Service User Experiences of Occupational Therapy in Acute Mental Health Settings: A Qualitative Evidence Synthesis

Abstract

The inclusion of service user perspectives in the development of acute mental health services is recommended in policy. Therefore exploration of their experiences in this setting is merited. This study synthesized qualitative research on service user experiences of occupational therapy in the acute mental health setting using thematic synthesis. The synthesis shows the unique role of occupational therapists in the setting. Service users identified the impact of the profession through environmental transformation, therapeutic relationships, and occupation-focused interventions. Issues of accessibility and availability of interventions were identified. Further research on this topic in a wider range of cultural contexts is recommended.

Keywords:

• qualitative synthesis
• acute mental health
• occupation
• service user experience

Introduction

Acute mental health services are inpatient settings that provide treatment to people in an acute phase of mental illness during which treatment at home or in an outpatient setting is not safe or desirable due to factors such as risk to self or others (Bowers et al., 2009). Service users may consent to admission or be admitted involuntarily under the relevant national legislation (World Health Organisation, 2021b).

The need to increase service user participation in the planning and development of mental health services is highlighted in international policy such as the WHO’s Comprehensive Mental Health Action Plan 2013–2030 (World Health Organisation [WHO], 2021a). However Stomski and Morrison (2017) identified that this participation remains largely an aspiration rather than a reality. While service users saw themselves as experts in their own experiences some mental health professionals doubted their capacity to make decisions and influence the treatment they receive.

Qualitative Evidence synthesis (QES) has been identified as a methodology that can be used to enable service user experiences to influence healthcare services, interventions and policy as well as develop the occupational therapy evidence base (Cahill et al., 2018). Furthermore it supports international research priorities identified for the profession, which have emphasized the need to support the effectiveness of occupational therapy interventions and explore how occupation supports participation in everyday life (Mackenzie et al., 2017).

There have been qualitative syntheses of service users’ overall experiences of acute mental health admissions. Akther et al. (2019) explored service user experiences of involuntary admission. This synthesis of 56 studies identified the important role the physical environment plays in service user recovery. This included the physical layout of the wards, the décor, the safety measures in place, and the availability and structure of therapeutic activities. Similar findings were identified by Staniszewska et al. (2019) in their systematic review of the experiences of inpatient mental health service users including both voluntary and involuntary admissions. The influence of the physical environment on recovery was again highlighted, as well as the need for staff to create a safe and supportive atmosphere. Service users stated that the inpatient setting should remain connected to the real world to support their recovery and return to everyday life.

Service users in the study by Akther et al. (2019) also expressed the need for activity to relieve boredom. There were diverse views about the structured provision of therapeutic activities, with some finding it constraining while others considered it beneficial to their wellbeing. Limited access to therapeutic activities was also identified as a problem by some service users, particularly due to low staff numbers.

The risks represented by boredom and lack of therapeutic activities were identified by Staniszewska et al. (2019), in which service users linked it to poorer mental health, lower self-efficacy, and increased risk of aggression. Service users also stated that they smoked or ate more due to lack of activities, affecting health outcomes.

Neither Akther et al. (2019) nor Staniszewska et al. (2019) explicitly mentioned occupational therapy. However, they highlighted the unique environmental context of the acute setting and the importance of therapeutic activities to service user wellbeing and recovery. These findings are echoed by a scoping review by Marshall et al. (2020) which focused on boredom in inpatient, but not just acute, mental health settings. It described boredom in these settings as the result of the interaction between the person and the acute mental health environment, characterized by a lack of power, lack of engagement by staff, and limited opportunities for meaningful activity. Similar negative consequences were identified such as risk of aggression, poor mental health, and increased rate of smoking. All three studies demonstrated the need for more research into service user experiences of these activities in this setting to ensure they are structured and provided in a way that most benefits their mental health.

Qualitative evidence syntheses have been completed of mental health service users’ experiences of occupational therapy; however, these have not been setting specific. Wimpenny et al. (2014) synthesized the experiences of service users, carers, and occupational therapists of occupational therapy interventions in mental health settings. Their findings highlighted the importance of occupational therapists’ “professional artistry,” as in therapeutic use of self, to engage with service users. Service users in the studies valued occupational therapy intervention highly as it created a sense of belonging and participation in a range of contexts. However, difficulties were encountered by occupational therapists when working with service users from another culture, such as those that have a collectivist rather than individualistic viewpoint. It was concluded that indigenous and immigrant perspectives were insufficiently represented in the literature. Wimpenny et al. (2014) concluded that treatment outcomes should be based on service user experiences. Therefore, researching and synthesizing service user experiences is of great importance to guide intervention and service planning.

