Feasibility of Partnering for Change (P4C) to create inclusive learning environments in Swedish compulsory schools

ABSTRACT

Many pupils experience restricted participation in Swedish schools due to a non-inclusive learning environment. Partnering for Change (P4C) is an evidence-based service delivery model, developed and employed successfully in Canada to create inclusive learning environments. P4C could potentially be used in Swedish schools, but its feasibility outside Canada is unknown. The aim of this study was to investigate the feasibility of P4C in Swedish compulsory schools. Fifteen interviews with teachers, occupational therapists (OT), and principals conducted after four months of applying P4C in seven classes, were analysed using deductive content analysis based on five feasibility areas. Quantitative questionnaire data concerning implemented interventions were analysed using descriptive statistics. Findings showed that participants considered P4C acceptable and its implementation possible. P4C integrated well with, and extended, schools’ existing work on inclusive learning environments. Teachers and OTs implemented 83 interventions, indicating a need for improvements in the learning environment, which P4C helped to address, as positive effects for both pupils and teachers were noted. In summary, P4C was considered feasible in fostering inclusive learning environments in Swedish compulsory schools, offering potential value to the pupil health team without requiring further adaptions.

KEYWORDS:

• engagement
• occupational therapy
• primary education
• pupils’ health team
• Response to Intervention (RtI)
• universal design for learning (UDL)

Introduction

Research indicates that pupils with special education needs (SEN) often face challenges in school participation (Coster et al. 2013; Haug 2020; Şahin et al. 2020; Yngve et al. 2019), mental health issues and a lower likelihood of attaining educational objectives (Fazel et al. 2014). Recognising the importance of participation in school activities to children’s development, well-being, and educational achievement (Law 2002) is part of inclusive education, as outlined in the Sustainable Development Goals (UN 2015). Inclusive education denotes to respond to all learners’ diverse needs, abilities and characteristics, in the same school and learning environment (UN 2016).

Inclusive learning environments hold the potential to facilitate participation for all learners, offering equal opportunities to engage in school activities – a crucial prerequisite for learning, well-being, and development (UNICEF 2017). Studies have established a connection between environmental factors and the level of school participation, indicating that an inclusive learning environment enhances pupil’s engagement and development (Anaby et al. 2013; Meuser et al. 2023), necessitating the application of evidence-based interventions (Carroll and Hurry 2018). However, there is a scarcity of research on effectively creating inclusive learning environments using evidence-based interventions. Recent literature reviews (Anaby et al. 2019; Meuser et al. 2023) revealed that while many service delivery models focus on individual pupil support, the Response to Intervention model (RtI), which addresses both class-level and individual needs, is common. A multilevel approach targeting the entire learning environment, as well as collaboration among stakeholders including teachers, health professionals, and parents was highlighted as beneficial for promoting participation among all pupils (Anaby et al. 2019; Meuser et al. 2023). Meuser et al. (2023) identified the ‘Partnering for Change’ (P4C) service delivery model as a collaborative, evidence-based approach that targets the learning environment at various levels based on pupils' needs. The application of P4C has shown promising results in Canadian primary education, co-developing capacity among teachers and occupational therapists (OT) to support pupils’ participation and inclusion (Camden et al. 2021; Campbell et al. 2023; Missiuna et al. 2012).

The move from individual interventions to collaborative service delivery models aimed at promoting participation and well-being of all pupils (Meuser et al. 2023; Missiuna et al. 2017) – prompted the development of P4C (Missiuna et al. 2012). Implemented in three tiers based on RtI (Grosche and Volpe 2013), the first level in P4C involves a universal design for learning (UDL) (CAST 2018), benefiting all pupils in the classroom. On the group level, differentiated instruction is applied for those still in need of support, and on the individual level, adjustments are provided for pupils with additional needs. Pupils may access services across levels simultaneously, and if pupils need change, they may receive services at any level, contingent upon their need and classroom environment. The focus is on establishing an inclusive learning environment where teachers and OTs collaboratively develop and deliver services in the classroom. Thus, adhering to P4C principles entails a close partnership between teachers and OTs, involving mutual exchange of expertise and problem-solving to implement interventions within the natural context to promote participation for all pupils (Campbell et al. 2023; Missiuna et al. 2012).

