Abstract
This research describes the use of practice-based inquiry by occupational therapy practitioners to facilitate the reconceptualization and redesign of occupational therapy services to address barriers often encountered in acute mental health practice and to enact occupation-centered and justice-focused practice.
Providing occupational therapy services within a complex, biomedically oriented acute inpatient mental health setting comes with many challenges. Risk-averse approaches and medically oriented payment systems present barriers to implementing justice-oriented, occupation-centered interventions (Whiteford et al., 2019). Dominant discourses from medicine as well as psychology in acute mental health can marginalize occupational perspectives, often leaving therapists devalued, dissatisfied, and questioning their professional identity (Ashby et al., 2015).
The focus on medical stabilization and safety in a highly regulated acute health care service often dominates other views of health and well-being. This leaves the core domain of occupational therapy—that is, enabling through occupation—constricted in what it can offer within the inpatient setting. Occupational therapists struggle against reductionist bottom-up approaches and an evidence base of psychological perspectives that prevail within the mental health care system (Ashby et al., 2015).
Our growing understanding of occupation and its link to health and well-being continues to highlight the fact that many people do not have access to health-promoting occupations, leading to occupational injustice (Braveman & Bass-Haugen, 2009; Nilssen & Townsend, 2010). This is certainly true for people with mental illness who, when hospitalized, lose access to personal belongings, connections to family and society, and meaningful occupational engagement, leading to occupational deprivation. In addition, when discharged, they face barriers to participation (Cogan et al., 2020). Addressing these injustices has been within the scope of occupational therapy practice since its inception; however, it is now explicit in the American Occupational Therapy Association’s (AOTA’s; 2020) Occupational Therapy Practice Framework: Domain and Process (4th ed.). The evidence base to foster justice-oriented practice—that is, practice that addresses environmental- and system-level barriers to participation in occupation—is developing (Bailliard et al., 2020; Pereira et al., 2020).
At the same time, there has been a call to put occupation back in the center of our practice (Fisher, 2013). This initiative makes the distinct contribution of occupational therapy visible to other health care providers and to patients and justifiable and defendable to funders. However, to demonstrate that our central domain, occupation, influences health and well-being and should be central to all occupational therapy practice, we need more relevant evidence (Ikiugu et al., 2017).
There has been an enormous increase in the literature supporting the science of occupation and occupational therapy practice in the past 20 years. In fact, evidence for mental health occupational therapy is quite robust (D’Amico et al., 2018). However, for many practicing therapists this body of evidence remains “out there,” distant from practice philosophically and difficult to translate to specific practice contexts (Gustafsson et al., 2014; Whiteford, 2020).
Practitioner-generated research, the intentional study of one’s own practice, can be used to address this gap. Common features of this work include the practitioner as researcher, community and collaboration, professional context as the site of inquiry, and professional practice as the focus of study (Cochran-Smith & Lytle, 2015).
Practice-based inquiry (PBI) is an action-oriented practitioner-generated research approach in which knowledge generated by practitioners as coresearchers can be used to empower and transform practice (Whiteford, 2020). This method is gaining traction in occupational therapy in Australia (e.g., Whiteford et al., 2019). However, the use of PBI has been quite limited in the United States, which may be attributable to differences in health care systems. Therefore, the purpose of this article is to describe the reconceptualization and delivery of occupational therapy services implemented by a community of occupational therapy practitioners as they engaged in a PBI in an acute mental health setting in the United States.
