything else related to to the referral process? That anything related to the referral process qualitatively, or is that more separated how you do the qualitatively?
Hannah Smiles
I think there was a lot of sentiment of like the team doesn't know what we do, but then once they find out, like they like they feel our impact kind of thing, and I think that falls into kind of the referral, and we'll talk more about that when we kind of put all the results together and we synthesize it, but the lack of referral scope really impacts the role that OTs feel themselves playing. Is kind of the the energy that we got from both sides of the the questions.
Jayson Davies
Okay, and then another follow up, and I totally understand if you don't have the answer to this, but you mentioned that two respondents reported mental health and wellness referrals as their top. Please tell me that you had something qualitative from those people to share, like about that. I'm assuming not, but maybe I don't
Hannah Smiles
know. I don't know if we pulled out their specific survey.
Jayson Davies
And maybe they didn't. They might have just put NA for whatever answer. But yeah, it would be interesting.
Hannah Smiles
That would be interesting. I would have to go back and go find their specific surveys themselves. But
Jayson Davies
All right, if you're listening to this right now, right? If you're the person, if you're the one of the two people that put mental health as your top referral source, we want to hear from you. We want to. We want more information on this because that's awesome, and and yeah, we want to hear more. So, all right, let's move on from the referral process to the evaluation. And with the evaluation piece, as you mentioned earlier, kind of lined up PEO. You got environment, individuals, and occupation here. What did you want to look at, or what were some of the questions that you were asking people within this part?
Hannah Smiles
So we were kind of trying to feel out how, for evaluation, what evaluation was looking like. Are we like, are we doing formal assessments, informal?
Jayson Davies
Okay.
Hannah Smiles
Where are we assessing? Like, which parts of PEO are we kind of? Leaning on, I think this is something that we had some evidence coming out of the literature pool that there was a lot of individual skill assessments, and so we kind of wanted to we wanted to ask that question again, but we also wanted to ask other questions, like specifically the environment, like what like what are you using to assess the environment, and are you doing occupation-based formal assessments? Things like that, to kind of build off what the literature is kind of already saying. We wanted to get more of a fuller snapshot of that, and yeah, it was a bit shocking. Over two thirds of the OTs didn't perform any formal assessments of the school environment, so it likely looked a lot like homegrown tools or observations, something like that. Which was, I mean, such a big part of who we are as OTs. You just you compare that to the skill-based assessments that we're seeing, and it's very it's very different. But it does like OTs were doing informal assessments of the school environment. The environment wasn't left out; it just wasn't formally assessed. If that makes sense.
Jayson Davies
Okay.
Hannah Smiles
So yeah, and that was in the classroom, lunch room, and playground. And then the most common assessments that were administered were sensory processing measure, the BRE, BMI, and sensory profile. So that wasn't really surprising to us there.
Jayson Davies
No, well, although I will say only one of those are performance based assessment tool. The other two are not criterion, but they're they're surveys from somebody else doing them. So, I mean, my kind of takeaway from that, and of course, I didn't get to see number four through however many else there are, and and you may or may not have more insight into that. But I think that OT practitioners are trying to save time any way they can because of their high case loads, and so we're using surveys that we can give out and be filled out asynchronously, so that way we can get the response back. The other side of that that I see here is the SPM, obviously sensory, the the the Barry very motor based, visual motor based, but then you've got the SFA, which a is freaking old, but b it's also more holistic, more occupation based, and it would be interesting, man. Again, right? Like I wish I had a little time machine here. Like even if we could just get your survey results from 20 years ago, and see what this looked like, and see how it's changed. Because, you know, what were people using 20 years ago compared to today, and what will they be using 10 years from now? Would be really interesting. And so, I'm not going to lie. I kind of wish you had published like an appendix with every single assessment tool listed out. And I'm not going to put you on the spot and ask you for that appendix, but like I would love something like that just to see because obviously we have your top three here, but for some reason there was a decision obviously to keep the article you know not too long to a degree, but yeah I would love to see the other tools because like the bot three isn't on here and which is a common one the Peabody so yeah that'd be interesting, but but again, yeah, always always great to to see everything. So, did anything?