In Sweden, obligatory pupil health team is responsible for the school’s health-promoting work and for providing services that support the educational development of all children (SFS 2010:800 and SFS 2022:1315). However, despite these responsibilities, Swedish schools do not seem to fulfil the requirements of an inclusive learning environment in regular classrooms. Improper investigation of pupils’ needs, inadequate interventions to facilitate their participation, and a lack of evaluations on the effect of implemented interventions have been reported (Swedish schools Inspectorate 2022), which may be due to inadequate access to and use of evidence-based school services in Sweden (SOU 2021, 11). When schools lack evidence-based methods to foster inclusion in regular classes, there is a risk of turning to segregating interventions for pupils with SEN, thus diminishing equality. Hence, it is crucial to consider a service delivery model like P4C, to foster inclusive learning environments within pupils’ regular classrooms.

Recognition has grown regarding the potential necessity to modify service delivery when introducing it in a new country or a different population (Dimitrova and Wiium 2021). In this context, feasibility testing plays a crucial role in the adaptation process (Marsiglia and Booth 2015), encompassing considerations such as content and delivery, acceptability, and providers’ capacity to deliver the intervention (Skivington et al. 2021). P4C has been successfully adapted to new provinces in Canada (Camden et al. 2021), making its use promising in the Swedish context. Therefore, the aim of this study was to investigate the feasibility of P4C in Swedish compulsory schools.

Methods

Study design

To illuminate different areas of the concept of feasibility, this study utilised both interview data and questionnaires (Bowen et al. 2009) (see Table 1) from school professionals with experience implementing P4C in seven classes in Swedish compulsory schools. Guided by Bowen et al. (2009), the feasibility areas of acceptability, demand, implementation, practicality, and integration were evaluated using qualitative interview data. As a complement, quantitative data from digital questionnaires, which covered implemented interventions, were used for the feasibility area demand. Selected areas were explored to gain insights into stakeholders’ perspectives regarding the feasibility of implementing P4C within a new cultural context and population.

Table 1. Description of feasibility areas by Bowen et al. (2009), used as categories in the deductive content analysis, their focus, and their outcome of interest (used as codes), related to the present study data, to examining the feasibility of P4C in Sweden.

Feasibility area, i.e. categories	Description	Outcome of interest, i.e. codes	Study data
Acceptability	Reaction to intervention: To what extent is P4C perceived as suitable, satisfying, or attractive?	Satisfaction Perceived appropriateness Perceived effect on organisation of schools’ work on accessible learning environments Intended continued use	Interviews
Demand	Use of intervention activities: To what extent is P4C likely to be used? How much need for P4C is likely to exist?	Actual use	Digital questionnaires on type and number of interventions
Implementation	Likelihood of implementation as intended: To what extent can P4C be successfully delivered in the Swedish school context?	Success or failure of execution Resources needed for implementation Factors affecting implementation ease or difficulty	Interviews
Practicality	Delivery within existing context: To what extent can P4C be carried out by intended participants with existing means, resources, and circumstances?	Effects on target participants	Interviews
Integration	Level of system change needed for integration: To what extent can P4C be integrated within the Swedish school context?	Perceived fit with infrastructure to deliver special educational support Perceived sustainability	Interviews

Ethics

Ethical approval for this study was obtained from Swedish Ethics Review Board, Dnr 2019–03954. Oral informed consent to participate in the study was obtained from school principals before schools and OTs were included and subsequently from teachers in intervention classes. An information letter concerning P4C’s objective and procedure was provided to parents of pupils in intervention classes, via the principal. If individual students were eligible for individual assessments and interventions according to the individual level in P4C, they and their parents received additional information before written consent was obtained.