Zedel and Chen (2021) completed a meta-ethnography of service user experiences of occupational therapy group interventions in mental health settings. They found that these interventions created connections between participants, similar to the sense of belonging described by Wimpenny et al. (2014) and shifted focus from diagnosis to the here and now. Positive emotions and skills development were facilitated. However, negative experiences were highlighted that focused on the grading of interventions. Participants struggled when others were at a different stage of their recovery and when the intervention was too difficult for them. These issues are particularly common in acute settings where service users can be at varying states of mental illness. Zedel and Chen (2021) specifically concluded that inpatient psychiatric settings are underrepresented in the literature and that greater understanding of service users’ experiences in this setting would be beneficial.

Lloyd and Lee Williams (2010) reviewed literature exploring the occupational therapy role in the acute mental health setting from 1990 onwards. They highlighted the shift in focus from acute to community mental health settings and that this appeared to have resulted in limited engagement in research on occupational therapy in inpatient settings. Four elements of occupational therapy were identified in acute mental health: Individual Assessment, Therapeutic groups, Individual treatment, and Discharge planning. The review concluded that evaluation of therapeutic interventions is necessary to ensure the survival of the profession in the acute mental health setting.

Hitch and Lhuede (2015) reached similar conclusions regarding occupational therapy research in this setting. They explored research priorities from the perspective of mental health occupational therapists. Four priorities were identified, including the service user experience of therapy groups and engaging patients in occupation on an inpatient unit. The researchers highlighted that these two areas have been the subject of less research than the others, representing a gap in the evidence base of the profession.

The literature therefore identifies the need for evidence syntheses in mental health occupational therapy and the exploration of service user experiences in the acute setting. QES of service user experiences in acute mental health have not mentioned occupational therapy. QES exploring service user experiences of mental health occupational therapy have not been specific to the acute setting. Therefore, this QES has the following question:

What are service user experiences of occupational therapy interventions in the adult acute mental health setting?

The following aims were identified for this QES:

• To explore service user experiences of receiving occupational therapy in the adult acute mental health setting.

• To provide insight into the specific value of the role of occupational therapy in this setting from the perspective of service users.

• To generate findings to support occupational therapists in the development of assessments and interventions in acute mental health settings.

• To identify gaps in the evidence base and guide further research on occupational therapy in this setting.

Methods

Qualitative research has been critiqued for its small sample sizes and has been excluded from some evidence-based practice frameworks (Gewurtz et al., 2008; Murray & Stanley, 2015). As a result, its findings have at times been ignored when developing clinical guidelines and recommendations. However, QES offers methods to combine studies with small sample sizes into a greater body of evidence. It has increasingly had an impact on healthcare policy (Cahill et al., 2018). Occupational therapists can be attracted to qualitative research given the client-centred philosophy espoused by the profession. QES therefore offers a potentially valuable method by which occupational therapy can develop its evidence base and influence clinical guidelines.

QES has been identified as an effective way to gain an understanding of the experience of participating in interventions as well as the interplay between interventions and the environments in which they are provided (Flemming & Noyes, 2021). Furthermore, it can give insight into the effectiveness and workings of complex interventions such as occupational therapy. Therefore, it is an appropriate methodology with which to achieve the aims of this study.

A comprehensive search was completed to find all relevant studies. The following databases were searched: CINAHL Plus with Full Test, PsychINFO, MEDLINE, OTSeeker, Web of Science, and AMED. In order to search gray literature OpenGrey was used. The following search terms and Boolean operators were used in each database:

• (inpatient OR acute OR hospital OR unit)

• AND

• (mental health OR psychiatr* OR psychotic OR psychosis OR schizophrenia OR bipolar OR manic depression OR depression OR anxiety OR personality disorder* OR obsessive-compulsive disorder* OR post-traumatic stress disorder*)

• AND

• (occupational therapy)

The following inclusion criteria were applied to the results of each database search:

• Design: Qualitative research

• Intervention: Occupational therapy practice as defined by the World Federation of Occupational Therapists (2010).