Hannah Smiles
I think when you have so much data, like we ended up coming out with like we had so much data within our hands, and I think part of our like goal was to create something that was again digestible and a snapshot kind of vision, and that's kind of why we landed where we did. But no, I agree. I mean, there's we had a laundry list of all of the different options, and we kind of were finding the most notable as well. And so.
Jayson Davies
When it came to the assessment tools, was this just like a choose your most used? Was it select all the different ones you used? Do you recall kind of how that was on the survey defined?
Hannah Smiles
I think it was like you check the ones that you do use. Was the the question? I think that's how I can't say the specifics of the wording,
Jayson Davies
but that but you gave people the the option to not just say they're most most used. It was use all or the the five that you use or select several the ones that you
Hannah Smiles
yeah yeah it was select more than one if if they used more than one and we also had options for an option for I do not do any occupation based, or I do not do any skill based assessment. I do not do any environment based assessment because I mean, 22% of respondents clicked that they do not perform occupation based assessments specifically, like formal occupation based assessments. Okay, so yeah, that was one of the answers as well.
Jayson Davies
I'm still blown away. Way that half of us are using a tool that was published in like 1990 and still asked about floppy disks. Like I, but I get it too, and and I love it. And and we've mentioned it already here on the podcast that the SFA is being renewed. They're working on an SFA too, and I can't wait for it to come out. That's going to be awesome. But it only shows like obviously we want to use it. School-based OTs are using it, despite it being older than old. So, in terms of assessments, of course. Now, you seemed a little bit surprised when you were talking about the school environment using a formal assessment versus an informal assessment. I'm interested. Go ahead.
Hannah Smiles
There was there was very little for us to like give as an option for formal.
Jayson Davies
Yeah that.
Hannah Smiles
So I mean I'm more surprised that it just doesn't like exist like as an entity, and I think that's where the surprise came. It wasn't surprising that nobody, like, performed it. It's more that like this area has kind of been in in comparison to skill based assessment so lost. When especially in schools, it's so important, and we feel ourselves doing so much intervention in relation to the environment, that the the assessment formal assessment not being there, it it feels like that's a miss. You know what I mean? Yeah. the The
Jayson Davies
only tool that I can think of, and it's a newer one, relatively newer one, is the CC or CSCEA. That's an environmental tool. I want to say like the SFA asks about the environment, but it's more about like the student's ability to access the environment. Same thing with like the SPM and the sensory profile. Same type of thing. It's not like asking about the environment specifically, but it's asking how the student responds in certain environmental situations. But yeah, like I can't think of something like where we would go into the classroom and almost evaluate the classroom, the accessibility of the classroom, or the accessibility of the playground or cafeteria. Which, I mean, as I say that, kind of like you, the shock is like, wait, why? How do we not have that? And then I also think, well, do teachers have that? Like, is there an assessment for an administrator to go into a classroom to evaluate a the way that a teacher has set up a classroom? Obviously, it wouldn't look the way that we would put together an evaluation. But yeah, that's interesting. I'm surprised too that that there isn't something. So, all right, another one, another PhD project, hands on it.
Hannah Smiles
I mean, I know Wash So there's a assessment out of WashU that's called the Check, which is an accessibility evaluation, and they have a playground version. So
Jayson Davies
Okay.
Hannah Smiles
that is that was one option that I do know of. But in terms of like classrooms themselves, that's not anything I've seen. Unless it's like within another assessment is kind of where we had to kind of pull from.
Jayson Davies
Yeah, yeah. All right. I think we've I think we've covered referrals and evaluation, and then that moves us on to interventions. Unless there was anything else that you wanted to talk about the evaluation piece, but otherwise, we can going to share with us a little bit about what was discovered in the intervention phase.