Participants and setting

OTs working in compulsory schools and interested in applying P4C were purposively recruited (Polit and Beck 2016) using a closed group for OTs working in Swedish schools on a social media platform and personal contacts. Four OTs accepted participation after approval from their principal, and three completed data collection. Two of the OTs were employed in the local pupil health team at the school, and one OT was employed at the central pupil health team in the municipality working with several different schools. Three schools, located in different municipalities in central Sweden accepted participation. Two schools were mainstream primary schools, and one school was a special school for children with intellectual disabilities. Principals identified two or three classes per school where pupils had unmet support needs and invited related teachers to participate in P4C. In total, six classes (grades 1–6) and one preschool class were included. Class teachers (n = 8) in identified classes and one special education teacher agreed to participate in the implementation of P4C. Two of the nine teachers were male, and the rest were female. The three OTs were female, as were the principals. The work experience among teachers ranged between 14 and 31 years (M = 26) and 1–15 years (M = 8) among OTs.

The partnering for change (P4C) service delivery model in Sweden

Preparations for this feasibility study began with an orientation phase. Researchers, teachers, and one OT in one compulsory school, not included in this study, familiarised themselves with P4C to initially assess its applicability to a Swedish context. P4C was adapted based on this exploration, including partial adjustments to the Canadian education packages for OTs (Partnering for Change OT Modules, developed by the P4C research group at CanChild) to align with the Swedish educational system. The online module content was complemented with information about the Swedish school system, and specific materials were translated into Swedish. Moreover, the application of P4C was expanded to encompass all pupils in the class, moving beyond its original focus on children with Developmental Coordination Disorder (Missiuna et al. 2012).

The P4C course

Prior to the implementation of P4C, the OTs completed the online course on P4Cs’ underlying concepts, assessments, and documentation, to acquire the knowledge and skills required to effectively implement P4C. In autumn 2019, the OTs participated in four digital meetings together with two of the authors (MB and HL). Different aspects of P4C were discussed, depending on the OTs’ pre-prepared readings, assignment, and reflections.

Application of P4C

As P4C emphasises collaboration in context, OTs dedicated at least half a day per week in the classroom to build relationship with teachers, observing the learning environment and pupils from an occupational therapy perspective, and exchanging expertise with the teachers. The collaboration aimed at creating a learning environment that enabled successful participation for all pupils, where the OT offered a supplementary medical perspective and knowledge on how to modify activities or the physical, social and learning environment based on pupils’ abilities and needs to achieve this end (Missiuna et al. 2012). In each P4C level, the OT observed the class in the specific learning environment to identify participation restrictions. At the first P4C level, after OT observations, the OT and the teacher together discussed potential reasons for identified participation restrictions, set goals and decided suitable interventions based on UDL-principles to foster all pupil’s participation. The interventions were collaboratively designed to, for example, offer diverse formats of information, engagement options and/or means of expression, such as varied material or learning activities, catering to different learning styles or abilities (CAST 2018). Next, universal, class-wide interventions were implemented by the teacher or the OT, and progress was evaluated through follow-up observations to determine if, and when, group-level and/or individual interventions were needed (Missiuna et al. 2012). If group-level interventions were needed, collaborative problem-solving resulted in interventions involving more targeted services to better match pupils’ abilities, followed by new observations. In level three, the OT used the School Setting Interview (Hemmingsson, Lidström, and Egilson 2020), in addition to the observation, to include the pupil’s own experience of their support needs in school activities. As in previous levels, the OT and the teacher collaborated to design modifications to the activity or environment addressing the needs for a specific pupil, such as using assistive technology or reducing stimulation in the physical environment, evaluated by follow-up observations. Additional details of the application of P4C are presented in the study protocol (Baric et al. 2023).