• Population: Service users in the relevant setting.

• Setting: Conducted in an adult (18+) acute mental health setting

• Outcome: Exploring the service user experience of occupational therapy intervention

• The study was published in the English language

• The study was published since 2010

The inclusion criteria limited findings to studies of acute mental health settings for adults (18+ years old). This was decided due to the environmental differences between acute mental health setting for adults and people younger than 18. As previously stated QES can identify associations between interventions and the environment in which they occur (Flemming & Noyes, 2021); however, this could be limited if a range of environments are included. Therefore, a clear environmental focus will potentially uncover valuable findings. A separate study focusing on acute mental health environments for people under 18 years old is merited. Due to the linguistic limitations of the researchers, studies published in languages other than English were excluded. Studies were limited to those published since 2010 to ensure findings reflect the contemporary acute mental health setting. This QES thus provides an update to elements to Lloyd and Lee Williams (2010) critical review of the occupational therapy role in this setting.

Both authors separately searched each of the databases using the search terms. The titles and abstracts of the studies found were separately screened according to the inclusion criteria to identify those that merited being read in full. These steps were completed separately to minimize bias and reduce the risk of missing potentially valuable studies due to human error. The two authors then met to present and discuss the studies they each believed merited being read in full. Discrepancies were resolved by carefully screening and discussing the title and abstract of the studies in question together.

When this was completed, each author separately read the remaining articles in full. Reference lists of these studies were separately reviewed for information about other potentially relevant studies. The authors then discussed the studies each believed met the inclusion criteria and should be included in the synthesis. Any disagreement was resolved by carefully reading and discussing the studies in question together.

There is ongoing debate about whether and how quality appraisal of studies should be included in the QES process (Murray & Stanley, 2015; Tong et al., 2012). Some syntheses exclude studies deemed low quality, others try to weight results toward higher quality studies in some way, while others just comment on the outcome of the quality appraisal. The latter approach was chosen for this synthesis. The included studies were appraised independently by both authors using the Critical Appraisal Skills programme (CASP) Qualitative Studies checklist (Critical Appraisal Skills Programme, 2018) but were not excluded or weighted in the synthesis process. The authors then discussed until consensus was reached on the quality assessment of each study. This approach was chosen due to the lack of consensus or evidence in support of excluding studies from QES as well as to ensure that conceptually rich but methodologically flawed studies were not excluded (Toye et al., 2013). By commenting on the quality of the studies included it provides methodological guidance for future research.

Thematic synthesis, as developed by Thomas and Harden (2008), was used to synthesize the included studies. This method of QES was developed to explore questions related to the acceptability and appropriateness of interventions (Barnett-Page & Thomas, 2009). It also aims to directly influence those who develop interventions. Thematic synthesis has been used successfully to explore service users’ experience of healthcare and illness (Flemming & Noyes, 2021) Therefore it is a suitable methodology to achieve the aims of the study.

Thematic synthesis has three steps (Thomas & Harden, 2008). First, the sections of the included studies named Findings, Results, or similar, were coded line by line in the similar manner to thematic analysis. This was done separately by each author using a hard copy of each study.

Second, the two authors discussed the codes they identified for each of the included studies. The translation of concepts between the included studies can begin to be identified at this stage. Similarities between the codes were identified to inductively group them together into a number of descriptive themes, agreed by both authors, which stayed close to the findings of the original studies.

The final step of thematic synthesis is the development of third order analytical themes that go beyond the findings of the included studies. Each author independently reviewed the descriptive themes to develop insights and interpretations in response to the research question. They then discussed and agreed on the final analytical themes.

Reflexivity is an important consideration in QES. The research pair are both white, one Irish and the other British. They are both qualified occupational therapists, one in mental health and the other in academia. They considered their biases and influences through discussion and reflection throughout the QES process. For example, they considered and discussed whether their wish to find positive findings regarding occupational therapy could lead to an unconscious bias that minimized negative findings. Each stage of the search and appraisal process, as well as initial coding, was initially completed separately and then discussed together until consensus was reached. This enhanced the rigor of the process and aimed to identify and address individual biases. The authors report there are no competing interests to declare.