Hannah Smiles
Yeah, so we were looking for all the different parts of intervention, so where they our respondents were delivering their intervention services, and also what kinds of interventions were they providing, as well? So, I think again, we really wanted to focus on that service delivery type. So, we had they were ranking their most frequently to least frequently used intervention types. So, direct pull out, direct push in, consultation, groups, co-teaching, and then school-wide programming was also included as an intervention type. So we wanted to kind of see how frequently they were doing all of those different things. So we definitely found that they most commonly deliver interventions in the classroom and the therapy room. So those were very close in and how we received the data, and then the playground and lunchroom were also areas that OTs were providing providing services as well. And then for service delivery type, we saw most commonly direct pull out was the most common response for most frequently used, and then followed by direct push in. So those were kind of our one and two, and then only 11 respondents reported doing schoolwide programming as their most frequent. So, and then the. Majority used had school-wide programming as their last ranked, or didn't rank. So they also didn't have to rank it if they didn't use it at all. So that also was a the least amount ranked was that school-wide programming.
Jayson Davies
Absolutely, and and I recommend everybody go and look at the article to really take this chart in and to to take in these numbers because you know we're talking about it on audio and I totally understand. Like it's hard to keep track of numbers when we're when we're on audio, but it's at the bottom of page five on the the downloaded version of the article, and the chart really does tell a lot. Before I do dive into the chart, though, you said that you know you talked about different areas that that students are seeing with the classroom and the therapy room being the most. Those are at 88% and 84% which like I'm actually surprised it's not higher. But then you have the playground and the lunchroom at 20 and 15% So that's that's not you know, that's not nothing. Like that's actually a decent amount. So people are seeing students most commonly in the playground and lunchroom. Maybe that's because they don't have a room to work with students in. I don't know, but but yeah, yeah. And then yeah, the table's great, and I can tell right like that, people did not have to respond to the most frequently used model because direct pull out had a total of 292 responses, which was actually lower than the 296 for consultation and push-in. So more people are using push-in and consultations, but they're not using it as frequently as those who are using direct pull out as their top use.
Hannah Smiles
Exactly.
Jayson Davies
And then again, notably, is that 189. So more than half, more than half, but not you know two thirds about are using school wide programming to some degree, which I think is actually pretty pretty good. Like I mean, the the two thirds of us almost, we'll call it maybe like 60 or 55% or so, are to some degree doing school wide programming, which is higher than I would expect. I actually, so yeah, I think that's not bad.
Hannah Smiles
Yeah, and we didn't have specifics on what that looked like. Like we didn't have any, but I mean, I think school wide programming could be a lot of different things, and it could be SEL, it could be sensory, it could be hand writing, all those things. So I mean, yeah, that's the amount of people who responded to that was encouraging. Yeah, in my opinion.
Jayson Davies
Granted, granted, half of those, half of the 189 ranked it as number six, so the the last one that they used. So how much they're doing it? Not that much, but still, like that. That's encouraging. You got to do something once before you can do it multiple times. So that's a good way to get started. Okay, you do actually have some information here, like you talked about earlier, with the different types of programs as well as RTI, and so I want to make sure I give you a chance to kind of elaborate on that.
Hannah Smiles
Sure. Yeah. So we also had a question about that formal intervention published intervention program and how those were used in practice. And I mean, respondents reported handing handwriting without tears and zones of regulations were their two top published intervention programs that they used, and only a few people said that they don't use any published intervention programs at all. Yeah, which we thought was notable as well. So these are having an impact on our, on the way that we do OT and the types of interventions that we're doing, and so I think that was an important part of the snapshot of, of the OT process in schools.
Jayson Davies
Do you do we have information on whether or not they were doing it like as planned, following the books, or if they were using strategies, do we have that information from the qualitative or not?
Hannah Smiles
I don't think we have anything that's like where you train. Like, do you have the formal training, and are you implementing it as trained? It's more the use of the intervention.