Data collection

Qualitative data included individual semi-structured interviews (n = 15) with three OTs, nine teachers, and three principals, conducted after implementing P4C. An interview guide was developed for the study, including open-ended questions concerning the implementation of P4C and participants’ experiences applying P4C. For example, the guide included the following questions: Can you please describe what it has been like to work with P4C this semester? What has the collaboration between the OT and teacher looked like? Can you describe any changes related to the class and/or individual pupils, etc., when working with P4C?

Quantitative data was collected weekly using a digital questionnaire including seven questions for OTs and six questions for teachers. Three questions focused on the quantity of implemented interventions at each level (class, group, and individual), followed by three open-ended questions to describe the implemented interventions at each level. In addition, OTs registered how many classroom observations they had conducted each week.

Procedure

After including participants, an initial meeting organised and carried out by the third and last author was held in each school to describe the implementation of P4C and data collection. In the spring 2020, OTs and teachers began their collaboration and applied P4C in seven classes for 18–19 weeks.

During the P4C implementation period, one teacher and one OT per class, respectively, filled in the digital questionnaire concerning interventions on a weekly basis. Due to sick leave or forgetting to answer the questionnaire during P4C implementation, there was a mean of 3.7 weeks of missing data per OT/teacher.

In 2020–2021, after the P4C implementation period, two of the authors (MB and HL) performed the qualitative interviews with teachers, OTs and principals.

Data analysis

Recorded interviews were transcribed verbatim and served as the unit of analysis in the deductive content analysis (Elo and Kyngäs 2008), guided by feasibility areas proposed by Bowen et al. (2009). Five feasibility areas (acceptability, demand, implementation, practicality, and integration) were used as pre-determined categories in the structured categorisation matrix (Elo and Kyngäs 2008). Initially, to validate the chosen approach, the first and last author read and analysed the same interview.

The first author read all transcribed interviews several times for familiarisation. Next, meaning units were marked with the related feasibility area, based on the content, with written notes explaining the marking. Meaning units were inserted in the categorisation matrix (Elo and Kyngäs 2008). The first author coded all data in the matrix, using the associated outcomes of interest for each feasibility area (see Table 1), moving between the transcriptions, the categories (feasibility areas) and codes (as defined by Bowen), throughout the analysis. During the analysis process, a dialogue with the last author to ensure credibility and confirmability was ongoing. In addition to discussing data in relation to content in feasibility areas and codes, the last author read transcribed interviews and the content in the categorisation matrix. Furthermore, all authors were engaged in dialogue to review and agree the reporting of the analytical process and the conformity between the data and the presentation of results.

Quantitative data from digital questionnaires on the number of classroom observations conducted and interventions implemented on each level was analysed with descriptive statistics. The text describing the interventions was summarised to portray what type of interventions were implemented on class-, group- and individual levels.

Results

Below, findings are organised under headings corresponding to feasibility areas, and outcomes of interest, utilised as codes in the analysis, are denoted in italics.

Acceptability

All participants (OTs, teachers, and principals) expressed feelings of satisfaction working according to P4C. They stated that it had been enlightening, fun, and exciting, and perceived the collaboration had added value to their own practice, which offered them a new perspective on their work supporting pupils. As stated by one OT: ‘So for me, the best thing has been to get someone, a competent professional, to discuss with […]. To get more knowledge, like how am I supposed to think now, new ideas’ (OT 3). The OTs’ presence in the classroom provided an additional pair of professional eyes, which was perceived as complementary to meeting schools’ different challenges related to making classroom adjustments and addressing special educational issues.