Method
Situating the Research
The idea for this research arose from the primary investigator’s (PI’s; MaryBeth Gallagher) interest in occupational justice. At the time, the PI was practicing in the acute mental health department of a large university hospital and was challenged by how the medical model shaped practice in ways that marginalized the occupational therapy profession and limited the unique contribution she believed occupational therapy could make. Understanding the importance of evidence-based practice, and sharing similar concerns with colleagues, the PI initiated research that would enhance the delivery of occupational therapy practice and empower therapists to enact a justice-oriented and occupation-centered practice. Having encountered a study that used PBI (Whiteford et al., 2019), the PI sought to conduct a similar study. Therefore, a PBI research design was used to explore existing practice with the intention of increasing occupation-centered and justice-focused practice. In this method there is no specific research question but rather a focus on ideas to explore within the process. PBI was chosen because it is a valid method of active inquiry that encompasses the complex situatedness of practice (Whiteford, 2020). This research would have a relatively low cost and be feasible to implement because research meetings could be held during regularly scheduled team meetings. Upon receiving approval from the university institutional review board in May 2020, the research process was initiated with a view to 1 yr of engagement.
Coresearchers and Community of Practice Scholars
The PI invited all occupational therapy practitioners in the mental health services (including Darren Peters) to collaborate as coresearchers and form a community of practice scholars (CoPS). Two occupational therapy practitioners at the hospital’s satellite facility (one of whom was Kimberly Godwin), the manager of the service, and one academic occupational therapist (Nancy Bagatell) from the hospital’s affiliated teaching university were also invited to participate. The academic’s role was to cofacilitate the research process with the PI, identify relevant literature in which to further situate the research, and provide qualitative methodological expertise. Because of scheduling conflicts and departures from the hospital, nine occupational therapists comprised the CoPS.
At the start of the study, the number of years the practice scholars had worked in the field of mental health ranged from 1 to 16, with four therapists at an advanced level and four at entry level. All practice scholars had master’s degrees, and the cofacilitators both had PhDs. There was diversity among the practice scholars regarding gender, ethnicity, and race as well as regarding international practice experience as occupational therapists.
Research Context
Services provided by the practice scholars focused largely on evaluation of and intervention for patients on seven distinct units in the mental health service. The patients included those in the behavioral health emergency department, perinatal mental health unit, adults with severe and persistent mental ill health, older persons, children and adolescents, adults needing crisis intervention, and patients with an eating disorder. One therapist was assigned to each unit, with the exception of the unit for adults with severe and persistent mental ill health, which was shared by two therapists.
Research Process
As a form of action research, the process was iterative in nature, with data collection and analysis happening concurrently. The PBI process followed Whiteford’s (2020) C model of facilitation, in which a facilitator coaches, challenges, and connects the CoPS, creating solidarity over time (Whiteford, 2020). This model of facilitation fosters a shared responsibility that empowers a community toward action. The C model also supports the organic process for which PBI is noted and thus is not prescribed. As such, the knowledge generated in practice reflects the realities of that particular CoPS.
Coaching, challenging, and connecting provided a process for engaging practice scholars in addressing practice concerns. Initially, the CoPS considered the research focus, that is, to become more occupation centered and justice oriented, as suggested by the PI. Confirming their interest in the topic, the CoPS committed to a process of inquiry. Next, the practice scholars and cofacilitators solidified an identity as a CoPS. The facilitators coached the practice scholars in collecting data in the form of individual reflections, capturing “thinking, feeling, doing” to situate and understand practice. Each practice scholar was responsible for documenting their own written or recorded reflections and uploading them into a designated folder on a secure site. These reflections were then the catalyst for biweekly research meetings in which the practice scholars shared stories from practice, reflected together, and challenged each other. The meetings were carried out in the mental health occupational therapy department office. The practice scholar working at the satellite site (Kimberly Godwin) and the academic cofacilitator participated virtually because of coronavirus disease 2019 restrictions. All others were in the same room, masked and distanced. These sessions became a powerful sharing of experiences, enabling the CoPS to collectively process challenges and successes in practice. All data, consisting of individual reflections, collective session recordings, transcriptions, and literature, were stored on a secure site.
