Occupational therapists’ experiences of photo-supported conversations – An intervention in primary health care

Abstract

Background

The health-promoting intervention BeWell^™, which includes photo-supported conversations, is intended for people with stress-related illnesses. Its focus is on improving the individual’s health and well-being by addressing what contributes to well-being from the patient’s own perspective. There is no current knowledge of the experiences of occupational therapists of using BeWell^™ in primary health care. It is thus important to gain knowledge of their experiences of using this intervention as part of investigating its feasibility.

Aim

To describe the occupational therapists’ experiences of photo-supported conversations about well-being (BeWell^™) with patients diagnosed with stress-related illnesses.

Material and methods

Six occupational therapists, working in primary health care, who had conducted the photo-supported conversations about well-being (BeWell^™), were interviewed individually, and one focus group discussion was also conducted. Systematic text condensation was used as the analysis method.

Results

Three main themes with two to three subgroups in each were identified; Discovering well-being through images, Enhancing patient’s own efforts towards well-being, and Contributing to one’s own well-being.

Conclusions and significance

The results provide important knowledge for the continued research work with BeWell^™ by investigating how the users of the intervention experienced it.

Keywords:

• Focus group
• photographs
• primary health care
• stress
• qualitative research
• systematic text condensation

Introduction

Mental ill health, such as stress-related illness, is a growing health problem globally [1] and is increasing in all age groups [2] and entails an economic burden on society [2,3]. Stress-related illness is the most common reason for sick leave in Sweden [4]. It may lead to personal suffering, often affecting the individual’s ability to cope with different activities in everyday life [5], and to manage social relationships [6]. People with stress-related illness often seek help at the primary health care services at an early stage, before they risk long-term ill health leading to sick leave [5,7,8]. It is thus necessary to implement new methods that aim to promote the individual’s possibility of influencing their own health and well-being and to increase their resilience when coping with stressful life events. One such health-promoting intervention is BeWell^™, which includes photo-supported conversations [12] and is intended for people with stress-related illness. One of its theoretical foundations are Galvin and Todres’ Lifeworld theory [9], humanising health care, placing well-being and the person, with all of his or her complexities, at the centre. The BeWell^™ intervention is also based on Wilcock’s occupational perspective of health [10] that understands health by exploring the physical, social, mental, environmental, and spiritual dimension of occupation and the role of doing, being, becoming and belonging. Occupational balance [11] that can be defined as the individual’s perception of having the right amount of occupations and the right variation between occupations is yet another of its theoretical foundation.

Visual methods such as photovoice, autophotography and photo elicitation have proven to be good methods for obtaining richer and fuller data in research studies, generating a deeper understanding of peoples’ lives. These methods can be particularly effective in the encounter with patients with mental illnesses, and dealing with complex phenomena, such as well-being [12]. The idea of developing an intervention, which includes patients taking photographs to improve their health and well-being, originated in a study conducted in a primary health care setting [13]. That study, which involved participants with stress-related illness, showed that taking photographs of what represents well-being in everyday life for them could trigger a process of change in terms of what well-being might mean for them and could be useful when identifying and prioritising occupations that could lead to increased well-being [13]. That study became the starting point for the development of BeWell^™, and a further step in this process is to focus on occupational therapists’ experiences of using these photo-supported conversations in practice.

People with stress-related illnesses commonly describe both physical and psychological symptoms, e.g. anxiety, depression, muscle pain, headache, insomnia, and cognitive symptoms [4]. The role of primary health care in Sweden is to promote health and prevent ill health, and to co-ordinate interventions [14]. A combination of interventions is commonly provided for people with stress-related illness, such as prescriptions for medication and rehabilitation interventions from occupational therapists (OTs), physiotherapists, and/or psychosocial counsellors [15,16]. People with stress-related illness in Sweden are frequent among the patients treated by OTs in primary health care. The latter commonly offer participation in interventions, focusing on lifestyle changes and group treatments, aiming to facilitate changes in the patients’ everyday life [9].

Intervention studies focusing on preventing ill health due to stress have previously been performed. Their focus has been on limiting the risk for sick leave [17–19] and on promoting health [15], which are important goals both for people with stress-related illness and those at risk.

New interventions, such as BeWell^™, need to be tested in terms of their feasibility, reliability, and validity [20], and it is also important to study interventions from different perspectives, such as from those who receive the intervention as well as from those who provide it. The focus in this study is on the latter, i.e. the experiences of the OTs who have used the intervention in practice. We want to explore whether the OTs experienced BeWell^™ to be an valuable intervention, and whether it could be useful in clinical practice in primary healthcare or not. Knowledge of how they perceived the intervention can be of importance for the implementation of BeWell^™.

The aim of this study was thus to describe the occupational therapists’ experiences of photo-supported conversations about well-being (BeWell^™) with patients diagnosed with stress-related illnesses.