P4C was perceived as appropriate to apply in school as it provided a platform and a structure for interventions made on class level with a preventive approach. Participants expressed that P4C was suitable, offering necessary time to talk and discuss interventions, as well as guidance and practical tips. The insights that the observations and discussions provided were appreciated as they confirmed and extended teachers’ own thoughts about their teaching and strategies in the classroom. Also, the theoretical basis of P4C to adapt on a class-, group-, and individual level, the related tools and assessments and OTs’ increased opportunity to be present in the classroom were perceived as attractive aspects. Furthermore, the preventive perspective of P4C – starting with the whole class – was perceived as applicable, as exemplified by one principal: ‘The approach, to get the whole. So somehow you feel like this was the little piece of the puzzle that was missing’ (Principal 2).

P4C had a positive effect on organisation on the schools’ work regarding accessible learning environments. The implementation of P4C had contributed to an awareness, and subsequent discussion, about accessibility and how to work with it on an organisational level. A positive effect on matters pertaining to pupils involving the principal and/or the pupil health team was also noted as the documentation provided via the observations and notes concerning pupils’ performance in class speeded up processes and contributed to faster decisions concerning support providence.

Participants described that their colleagues were curious and wanted to know about P4C, indicating the potential to spread P4C within the school. For example, other teachers wanted to borrow assistive technology (AT), such as time aids, and they were invited to share their experiences in different forums. How teaching was organised had also been affected. The collaboration between OTs and teachers intended to cater to pupils’ diversity, had led to the application of new teaching strategies and adjustments in classrooms. For example, clarification of instructions and the structure of the lesson, so pupils would feel confident about what is expected of them, as stated by one teacher, ‘I have received very good tips about clarifying things, visually with support from pictures, for example […]. Also, standing next to the schedule and point when I'm talking [about the structure of the day] so it becomes extra clear’ (Teacher 3).

All participants were positive about continuing to work with P4C and stated an intent to continue use P4C. Some participants had already decided which classes they would apply P4C the coming semester, and principals expressed thoughts or actions about how to implement P4C in the entire school, via, for example, information about P4C during staff meetings.

Demand

All participants saw a need for more supportive learning environments to cater to pupils’ diversity, and gave examples of pupils with difficulties maintaining concentration, inappropriate classroom furniture, and disorganised and messy lessons. The OTs’ and teachers’ actual use of interventions showed that the OTs had conducted 47 observations during the implementation of P4C. Altogether, 83 interventions were implemented, among which teachers had been responsible for 69% (n = 57). Most interventions (n = 50, 60%) were implemented on the class level, see Table 2.

Table 2. Summation of implemented interventions during the 18–19 weeks of applying P4C.

	Total amount of interventions (%)	Interventions at class level (%)	Interventions at group level (%)	Interventions at individual level (%)
Total	83 (100)	50 (60)	18 (22)	15 (18)
Teachers	57 (69)	34	12	11
OTs	26 (31)	16	6	4

Class-level interventions included applying new teaching strategies, adjusting the physical classroom environment, and the use of different ATs. Concerning strategies, examples included making instructions clear and more accessible, e.g., by using pictures as a complement to oral instructions. Interventions in the physical classroom environment included, among others, the use of screens and sound-absorbing tables to reduce disruptive noise and stimuli, changing pupils’ physical placement in the classroom, and labelling work materials. ATs were implemented to help pupils maintain concentration, including time-timers and the introduction of a weighted vest. At the group-level, tablets/computers were introduced and adapted with various applications, including a read-aloud function. Other examples of group-level interventions were pupils’ use of ball cushions, ergonomic pen grips, and simplified school material. Interventions at the individual level concerned changing conditions for taking exams and additional breaks during the school day.

Implementation

For successful implementation of P4C, the purpose behind the application of P4C must be clear and specified, and a routine for collaboration must be incorporated. It was important to have a common understanding of what P4C was and the mutual gain of applying P4C to commit to collaboration. Participants also expressed that understanding of each respective professional’s role and knowledge was considered a basis on which to build respect and collaboration. Finding time together to build relationships and to ensure collaboration was both a prerequisite and an occasional challenge. Participants expressed the importance of finding a routine for the collaboration, as stated by one OT, ‘Yes, there are times when we can talk, “class talk”, for example. And we have used and planned those occasions, but it would be even better to plan them earlier, so they are standing elements’ (OT 2). When a routine for collaboration was missing, or meetings were cancelled, it made the implementation more difficult, and it was easy to fall back into old patterns and for participants to think the same way as they had previously.