Throughout the PBI process pertinent literature identified by the cofacilitators was incorporated into the group discussions, further challenging the CoPS and providing a theoretical anchor as topics emerged. For example, initial feelings were those of frustration with perceived barriers to enacting occupation-centered and justice-oriented practice. Thus, literature on occupation-centered practice (e.g., Fisher, 2013) and occupational justice (e.g., Bailliard et al., 2020) was deliberated to increase an understanding of the type of practice the CoPS was seeking to enact. Readings were limited to one to two articles per biweekly session to reduce the burden on the practice scholars.
Data Analysis
Because practitioners were new to their role as coresearchers, the cofacilitators provided the CoPS with readings on qualitative data analysis. In addition, they provided a workshop on data analysis, specifically, on coding and clustering data based on Saldaña’s (2011) process. This process was not driven by a particular theoretical tradition. During this session, practice scholars individually coded data segments and then discussed the codes as a group. Next, the practice scholars individually coded their own reflections and transcripts. They then brought these codes to the CoPS and continued to engage in group data analysis, which involved iterative cycles of coding, clustering, and generating of themes. Codes from individual reflections were transferred onto sticky notes and poster paper during the group sessions for visibility and reconsideration. Mind maps were also created to analyze relationships between codes and to form clusters. Recordings of the data analysis sessions enabled the cofacilitators to undertake further analysis. All analytic insights were shared with the CoPS for confirmation, providing a form of triangulation to enhance the rigor of the study (Saldaña, 2011).
Findings
Our analysis resulted in two themes characterizing how the CoPS reconceptualized practice to create opportunities to enact occupation-centered and justice-focused occupational therapy. The first theme was occupational opportunities through direct services, and the second theme was occupational opportunities through system-level change.
Occupational Opportunities Through Direct Services
Throughout the research process the CoPs became more attuned to barriers that created occupational injustices for patients. These barriers included risk-averse, occupationally deprived environments for patients, a lack of cohesiveness and philosophical alignment with team members, and system policies that limited how therapy could be delivered. Reading and discussing literature on justice-informed and occupation-centered practice (e.g., Bailliard et al., 2020; Fisher, 2013; Pereira et al., 2020) generated ideas about what best practice is and what it looks like. As practitioners told stories about practice, many resonated with the conceptualization of occupation as a synthesis of doing, being, becoming, and belonging (Hammell, 2014; Wilcock, 1999; Wilcock & Hocking, 2015). With a renewed appreciation for the complexity of occupation and the centrality of justice to practice, practice scholars felt validated and embraced opportunities for patients to do, be, become, and belong. Although in this article we present doing, being, becoming, and belonging as discrete subthemes, these dimensions of occupation are interdependent (Hitch et al., 2014).
Doing
The CoPS renewed their commitment to prioritizing doing, defined here as facilitating participation in and performance of meaningful occupations despite a restrictive environment. The practitioner scholars recognized that just practice “targets doing and the freedom to participate in occupation” (Bailliard et al., 2020, p. 145) and found ways to provide opportunities for patients to do, because engaging in occupation is an innate need of all humans (Wilcock, 1999; Wilcock & Hocking, 2015). For example, one practice scholar shared a story about taking a patient to the kitchen to make iced tea and then going outside to drink the tea and talk. This provided an opportunity for this patient to do something familiar and meaningful off the unit. At times, enabling doing involved taking a risk and challenging policies. For example, one practice scholar reflected on a dilemma regarding whether to allow a patient to have a hairbrush so that she could engage in grooming during the day, even though patients were not permitted to have a hairbrush unless supervised: I chose to leave [the patient] with her hairbrush, to allow her to have some agency in her life at a time when nothing was in her control—engage in self-care and have at least one of her needs met. I have no regrets, although there’s certainly a risk.