Material and methods

Settings and study design

This study was part of a larger project [12] in which an intervention with the BeWell^™ was carried out at six primary health centres in two regions in the south of Sweden with a catchment area of approximately 370 000 inhabitants. The present study had a descriptive design, with a qualitative and inductive approach [21], with individual interviews and one focus group discussion [22] as the methods for data collection. In order to gain knowledge and in-depth understanding, it was considered appropriate to use a qualitative method. There was a small number of participants, and in order to gain richer data and a deeper understanding we decided to let them develop their reasoning and reflection through the group dynamics of a focus group discussion. An advantage of using a small number of participants who already know each other is that it will be easier to create a good atmosphere that makes the participants feel safe to share their opinions. All six OTs participated in both the individual interviews and the focus group discussion [12].

Participants

The participants in this study were the six female OTs who conducted the intervention BeWell^™ and who worked at the primary healthcare centres that had shown an interest in participating in the project. All had received two days of special training in the structures and techniques of Be-Well^™. The following topics were included in the training: the concepts of well-being and occupational balance, well-being despite stress-related illness, how to look at images and narratives, and how to encourage reflective conversations. The OTs practiced performing the intervention by exchanging their roles as the treating OT, the patient, and the observer.

The participants had used BeWell^™ with between two and thirteen patients each. They all had Swedish as their mother tongue and several years’ experience as OTs. Their age range was 32–63 years of age (mean: 48 years) and they had worked as OTs 7–31 years (mean: 20 years). Five of the six also held a part-time position as rehabilitation coordinators within primary care, which in accordance with Swedish law [23] entailed that they were responsible for the collaboration between the individual on sick leave, the employer, healthcare providers and other relevant authorities.

The content of BeWell^™ – Photo-supported conversations about well-being

The BeWell^™ consists of 12 sessions. The first four sessions are longer (approximately 45 min) and the following six are shorter follow-up sessions (10-15 min). The outcome of the intervention is summarised in the final two sessions (45-60 min). Prior to each session, the patient uses their mobile phone to photograph situations related to their well-being, and then sends them to the OT, who prints them in A4-format. The photographs are used as a starting point for each session, in which the patient and OT discuss what may contribute to enhance the patient’s well-being. The discussion could be about doing, about what occupations the patient can do because of noticing what contributes to their well-being. During the final two sessions the aim is first to compile the patient’s experiences of well-being from the previous sessions. The patient is encouraged to reflect on all their previous photographs, which are placed in front of them, and together with the OT plan to maintain their well-being in everyday life in the future. The patient is encouraged to work with a self-selected assignment connected to their well-being between each session. For more information on BeWell^™ please see the study protocol [12].

Data collection

One of the authors (KH) conducted six individual semi-structured interviews with open-ended questions based on an interview guide. The interviews were carried out on-line via Zoom after the OTs had conducted the intervention with the patients. The interviews were audio-recorded and lasted for 42–59 min. The interviews dealt with the relevance of BeWell^™ for patients with stress-related illness, how it worked in practice, the conditions for OTs to be able to use BeWell^™, and the relevance of the different components of BeWell^™.

A face-to-face focus group with all six OTs was conducted approximately two months after the individual interviews, this to give the participants time for reflecting on their own first. The focus group methodology used in the study is a form of group discussion where the interaction between the participants stimulates them to gain a greater understanding of their experiences of the intervention [24]. The focus group session was conducted by two of the authors (KH and JN) and held in a neutral conference room. The questions for the focus group discussion were based on themes found in the data from the previously performed individual interviews and focused on the key components of the intervention, the patient’s process, the therapist’s process and its feasibility in practice. The session was audio-recorded and lasted for about one and a half hours. The interviews and the focus group session were transcribed verbatim.

Data analysis

The process of analysis followed the four phases of Malterud’s [21] systematic text condensation (STC), i.e. phase 1) total impression and identification of themes; phase 2) identification and sorting of meaning units, developing from themes to codes; phase 3) condensation, going from code to meaning and phase 4) synthesising condensations, developing descriptions and concepts. All data from the individual interviews and the focus group discussion, were analysed together in this way. The aim of the first phase was to gain an overall picture and to identify preliminary themes by reading through the data with an open mind.

All data that was irrelevant to the aim of the study was removed in the second phase of the analysis. The meaning units, which remained, were highlighted in colour according to the previously identified themes, and then the coding started, in which the meaning units were classified and sorted into code groups.

In the third phase, the content of each different code group was sorted into subgroups. The meaning units were moved between subgroups during this process and the names of the codes constantly adjusted as our understanding increased during the analysis. A condensate was then developed for each subgroup, and this condensate became a summary of the content of the meaning units in each subgroup.

The synthesising process took place in the fourth phase, where each code group and subgroup were summarised, based on the condensate, and selected quotes in a text. All subgroups were subsequently given a category heading. Finally, the subgroup text and headings were reconceptualized to validate that these still matched the original data. In order to strengthen the trustworthiness of our analysis a form of researcher triangulation [25] was used, in which two of the authors (ABG and JN) had the main responsibility for the analysis process. They started by independently analysing the data, and to increase credibility all the authors discussed the interpretation of the results in an iterative process until consensus was met. The researchers have experience of working with people with mental illness, three as OTs and one as a registered nurse, and they are all experienced in qualitative methodology, individual interviews and focus groups.