Considering the type of resources needed to implement P4C, participants stated that the implementation had required allocated working hours and financial resources to purchase ATs. Nevertheless, invested resources were considered adequate. With P4C, fewer resources may be needed to accommodate pupils’ individual support needs. As exemplified by the statement from the special education teacher: ‘In a way, we get fewer pupils to talk about in our team meetings, because the teachers do the adjustments themselves. […] So yes, it actually takes less time’ (Teacher 9).

Different factors affecting the implementation ease or difficulty of P4C were revealed in the analysis where support from school management and the teacher’s confidence in their role and attitude towards new knowledge and perspectives were considered to ease implementation. On the opposite, an aggravating factor was the outbreak of the COVID-19 pandemic. On an organisational level, explicit support from school management was considered to ease the implementation of P4C. If the principal had decided that P4C was the way to address classroom inclusivity, they mandated the approach. Principals, in turn, leaned on support from the Swedish Education Act to justify using P4C to work on classroom inclusivity and address pupils’ right to support. On a personal level, confidence in the teaching role and openness to acquiring new knowledge and perspectives positively affected the implementation of P4C and the willingness to have an OT present in the classroom. As stated by Teacher 6: ‘You have to be ready as a teacher and think that this is a good thing and that you want to be observed’ (Teacher 6).

Practicality

P4Cs’ effects on target participants included more confident and concentrated pupils and increased capacity among teachers to adapt their teaching to pupil’s diversity. Participants perceived that the classroom where P4C was implemented had become more peaceful, positively influencing all pupils. Interventions reduced stress and moments of disturbance in the classroom, which made pupils more confident and enabled them to take instructions, maintain concentration, and find peace in their work. One teacher said, ‘We have received various ATs for the class that the OT and the pupils have tried out, and we were able to see that they … well, maybe not so obviously performed better, but had an easier time concentrating and sitting still’ (Teacher 3). Positive effects on pupils had also been noticed by caregivers/parents. For example, one principal said ‘The caregivers we have worked with are incredibly positive. It’s hard for them to see differences that way, more than that they can see more motivated children who come home and have had a good school day’ (Principal 1).

Teachers saw personal gain in applying P4C and the collaboration with OTs. As they had learned more about how to cater to pupils’ different needs, they had become more aware in the classroom, which had led to reflect on their teaching. Teachers exemplified a changed perspective and approach to pupil’s diversity and how they adjusted their teaching accordingly, as Teacher 2 said; ‘I think in a different way, especially with those pupils who have difficulty sitting still, how you can help them. Not to constantly nag them to sit still, or do this, do that, but there are other things you can use and show’ (Teacher 2). This change in teachers was also visible for principals, who had noticed that they had become more positive about adopting new ATs or applying ATs in a different way to make the classroom accessible to all pupils.

Integration

There was a consensus about P4C’s fit within the school’s infrastructure for delivering special educational support. P4C was considered to supplement and strengthen the school’s existing work on supportive learning environments. P4C provided a forum to discuss and reflect upon pupils’ difficulties reaching educational goals, which integrated well with, and enhanced the structure of collaboration between professionals. As one teacher said, ‘You have this continuous contact with the pupil health team that you don’t have otherwise, which I may have missed a little before’ (Teacher 7).