Jayson Davies
in some capacity.
Hannah Smiles
I believe it was in some capacity. It's there. We didn't have them describe their level of training or anything with those.
Jayson Davies
Yeah. No. Fair enough. Fair enough. I think we all pull strategies from all the different trainings we go to, right? Yeah. And so many of us have taken the zones training, and so many of us have taken the handwriting without tears. Like we are naturally going to embed some of that into our into our practice, so that that makes sense. And okay, and then so after that, also RTI.
Hannah Smiles
Yeah, so we actually were we created a question on RTI based on a question from a full. Survey done about RTI, and so that was we were using that because of how well it was made. And Dr. Cahill created a specific AJ article on OTs' involvement in RTI, so we kind of wanted to reinforce what she created, and that's kind of how this came about, and so they were ranking whether always, often, somewhat rarely, or not at all in all the different RTI activities that OTs can be involved in. So, one-on-one intervention, data collection, progress monitoring, in-service, universal screenings-all of those are included in response intervention RTI activities, and so they were ranking how involved they were in all of those. If that if that is clear, and I believe that there is not anything super new that we have discovered, but a lot of one on one, a lot of data collection and progress monitoring, which is great. And then we have a lot of almost not almost half about a third of the OTs who responded have don't do any universal screenings, and that that was notable to us. And program development was also pretty low as well as as kind of the not involved, and then everyone else was somewhere in between. So there's, it's, I guess it shows progress. It shows movement.
Jayson Davies
Yeah.
Hannah Smiles
We're not where we want to be, but we got to see some some movement in these in some of these areas that we would like OTs to be more involved in.
Jayson Davies
Yeah, I mean, I'll look at the bright side. You know, 35% of us aren't doing universal screenings, but 65% that are am I doing my math wrong? Yeah, 65% I mean, are doing some sort of universal screenings. Then, like, I don't know. I could, I could go and list all the OTs that I've worked with in the last you know decade, and I think it would be lower than 60% of them are using universal screenings. So, I I think it's a step in the right direction. It's also hard to do universal screenings because the systems really aren't designed for us to do universal screenings, none of the assessment tools that we do are designed to be a universal screening for the most part. So it's one of those things where we kind of have to break this mold. Like, if you go and work for a district, and the district OTs there have never done universal screenings, you're not likely to do universal screenings, right? And so it does take time for something like that to to start to get put into to place. So, yeah.
Hannah Smiles
Exactly.
Jayson Davies
Yeah, awesome. All right. Well, at the bottom of page seven, for all of you following along at home, right? There is a beautiful chart. It reminds me of the PEO chart, which makes sense now because you kind of use the PEO model to a degree, PEOP model here, and that's kind of what you use to kind of put all the qualitative information together here. So I just want to let you talk a little bit about some of the significant findings and you know the surprises, the not surprises related to the qualitative findings.
Hannah Smiles
Yeah, so we asked questions of the OTs to respond on the impact they found themselves having in schools, their role as part of the education team, and we kind of wanted to create themes based on those questions, and then as well as our data that we received from the quantitative section, and we kind of discovered this synergistic relationship between barriers and school-based practice and things like that. So the major themes that we came up with were role confusion, OTP role confusion, inconsistent view of OT leadership and empowerment of OTs, and the incomplete transition to the workload approach. So these were kind of things that emerged as the three major themes, and we kind of discovered that they all interact with each other in both a cause and effect relationship, and they're all the other, a lot of the other quantitative findings that we found, like our service provision, like providing mostly one-on-one and our high caseloads and things like that, are all kind of creating these themes along with kind of our qualitative questions that kind of had these themes arise, so.
Jayson Davies
Yeah.
Hannah Smiles
That was kind of how we discovered these these themes all kind of coming together.