The ENTREQ checklist (Tong et al., 2012) was developed to enhance the quality and transparency with which QES are reported. It was used to guide the writing up and reporting of this synthesis.

Results

Figure 1 illustrates the results of the search in a template adapted from Page et al. (2021). Table 1 outlines key characteristics of the studies included in the synthesis.

Table 1. Characteristics of the Identified Literature.

	Bryant et al. (2016)	Radnitz et al. (2019)	Birken and Bryant (2019)	Ngooi et al. (2021)
Participants	22 Current or recent (last 6 months) service users aged 18–70.	25 Current service users aged 18–50.	5 Current or recent (last 6 months) service users aged 18–70	6 Current service users who had participated in at least 5 group interventions and at least 21 years old
Country	United Kingdom	South Africa	United Kingdom	Singapore
Aims	To explore how acute inpatient mental health occupational therapy services were perceived by service users.	To explore the effect of occupational therapy groups on clients’ interpersonal relationships.	To investigate how an occupational therapy department with specific facilities is experienced by service users in an outer London Borough acute mental health unit.	To understand the benefits of participating in occupational therapy activity-based groups in an acute psychiatric ward from an Asian perspective.
Data collection	Semi-structured interviews (6 participants) and focus groups (16 participants)	Focus groups	Participatory research Photovoice	Semi-structured interviews
Methodology	Thematic analysis	Thematic analysis	Thematic analysis	Thematic analysis
Findings	Three themes: A tiny sort of world Relief Something to do	Four themes: We all have relationship problems We were given skills and applied them I am less demanding now I wish I could do this but it seems impossible	The kitchen: a domestic rather than clinical place The garden: transformation and coping The art room: choices can be made The gym: learning about healthy living The internet café: self-expression and sharing	Three themes: Therapeutic Relationship Connection with others Opportunity to engage

Table 2. Quality Assessment.

	Bryant et al. (2016)	Birken and Bryant (2019)	Radnitz et al. (2019)	Ngooi et al. (2021)
1. Was there a clear statement of the aims of the research?	Yes	Yes	Yes	Yes
2. Is a qualitative methodology appropriate?	Yes	Yes	Yes	Yes
3. Was the research design appropriate to address the aims of the research?	Yes	Yes	Yes	Yes
4. Was the recruitment strategy appropriate to the aims of the research?	Yes	Yes	Yes	Yes
5. Was the data collected in a way that addressed the research issue?	Yes	Yes	Yes	Yes
6. Has the relationship between researcher and participants been adequately considered?	Yes	Yes	Yes	Yes
7. Have ethical issues been taken into consideration?	More detail would be beneficial	More detail would be beneficial	More detail would be beneficial	More detail would be beneficial
8. Was the data analysis sufficiently rigorous?	More detail would be beneficial	Yes	More detail would be beneficial	Yes
9. Is there a clear statement of findings?	Yes	Yes	Yes	Yes
10. How valuable is the research?	Yes	Yes	Yes	Yes

Quality assessment

Quality Assessment was conducted on the included studies using the CASP Qualitative Studies Checklist (2021). Table 2 illustrates the results of the Quality Assessment process.

Figure 1. Search results.

All scored at least 8/10 on the checklist. However, the studies did not explicitly consider how participation in the study could potentially affect participants, both during the study and after. Considering they are in or recently experienced an acute stage of mental illness, explicit consideration of this is suggested in future research in this setting.

Themes

Following the thematic synthesis process six themes were identified: (1) a therapeutic environment (2) occupational therapists’ approach (3) impact of occupational engagement (4) skill development (5) negative experiences of occupational therapy (6) doing with others. These six themes are described below with quotations from the included studies.

Theme (1): a therapeutic environment

Service users highlighted occupational therapy as a welcome “escape from the ward” (Bryant et al., 2016, p. 610). The ward environment was defined by restrictions, lack of opportunities for occupation, and monitoring. Ward processes, such as being checked on when resting in one’s room and needing to ask to have doors opened, were a source of great frustration and considered to have a negative impact on mental health. The ward environment served as a reminder of their mental illness. By contrast the occupational therapy environment was considered “a distinct therapeutic place” (Birken & Bryant, 2019, p. 540) that has a positive impact on mental health as it presented an opportunity to “forget […] I’m warded in a hospital” (Ngooi et al., 2021, p. 45). As stated by a participant called Catherine in Bryant et al. (2016) it is a place to “think about other things apart from illness” (p. 610).