Even though participants perceived that P4C integrated well with the school’s pre-existing work in making learning environments supportive for all pupils, they also raised a concern about resistance among other teachers in higher grades. Some teachers may not be open to having an OT present in the classroom or the different interventions that had been implemented, as visible in Teacher 1’s expression: ‘So, the teachers in fourth grade, they can imagine implementing some adjustments. But higher up, in fifth to eighth grade, then there will be more adversity, I think’ (Teacher 1). Without a change in attitudes among teachers, it could be difficult to adopt P4C to the whole school.

Regarding perceived sustainability, participants mentioned important aspects to consider but deemed P4C a sustainable way to foster supportive learning environments over time. Aspects included the importance of continuity, the involvement of the pupil health team, and the maintenance of elaborated routines. Participants spoke about the importance of continuity in the work with creating supportive learning environments since the learning environment is not static, and the risk of failure is high when pupils transfer to a higher grade, i.e., change teachers and classrooms. Involving the pupil health team to help continue P4C was suggested as one way of creating continuity and maintaining established routines. As stated by OT 1, who was employed at the central pupil health team in the municipality, ‘I really think it is important that you include the pupil health team, since it is via them the school can hold on to P4C and make it live on’ (OT 1). Furthermore, participants mentioned that they had established working routines and relationships that they thought would last and would aid them in continuing to work according to P4C.

Discussion

The present study investigating the feasibility of P4C in Swedish compulsory schools used both qualitative and quantitative data to evaluate five feasibility areas suggested by Bowen et al. (2009). In summary, P4C was found to be acceptable among participants, addressing important demands in classrooms. Also, P4C was found to be implemented and applied as intended and feasible to integrate within the school’s context. The collaborative application of P4C was perceived to have a positive impact on the target participants (practicality), from the participants’ perspective. Taken together, findings indicate that P4C is feasible to apply in Sweden.

Participants’ acceptance of P4C, including appropriateness, suitability, and its positive effect on the organisation (deliver special educational support and create inclusive learning environments) is an encouraging finding. Acceptability among those responsible for implementing an intervention is a crucial factor in their commitment and engagement (Skivington et al. 2021; Yardley et al. 2015) and a requisite for successful application in a new context (Barrera Jr and Castro 2006). Therefore, participants´ acceptance of P4C implies that P4C can be successfully used in Swedish compulsory schools without further modification. Acceptability of an intervention means that it is received well by the target population, and that the content meets important needs in their context (Ayala and Elder 2011). Thus, the adaptions to P4C that had already been made (e.g., extended target group) seems to be sufficient for the Swedish context.

During the implementation period, 83 interventions had been implemented, disclosing many unmet needs for special educational support in classes. This result not only highlights the demand for interventions in the learning environment but also echoes findings concerning Swedish school’s unsuccessful support of pupils with SEN (e.g., Swedish schools Inspectorate 2022). This suggests that Swedish compulsory schools could benefit from additional strategies to foster inclusive learning environments, in which P4C may contribute to the pupil health team. An innovative aspect of P4C is the alignment of perspectives between teachers and OTs when considering pupils’ diversity. Interprofessional collaboration to enable supportive learning environments has been highlighted before (e.g., Äikäs et al. (2023), Wiedebusch et al. (2022)). The structured collaborative approach provided by P4C may have strengthened the joint ability of teachers and OTs to successfully identify the need for, design and deliver interventions. P4C was considered to fit well with, and extend, schools’ existing work on inclusive learning environments. In line with these findings, the application of P4C may contribute to an increased capacity within the school to create inclusive learning environments that enhance pupil’s participation, also noted in Canada (Campbell et al. 2023).

According to P4C’s perceived effect on target participants (practicality), P4C is considered promising for both pupils and teachers. By applying P4C, pupils were perceived as being more engaged and confident when it came to knowing what to do, while teachers had increased their capacity to cater to diversity in the classroom, consistent with findings in Canada (Campbell et al. 2023). Despite these promising results, P4C’s effectiveness needs to be evaluated before it is implemented on a larger scale. Evaluating complex interventions, like P4C, requires, in addition to understanding their feasibility, an examination of their impact on various levels (Skivington et al. 2021). Future research evaluating P4C’s effectiveness is therefore suggested to include outcomes concerning teachers’ and OTs’ knowledge and capacity to create inclusive learning environments since learning environments influence pupils’ participation and development in school (Anaby et al. 2013; Meuser et al. 2023). Additionally, outcome measures on the individual pupil level should be included.