Enabling doing also included moving beyond direct service to facilitating opportunities for meaningful engagement. One practice scholar reflected: I had a client who wanted to paint today, a meaningful creative occupation she uses to process her feelings. . . . Although I would have loved to have been there alongside her, I had to ask the activity therapist if she could support my patient’s meaningful engagement. . . . Although I didn’t provide the occupation, did I enable her engagement by finding a suitable person to facilitate her participation? It certainly feels like I did. When I went up to the unit she called me over, with a smile on her face and enthusiasm in her voice, to proudly share with me what she had accomplished. In a way, I facilitated her meaningful experience and still got to share it with her.
Practice scholars thus recognized that facilitating doing and “enabling the freedom to participate” (Bailliard et al., 2020, p. 145) involved many skills, including risk assessment and role release.
Being
Being, as Wilcock (1999) described, “requires that people have time to discover themselves, to think, to reflect and to simply exist” (p. 5). The CoPS often noted how little time patients were given to just “be” and have their feelings and experiences validated. The CoPS came to recognize the importance of offering this time to patients and viewing it as an important part of justice-oriented occupational therapy practice. One practice scholar reflected: Sometimes, I give patients a space to “be” because I feel that I am one very few who understand the importance of truly being. A patient said to me, “Thank you for letting me talk and actually listening. Thank you for letting me be me.”
Becoming
Becoming refers to notions of potential and growth, of transformation and self-actualization (Wilcock, 1999, p. 5). Despite the facts that patients were in an acute mental health setting and the primary medical goal was stabilization, practitioner scholars recognized the importance of providing patients an opportunity to engage in occupation with both the present and the future in mind. The CoPS saw occupation as a way for patients to cultivate a sense of hope as they imagined a future. For example, one practice scholar recounted a time when she enabled her patient, who loved salsa dancing, to teach her how to dance: [The patient] was teaching me how to dance; it was really fun to be led by somebody and not feel like I was teaching something but having someone engage in that occupation. I also shared with her that we were doing it so that I could lead older adults on another unit and help share her talent with the world; [this] was something she was really excited about and proud of.
In this example, the practice scholar provided the patient the opportunity to imagine herself as a dancer, envision a future where she could help others, and share her talents. Another practice scholar recounted working with a patient who was pregnant and was deciding whether she would have the baby. After some deliberation, the practice scholar recognized how she could support the patient in making the decision by thinking about her roles and what becoming a mother would entail. The practice scholar noted that she now saw her role as an occupational therapist as one who could help this patient “step into a huge role, a new role in her life.”
Belonging
Hammell’s (2014) call for practitioners to address belonging—feeling connected, cared for, and like one is contributing to others—fueled practice scholars to implement changes that enabled patients to work together and to feel a part of the unit. Drawing on Wilcock and Hocking’s (2015) notion that “belonging is enacted through everyday practices, social conventions, behavioral norms, and rituals” (p. 212), practice scholars recognized the importance of creating a sense of community and helping patients “feel like it’s their home where they belong.” For example, one unit had a morning meeting; however, there was little opportunity for patients to make choices and interact. Therefore, one practice scholar implemented “coffee and music.” He described, “Together the clients made coffee, poured it for one another, listened to music, shared their interests, and from what I can tell, connected. We all know this connection and belonging has the capacity to heal.”
Being able to engage in the activities of making and drinking coffee, listening to music, and talking together provided patients autonomy and choice and the opportunity to feel a sense of belonging in the moment.
Occupational Opportunities Through System-Level Change
With literature to support this expanded notion of occupation, practice scholars felt more confident creating opportunities for intervention that acknowledged doing, being, becoming, and belonging. Buoyed by these successes, yet recognizing that individual efforts were not enough, the practice scholars committed to taking collective action to address systemic barriers. This included advocating, educating, and disseminating.
Advocating
The CoPS recognized the importance of advocating for the occupational rights of all patients. Through discussions, practice scholars felt emboldened to advocate not only for individual patients but also for occupational therapy as a valued and unique service. One practice scholar recounted, “I’ve been getting more firm with doctors and other providers because I’m realizing that my job is important too, and what I’m doing is often probably more important than whatever five-minute conversation they are going to have.”