It was also identified that the presence of occupational therapy staff on the ward caused a change. Abhu, another participant in Bryant et al. (2016), stated that “as soon as OT lot come in you just see everyone’s behaviours changed” (p. 611).

Theme (2): occupational therapists’ approach

Service users across the included studies described how occupational therapists have a different manner and approach to other professionals. Ngooi et al. (2021) found that occupational therapists “don’t look at you like some patient […] you were treated normally” (p. 44). Similarly, three participants in Bryant et al. (2016) identified that they “make you feel welcome,” “try to encourage you” and “talk to you like a normal person” (p. 611). This approach was identified as encouraging people to engage in both conversation and intervention, with service users stating “you step up” (Ngooi et al., 2021, p. 44) and “your attitude changes so much quicker” (Bryant et al., 2016, p. 611). Others deemed it important that “You don’t have to speak and that was helpful as well” (Birken & Bryant, 2019, p. 536).

Participants in Ngooi et al. (2021) stated that the encouragement of occupational therapy staff helped them overcome anxiety in the group environment, as it is “very structured” and “If you do wrong also no need to worry so much as they won’t scold you” (p. 44). Therapists were perceived in this study as being like teachers who guide and set rules. The researchers in this study discussed that this perception may be linked to the Asian context and that being client-centred can in some contexts mean being instructive rather than collaborative.

Theme (3): impact of occupational engagement

Service users in the included studies identified various benefits of engaging in meaningful occupation, highlighting the importance of having “something to do…something different” (Bryant et al., 2016, p. 610). Occupational therapy was a source of relaxation, fun, and a distraction from sources of stress, as “when you are really into the activity you do not think so much” (Ngooi et al., 2021, p. 43). It also lifted mood and increased self-confidence; service users in the study by Birken and Bryant (2019) stated it “enables you to reach a goal” using an example of gardening where they “start out with nothing and then you can see nice flowers” (p. 537). It also lifted mood by invoking positive memories, reminding participants in Ngooi et al. (2021) about “playing hockey in school” and “baking for the festive season” (p. 45). The importance of autonomy and choice of occupation was highlighted as creating motivation and hope, with a participant in Birken and Bryant (2019) stating that engaging in physical activity “gave me a bit of purpose in life” (p. 539).

Theme (4): skill development

Service users also described the opportunity to develop new skills presented by occupational therapy “so that your mind will not turn rusty. Because next time you still need to go out to the outside world […] when you are at home, you have to do everything by yourself” (Ngooi et al., 2021, p. 45) The skills to maintain physical health and wellbeing were given as an example, with a service user highlighting that physical activity sessions “made me healthy” (Birken & Bryant, 2019, p. 539). Practical skills such as cooking were also learned, such as another participant in Birken and Bryant (2019) who said “I hadn’t used the kitchen in a long time. When I first came in, I didn’t know what to do. Took me time to get used to the cooking” (p. 536).

Radnitz et al. (2019) highlighted the development of social and communication skills. This is understandable given that the study aimed to explore the impact of occupational therapy group interventions on service users’ interpersonal relationships. A participant called Grant stated the skills learned through occupational therapy enabled them to “communicate properly […] I know which tone of voice to use” (p. 8), while Janet said it brought them “a little bit closer together” with loved ones (p. 8). Conflict resolution skills were highlighted as Khanyi said: “But I must say guys, I am proud of the way in which we handled the conflict we had within the family…so we were given skills and we applied them” (Radnitz et al., 2019, p. 7).

Theme (5): negative experiences of occupational therapy

Some negative experiences of occupational therapy were also found in the studies. Some did not have the role and potential benefits of occupational therapy explained to them. The process of accessing occupational therapy could be off-putting, making Alan “feel like a lemon” (Bryant et al., 2016, p. 610) and thus undermining the positives described above of being treated as normal and an equal. Others raised issues around the general access to and availability of occupational therapy interventions.

Some service users did not see any benefit in the interventions provided, with service user Anna questioning “the point of it […] What are you going to get out of drawing a picture?” (Bryant et al., 2016, p. 610). Others saw value in the interventions during the time in the acute setting but questioned “if the theory would be effective in practice” (Radnitz et al., 2019, p. 8), in other words the world outside.