Jayson Davies
Yeah, very interesting the wording that you chose here: incomplete transition to workload approach. That. I've never heard it phrased that way. We always talk about caseload and workload. Sometimes I'll hear people say we use a combination of caseload workload, and I'm always like, "How does that work? So you using the term, or the team using the term, incomplete transition to workload approach. Why? Why that phrasing?
Hannah Smiles
Sure. So we did have a question related to the caseload versus workload model and how therapists were operating within their own practice, and we got a very mixed answer. We got a few people saying that they were only caseload, a few people saying they were only workload, and then again, like you said, some a lot of people were somewhere in the middle saying they use a blended approach. So they don't feel like their whole workloads represented, but they don't feel like they're managed just based on their their caseload. So we see that as progress. We saw that as things are moving towards the workload model, we have a lot of people in this blended in between, and so we feel that there's a possible transition, but it's not complete yet. We don't have we don't have a group of therapists who all feel like they are their workload is represented. So that's kind of where that comes from, we see that in transition. If that makes sense.
Jayson Davies
Yeah, yeah, no, it makes sense, and like, it makes sense to be in transition. To me, like when I think about caseload and workload, I see them as almost like very different. And so, whenever I hear blended, I'm always like, I don't quite understand that because when you're in a workload model, you're counting the number of students versus when you're in a caseload, or sorry, vice versa, a caseload model you're counting the number of students. Workload, you're counting the number of hours. But I guess you can kind of you know find a system that works where you're you're taking into account both. But yeah, no, it's interesting to to see how that has become like the number one answer I get to when I ask people case loader workload, they're blended, and so I'm like, okay, okay.
Hannah Smiles
Yeah, I think they see. I think there's cases where parts of the OT's job is being considered. Maybe they get time for IEP writing, or they get a certain amount of plan minutes a week, but then that that's only part of the workload, you know. Then the other things are still being left out. So there's a few things included. That's kind of how we phrased it on our okay on our survey.
Jayson Davies
Gotcha. All right. And as we start to wrap up here, kind of at the end of the day, you know, you got all this data, you had the lit review behind it. What were some of the overall findings that you know, kind of good or bad? What did what did how did you put this all together and tie it up in a nice little bow?
Hannah Smiles
Yeah, so I think that our major themes are all interacting with each other, right? The role of the OT is misunderstood by the the education team, but also by OTs themselves, and that is really important to understand as an OT. Is you have to know kind of your role, and then that role confusions then also interacting with OTs' ability to be in leadership and feel empowered to kind of take the step further into what the best practice is suggesting to kind of be more involved at that population systems level and educate the team on that. And then the incomplete transition to workload is affecting both of these and is being caused by both of these, so we can kind of see how these all interact with each other. We need more OTs in leadership in order to transition to workload, but also being stuck in the caseload model causes it to become difficult to be a leader in other ways. So we can kind of see how all of these are interacting at the same time, and that's what makes it complicated, but it also shows us where our intentions need to lie and where we can grow as a profession and as OT practitioners ourselves. We are, I think, having the question about what we feel like our impact was on the education system was really powerful, and we got to see the OTs talking about how they're the only profession that links the whole child to the whole community in the whole environment, and that was, I think, the most powerful things for us. And we got to see that although we're we painted a picture and a snapshot of where we are, which is not quite where we want to be the power of OT is still so eminent and so there, and it's it can revitalize the hope for what school based OTs are and what they can be. So.
Jayson Davies
Man, that could go viral. We need someone to develop a marketing program around like we we are the. Only people on campus looking at all the different aspects. I that could go viral in a in a post or something like. Yeah, no, I think that's absolutely true. Yeah, and you know, you you've also got in there a little bit. I remember that you got a little bit about leadership and expanding the OTs' role within leadership, which you know anyone who's listening to the podcast for a few episodes know that I'm big on, and that's important, right? Like that leadership is where we can begin to to do more marketing for for ourselves a little bit, and so it's important.