Another aspect to consider in future studies is the relative value of implementing P4C (Skivington et al. 2021). Participants expressed a favourable view of starting with class-level interventions as a preventive approach, which could reduce the need for individual interventions. Notably, the lowest proportion of implemented interventions in the present study was on the individual level (18%), aligning with the proposed benefit of applying UDL (CAST 2018) and RtI (Grosche and Volpe 2013). Therefore, the current cost of applying P4C may yield long-term benefits and warrants further investigation.

Key factors that eased the implementation in this study included explicit support from school management, and the willingness of professionals to embrace new knowledge and perspectives. These findings comply with the facilitating role of leadership support and the adequacy of human resources when implementing new interventions (Rycroft-Malone 2004) and emphasise the importance of embedding P4C in the organisational structure and considering the readiness of professionals to effectively apply P4C.

Methodological considerations

It is important to consider certain methodological aspects. First, all-participating OTs were purposively recruited, which was primarily due to the limited number of OTs working in or towards school in Sweden. However, these OTs may have had pre-existing positive attitudes towards P4C, possibly, even before applying it.

Additionally, the inclusion of classes where P4C was applied was based on the knowledge of school principals regarding pupils with unmet special educational needs. Consequently, all intervention classes needed a more inclusive learning environment, which might have influenced the number of implemented interventions. However, since deficiencies in the inclusiveness of learning environments in Swedish compulsory schools have previously been revealed (Swedish schools Inspectorate 2022), included classes are considered representative to evaluate the feasibility of P4C.

The deductive content analysis employing five feasibility areas outlined by Bowen et al. (2009) proved instrumental in addressing aspects pertinent to P4C’s feasibility. However, it’s important to note that the feasibility areas of Adaptation, Expansion, and Limited Efficacy (Bowen et al. 2009), were not explored in the present study. Consequently, P4C’s feasibility regarding these aspects remains uncertain. The decision to exclude these feasibility areas stemmed from their limited relevance in the initial stages of implementing P4C in Sweden. For instance, the feasibility area ‘Adaptation’ involves comparing outcomes between different populations using the intervention.

Conclusion

Findings showed that participants considered P4C feasible for creating inclusive learning environments within Swedish compulsory schools, suggesting that P4C does not require further modification for successful implementation in the Swedish context. The alignment of P4C with the existing organisational structure of schools’ work on accessible learning environments, which may have facilitated its adoption, implies its potential as a tool for policymakers to enhance inclusivity without requiring extensive modifications to existing policies.

The collaboration between teachers and OTs in identifying needs and implementing interventions accordingly demonstrated the potential to enhance the school’s capacity to create inclusive learning environments, potentially improving pupil’s participation within these learning environments. Nevertheless, the effect of implementing P4C needs to be rigorously evaluated in future research to provide evidence of its efficacy.

Moreover, present findings emphasise the significance of interdisciplinary collaboration in addressing pupils’ diversity, which holds potential implications for both present and future practitioners within the compulsory school setting. Integrating concepts and strategies, such as UDL and collaborative problem-solving, drawn from initiatives like P4C, into current practices and university education programmes for future professionals, could better equip practitioners to collaborate and co-design interventions tailored to meet the diverse needs of pupils in today’s inclusive classrooms.

Acknowledgments

The authors would like to thank the teachers, OTs, and principals who participated in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by Jerringfonden [the Jerring Foundation], Stiftelsen Sunnerdahls handikappfond, Clas Groschinskys Memorial Foundation, and Lars Hiertas Memorial Foundation.