The CoPS discussed theories of change and strategies to address system-level concerns to advocate for justice-oriented services. Given the recognition that occupational justice can be enacted at the micro, meso, and macro levels (Bailliard et al., 2020) and the importance of capabilities, opportunities, resources, and environments (Pereira et al., 2020), the CoPS addressed the culture of the unit by advocating to be part of interdisciplinary team and leadership meetings. One practice scholar noted how these opportunities made him hopeful for change: “I am now part of teams to make larger scale changes to the unit schedules and wrap up group; I’m excited to be able to use my OT brain to hopefully help improve the quality of care patients are receiving.”
Educating
Collectively, the CoPS embraced the notion of educating others on their teams about occupation-centered and justice-oriented practice. They committed to sharing information with other professionals, especially nurses, who were often responsible for managing challenging situations on the unit. One practice scholar relayed a story about explaining to a nurse the importance of giving a patient space for letting her work her way through something difficult and scary for her, [which] can then allow her to do a lot of other things the rest of the day. They were like “she’s a whole new person.” Just holding space for somebody can make a huge difference.
After the CoPS discussed educating others about occupation through documentation, one practice scholar noted how she has changed the language in her notes. She reflected, “I have more confidence with trying to enact change and include language in day-to-day communication with other non–occupational therapy professionals.” The CoPS recognized that educating others would require perseverance and time.
Disseminating
The CoPS acknowledged the importance of disseminating their ideas about occupation-centered and justice-focused practice, in particular to those with power, “to get more people on board and work towards making a ‘Big C Change’ in the way things are done not just on that unit, but everywhere else.” The CoPS worked together to create a presentation for management, tying their vision of occupational therapy practice more broadly to the goals of the facility. Finally, the CoPS committed to disseminating their insights and findings to other providers in the health care system and to occupational therapists outside of the hospital to bring awareness of occupation-centered and justice-oriented occupational therapy practice. Although the CoPS experienced some resistance to change, they recognized the need to take a long-haul approach. By working together to take action, the CoPS came to recognize the importance of maintaining a CoPS to see this work through.
Discussion
n this article we have described how, using PBI, a CoPS in an acute mental health setting reconceptualized occupational therapy services to be more occupation centered and justice oriented. Acute mental health environments are dominated by a medical model that may inadvertently oppress patients and constrain occupational opportunities (Ashby et al., 2015). For the CoPS, conducting this research illuminated everyday occupational injustices as situated within hospital practices, policies, and structures. The PBI process that unfolded involved situating practice, reflecting on occupation and justice, and reconceptualizing practice to appreciate and realize the impact of the multiple dimensions of occupation on mental health. This reconnection to occupation as inherently justice oriented provided practice scholars with a renewed sense of, and confidence in, their unique contribution.
It is not surprising that practice scholars first identified the multitude of barriers to justice-oriented occupation-centered practice, including feeling undervalued and unrecognized for their unique perspective as occupational therapists. Indeed, these themes are present in much of the literature regarding mental health practice (e.g., Ashby et al., 2015; Whiteford et al., 2019). However, bridging the gap between theory and practice (Nilsson & Townsend, 2014) by using existing frameworks, such as Bailliard et al.’s (2020) micro, meso, and macro approach and Pereira et al.’s (2020) CORE (capabilities, opportunities, resources, and environments) approach to justice- and occupation-centered practice, provided practice scholars with a way to address the barriers and challenges they encountered every day.
The CoPS struggled with the disconnect between their values as practitioners and the values of other practitioners and the organization, and at times they questioned their ability to practice in an environment of such discord. Their growing awareness of their position within the system empowered them not only to make individual changes in practice but also to actively seek opportunities by advocating, educating, and disseminating to demonstrate how their professional values aligned with and supported the organization. Acquiring knowledge of the system, and taking actions for change, the CoPS embraced a “fundamental justice orientation” (Bailliard et al., 2020).