Hannah Smiles
Yeah, and leadership leadership doesn't have to mean formal leadership. Leadership can be getting in on a problem-solving team and advocating for yourself to be in the room and have a voice there, and like for example, after doing this, that was something I had to do in my practice. Was I had to ask to be invited to team meetings and to problem-solving meetings so that I could have a voice there, and it wasn't a part of what my job requirement was, but I went to the leaders of those teams and asked to be a part of it, and that's an example of being intentional about a small way you can become more of a leader in your school and start working towards kind of those larger changes. It's a snowball effect, really.
Jayson Davies
Yeah, yeah, absolutely. Well, Hannah, thank you so much. It's been a pleasure learning about this, and I really do hope that 10 years from now you come back on the show and like, hey, I haven't updated. Right, we've got doing the same study 10 years later. Hopefully, the SFA two will be there instead of the SFA and a few other things. But I do want to know and ask you. You know, you talked about there being a capstone student before you, those kind of doing some things. You obviously you and the team did this study. Any follow up, either already completed or in the works or anything like that, kind of based upon this.
Hannah Smiles
Um, not specifically from our our end. Actually, after we were in publish, AOTA actually released a survey of school-based practice specifically to inform their policy and advocacy, and it looked like pretty similar to yeah, it looked pretty similar to a lot of what we were asking. So it's another another survey to see the results of how OT.
Jayson Davies
I don't know if we got it yet.
Hannah Smiles
Yeah, I'm. Yeah, I don't know. I'm. I. I'm looking forward to it. I don't think it has. I've seen anything yet. So.
Jayson Davies
Yeah, I'm gonna follow up on that and see if we can find something because I don't know if the intentions was to put together a report and put it out or not. But yeah, it would be nice because, in theory, right? Hopefully, AOTA has a very large sample size, and it'd be really, really cool to see some of those results. So I do remember that. So hopefully.
Hannah Smiles
Yeah, it was. It felt like a nice follow up to what we were doing as another another way to understand the perspectives of OT in schools.
Jayson Davies
Yeah, yeah, great. Well, Hannah, thank you so much for sharing. Really appreciate it, and we'll definitely link everybody to this article. Is there anywhere where people can go if they want to specifically connect with you? I'm thinking like LinkedIn or something like that.
Hannah Smiles
Yeah, I'm on LinkedIn, and I believe there should be a way to contact me through the if there's somewhere in the paper as well, but you can definitely find me on LinkedIn. It's just my name, Hannah Smiles. So
Jayson Davies
awesome!
Hannah Smiles
Find me there.
Jayson Davies
Perfect. Well, thank you, Hannah, and definitely look forward to 10 years from now when we get to do it again.
Hannah Smiles
Thank you!
Jayson Davies
One more time, thank you, Hannah, so much for joining me on the podcast today, and for sharing the findings from this really important research. I also have to give a big shout out to Charlie, Stephen, and Lauren for their part on this project as well. And of course, thank you also to the Open Journal of Occupational Therapy for making this research available to all. That is not common. There are a lot of journals out there that make it difficult to access the work that they publish. You do not. We really appreciate it. I also want to thank you for listening. Of course, whether you are at the gym on a flight home from a summer vacation, or maybe you are even driving between schools right now, I'm grateful that you've made a decision to spend that time with me here on the OT Schoolhouse podcast. I really appreciate it. Hopefully, I made your drive or your vacation trip home, whatever it was, a little bit easier. And yeah, just appreciate you being here. If today's episode got you thinking about your own practice, maybe your referral patterns or your leadership opportunities, or maybe even the gap between knowing best practice and actually living it out. I want you to know that you don't have to do this all by yourself. The OT Schoolhouse Collaborative is a community built specifically for school-based OT practitioners like you. You'll get resources, professional development, and direct mentorship from my. In a group setting, head on over to otschoolhouse.com to learn more about the collaborative and join us today. Until next time, take care.
Amazing Narrator
Thank you for listening to the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to OTSchoolHouse.com. Until next time, class is dismissed.
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