Theme (6): doing with others

Service users valued the opportunity to engage in group interventions. Similar to findings concerning the manner and approach of occupational therapy staff, the informal nature of the group setting was perceived as having benefits: “We’d talk and we’d have drinks and stuff […] having a laugh, having a bit of conversation when you’re down.” (Birken & Bryant, 2019, p. 538). The same participant also stated that “sometimes it might be silent […] but it’s a nice kind of silence” (p. 538).

Participants described feeling authentically valued by other services users during group interventions, with Khanyi in Radnitz et al. (2019) stating “They are not feeling pity for me and they are not faking it” (p. 7). In the same study Buhle stated “I realize I am not alone. It gives me that hope” (p. 7) while Londi said “I’ve learnt trust, to trust people that are around me” (p. 8). Peers could also be encouraging: “I thought like okay I’m not going to sing … but seeing others all sing, I feel left out. So I started to sing also, then everyone joined in … then they were laughing, they were smiling” (Ngooi et al., 2021, p. 45).

Ngooi et al. (2021) found that cultural context influenced how group interventions were perceived, as social norms from outside the acute setting influenced those within. This study was set in Singapore and a participant described “the Singaporean kind of trait that we don’t really talk to strangers as compared to like Western countries … So group therapy actually allows you to kind of create this area … this time where you can actually interact” (p. 44). The structure and direction given by occupational therapists provided a space in which participants were allowed to interact. Another participant stated that service users deciding to do activities together in the acute setting “probably wouldn’t have happened if they (occupational therapists) didn’t do it. Because they subject (sic) us to come together … we find it fun so want to recreate that again” (p. 44).

Discussion

Synthesizing service user experiences of occupational therapy in acute mental health settings provides supporting evidence for the impact of the profession within this specific environment. Service users in the studies identified the ward processes and constraints, as well as the lack of opportunity to engage in activity, as having a negative impact on their mental health. By contrast the occupational therapy environment was seen as less constrained and defined by formal processes with a corresponding positive impact on mental health. It also provided opportunity to engage in activities and distract from thinking about sources of stress and mental ill health. This supports and refines Akther et al. (2019) and Staniszewska et al. (2019) findings that the physical environment, and the structure provided by therapeutic activities, affect service user recovery in acute mental health services. It suggests that there is variation within different areas of the setting. One of the studies (Birken & Bryant, 2019) explicitly focused on an occupational therapy department that was separate from the ward. By contrast in some acute settings interventions are provided on the ward, perhaps in a designated occupational therapy room. It is possible that being on the ward has a transformational, positive effect on the atmosphere and milieu as suggested by a participant in Bryant et al. (2016). Further research is needed to identify the differences in effectiveness and service user experiences between these different models.

Given this positive impact of occupational therapy on service users, it is concerning that issues were raised about availability and accessibility to intervention. Reflecting the aforementioned frustrations with ward processes, the practical steps required to engage in interventions, such as asking to get through doors, were highlighted as potentially disempowering and humiliating. While often these are required to address concerns around risk it can also undermine the profession’s philosophy of empowering service users through client-centred practice. This also returns to the question of where interventions are best provided. If occupational therapy is provided on the ward it reduces issues of accessibility. By contrast having a separate department has the benefits as well as potentially enabling a wider range of interventions as service users can be risk assessed prior to entering the therapeutic space. A recommendation for practice arising from this research is that clinicians should consider whether and which interventions are provided in and away from the ward environment for service users to avail of the identified benefits of intervention in both environments.

The findings support the link between occupation, health, and wellbeing that is at the foundation of occupational therapy and occupational science. Engagement in meaningful activity was found to have numerous benefits such as lifting mood, creating hope, and developing useful skills. It therefore inversely supports findings from Marshall et al. (2020) scoping review which highlighted the detrimental impact of boredom. This QES supports evidence that meaningful activity in acute mental health settings positively impacts service users subjectively but also reduces phenomena such as incidents of aggression. However, service users identified that the activity must be purposeful and graded so its value is clear to them. This includes the transferability of the skills used to the world outside the acute setting.