Collectively discussing actions toward change supported the practice scholars in widening their occupational lens. Reconnecting with occupation-centered practice as a process of doing, being, becoming, and belonging (Hammell, 2014; Wilcock, 1999; Wilcock & Hocking, 2015) illuminated the temporal and cultural aspects of practice. The practice scholars’ use of being as a therapeutic intervention acknowledged the value of the here-and-now for patients needing to rest their mind, body, and soul. At the same time, doing and becoming were essential features for providing a sense of growth, a future orientation, and hope (Hitch et al., 2014). Balancing the temporal horizons was often challenging for practice scholars; however, recognizing that all dimensions of occupation have therapeutic potential and are essential for promoting justice-oriented practice empowered them to validate each as part of their unique occupational lens. These temporal aspects of practice resonate with Mattingly’s (1994) notion of therapeutic emplotment as the practice scholars appreciated the separate unfolding narrative “plots” while simultaneously supporting a vision for a future. This led the CoPS to appreciate, validate, and understand their practice within a particular system and motivated them to seek system-level change.
That system also operates within a cultural context, which in this research was a medically oriented acute mental health system. The policies and power structures deny patients the opportunity to engage in roles and activities that engender a sense of purpose and achievement and promote recovery (Nilsson & Townsend, 2014), often in the name of safety. The outcome of this is occupational injustice. By creating occupational opportunities and roles—for example, within a morning unit meeting—practitioner scholars challenged the culture that envisioned patients as risks and provided them with a sense of meaning and purpose.
Although this study confirmed the marginalization of occupational perspectives in mental health practice noted by Ashby et al. (2015), using PBI and a longitudinal approach, rather than interviews at two distinct time points, enabled practice scholars to move beyond recognizing marginalization and injustice to taking action toward sustainable change. By bringing the research “right here,” the CoPS created knowledge through practice.
Limitations
Because this PBI took place in a particular setting (acute mental health) with a particular CoPS aimed at addressing practitioner concerns about enacting justice-oriented, occupation-centered practice, the findings are not generalizable to other contexts. However, generalizability is not the intent of PBI; instead, the findings provide an example of a process that can be used to address practitioner-generated practice concerns. Of note, PBI requires time and commitment by practitioners that may not be feasible in all settings. In addition, having access to literature and support for data collection and analysis may not be possible in all settings. We acknowledge that the PBI process undertaken for this project was influenced by the facilitators’ positionality. Future research should continue to explore how PBI can be used in various practice settings and address long-term changes in practice after a PBI to determine whether sustainable changes occur.
Implications for Occupational Therapy Practice
The findings of this study have the following implications for occupational therapy practice: ▪ Reconceptualization of context-specific practice can engender justice-oriented, occupation-centered occupational therapy services. ▪ Occupational therapy practitioners must recognize occupation as complex and inherently justice focused. ▪ For changes in practice to occur, occupational therapy practitioners must understand systemic barriers and develop skills to advocate, educate, and disseminate. ▪ PBI can be a powerful and transformative process to help occupational therapy practitioners address important practice questions and dilemmas.
Conclusions
This CoPS engaged in a useful and transformative process to address specific research questions arising from their own practice context and translate their findings directly back to their practice. The process enabled a deeper and more nuanced understanding of justice-focused and occupation-centered practice that validated the CoPS’s appreciation and articulation of their unique occupational perspective. This empowered the CoPS to construct meaningful changes to their direct practice as well as take action toward sustainable changes within the broader contexts. To engage mental health practitioners in creating and using a robust evidence base to support and transform their practice, PBI is a worthwhile methodology.
Footnotes
Acknowledgments
We acknowledge the occupational therapists who participated in this research process and the management at the setting who enabled their participation. We also acknowledge and thank Dr. Gail Whiteford for her mentorship and guidance in using a practice-based inquiry.