Service users in the studies identified the manner in which occupational therapy staff interact with service users as different from that of other professionals. This was described as positively influencing engagement and perceived efficacy of interventions. In particular occupational therapists were identified as having an informal and respectful manner that created a feeling of being equal, having choice, and being treated normally. These characteristics have been previously identified by service users as being desirable in their relationships with staff in this setting (Staniszewska et al., 2019; Wimpenny et al., 2014). However, Newman et al. (2015) found that often staff-service user relationships in this setting are defined by lack of power and choice. Participants described fear as being an element of the relationship. Similarly, Allison and Flemming (2019) found that the relationship can feature coercion ranging from verbal threats to physical restraint in order to manage risk. However, these studies explored relationships with staff in general in this setting. The findings of this QES suggest that there may be variation in the relationships with different staff groups which merits further research. It is possible that the profession’s focus on service users’ occupations rather than directly on mental health supports relationships built on perceived equality, choice, and respect. This echoes Zedel and Chen’s (2021) finding that group occupational therapy interventions support participants to be in the here and now and have conversation about topics other than their diagnoses. As previously stated, service users valued the occupational therapy environment as one in which they did not need to think about or discuss their mental health, therefore supporting them to feel “normal.” These findings suggest that occupational therapists in this setting should reflect on the processes, including that of assessment and intervention, which they use in practice and consider whether they cultivate the qualities identified by service users as the ideal therapeutic relationship.

However, the findings also caution that cultural context should be considered when interacting with service users. This could potentially impact the acceptability of interventions. It was suggested by Ngooi et al. (2021) that service users from collectivist cultures may prefer occupational therapists taking on an instructive, teaching role rather than focusing on individual service user choice, such as during group interventions. Malfitano et al. (2021) completed a scoping review on collectivist occupational therapy practice and discussed the necessity to actively create bonds and relationships within groups. The findings suggest that clinicians should in some contexts take on an instructive role to actively establish an environment where open communication between service users is permitted and encouraged, to mitigate fears of causing offense. Malfitano et al. (2021) highlights that exploration of collectivist rather than individualistic practice is still in its early stages within the profession. This supports the findings of Wimpenny et al. (2014) QES on mental health occupational therapy, which found that therapists encounter difficulty when working with service users from collectivist cultures. These findings demonstrate the need for a more diverse range of voices in occupational therapy research, including from collectivist cultures, to enrich and improve clinical practice in settings such as acute mental health.

These findings also offer insight into the QES process itself and what it can offer occupational therapy practice. QES has been critiqued as removing findings too far from their original context and words of participants (Gewurtz et al., 2008). However, Flemming and Noyes (2021) pointed out that a strength of the methodology is uncovering the impact of interventions in different contexts and groups. The findings here related to culture support this latter point. While this QES has developed cross-contextual understandings, it has also given insight into the nuances of occupational therapy in differing cultural contexts to support practice.

This QES features several limitations. Studies were excluded if in a language other than English given the linguistic limitations of the authors. This potentially prevented a more diverse range of articles being included to deepen insights, such as those related to the influence of cultural context. Studies were also excluded if more than 10 years old. While this could have led to potentially useful studies, this decision was taken to ensure the synthesis offered relevant findings for the contemporary acute mental health setting. Finally, as discussed studies were not excluded if they did not meet pre-determined quality criteria. This decision was taken due to the lack of consensus on this in the literature on QES and concern about excluding studies that may have methodological limitations but still offer useful conceptual insights (Toye et al., 2013).

This QES identified only 4 articles exploring service user experiences of occupational therapy in this setting in the years 2010-2021. This is a limitation of this study but also highlights the need for more research to support the profession’s role in this setting and provide evidence-based guidance for clinicians. The need for more diverse cultural perspectives in research on this topic was also identified.

Conclusion

This QES identified the unique role of occupational therapy in the acute mental health setting. The profession influences the environment, creating a space away from processes and restrictions that have a negative impact on mental health. A milieu is created in which peer support is encouraged. Service users described their relationship with occupational therapy staff as being different from those with other staff groups, characterized by feeling equal and being treated as “normal.” The findings support the link between occupation, health, and wellbeing that is at the foundation of occupational therapy and occupational science. The choice to engage in meaningful occupation mitigates the detrimental impact on boredom, improves mental health, and provides opportunity to develop useful skills.

Disclosure statement

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