Ethical considerations

The study was approved by the Regional Ethical Review Board in Stockholm, Sweden (Dnr 2019-04334). The study complied with the stipulations in the Swedish act concerning the Ethical Review of Research Involving Humans [26], and the principle of informed consent was applied. The participants were informed about the voluntary nature of the study, that they could refuse further participation at any time and that their answers would be handled with confidentiality.

Findings

Three main themes, with two to three subgroups in each, were developed from the analysis, resulting in a total of seven subgroups (Table 1). The subgroups will be presented with illustrative quotes from the individual interviews (in italics) and from the focus group discussion.

Table 1. Themes and subgroups related to the occupational therapists’ experiences of using BeWell^™.

Theme	Subgroup
Discovering well-being through images	The image as an enabler for conversation about well-being
	The image as a tool for identifying and supporting well-being
Enhancing patient’s own efforts towards well-being	The patient as an agent in enhancing their own well-being
	The focus on well-being in everyday life
Contributing to one’s own well-being	The method facilitates enjoying the work
	Well suited for the professional role
	The use of the intervention spills over to the OT

Discovering well-being through images

The OTs described their experience of how the photograph had a major impact on enabling the patient’s communication about what constitutes well-being for them and how important the photographs are for the intervention.

The image as an enabler for conversation about well-being

The OTs described that the use of photographs gives a clearer image, both for them and for the patient, of what exactly the patient experiences as well-being. Enlarging the image to A4 format further reinforces this. One of them said, ‘But just when you see it in that size, it becomes … it becomes sort of clearer’ (OT #4). The OTs experienced that the photo contributed to the method becoming a visible and clear way of working towards well-being for the patient. The patient maintains their focus on well-being when he/she has the photo to look at. The OTs believed that the photo, i.e. the bigger picture, contributes to another insight into the patient’s life, compared with standard occupational therapy. They are able to see what the patients talk about actually looks like, and what they mean. The OTs experienced that the patients reveal a little more of themselves through the photo and that this also leads to completely different conversations compared with their other meetings ‘… and because of that you might get a little closer to each other in some way. So, I think the picture itself is super exciting and I’ve seen all sorts of things’ (OT#3). They also described the experience of the photos as essential for the method. The conversation focuses on the photo and the method would not have worked without the photos, ‘If they had only been able to reflect on one occasion when they feel good, a situation when they experience well-being, an opportunity when they feel good, it would not have worked. They need to have the photo as well’ (OT#1). This was further discussed in the focus group:

OT 3: This reflection that the patients do, ‘yes, but then I felt that way and then this happened…’. Just like a woman that I met said ‘oh, that photo, it was just then when I started thinking, yes, but now I have to start working and what am I going to work with in the future, should I change jobs, should I change careers?’. It’s like a journey for them, where each photo symbolizes their path to a better health.

OT 5: A story.

OT 3: Yes, it does… Mmm, it really does.

(Focus group)

The image as a tool for identifying and supporting well-being

According to the OTs, the method amplified an experience of well-being for the patient. This was seen in several ways; when taking the photographs, both when they paused what they were occupied with to take the photo, and then later when they look at the photo. The OTs describe that the patients have used the photos as tools in their everyday life. The patients use their photos to remind themselves of activities that they perform and moments when they feel good. Further, the OTs also described being told that their patients’ relatives have also used the photos to remind the patients of what they need. One OT said that a patients’ daughter had said: ‘… But mom, now you need that picture, put it on the fridge!’ (OT# 4). Another OT emphasised the importance of the images as a tool for the patient: ‘And that you can actually use… that you consciously use them [the photos] as a tool in that way…’ (OT #5).

During the focus group discussion, the OTs talked about the final two sessions where the patients look at all the photos they have taken during the intervention. The OTs witness that these sessions make a strong impression on the patients, both emotionally and regarding their progress.

OT 4: Plus, you have prepared all the photos when they come in and so many [patients] are very affected, ‘Wow, there’s my life’.

M: Yes.

OT 4: When you look at all the photos. It’s very rewarding, I think.

OT 3: There is a visible process.

OT 4: Yes.

M: What happens to the patients then, in the moment when they get to see all the photos together?

OT 4: Yes, no, but then….yes, many are moved, I can’t say exactly what happens, but they are touched and tearful […] everyone has been very good at taking photos, preferably two or three photos per session almost, so that there are many photos […] Everything that hopefully makes them feel good about.

M: Mmm.

OT 4: I think that….it’s probably pretty cool to be confronted by that [all the patient’s photos].

OT 5: That they see their journey I think….

OT 4: Yes, exactly!

OT 5: See what’s happened during this period…

(Focus group)

Enhancing patient’s own efforts towards well-being

The OTs thought that BeWell^™ had a clear focus on well-being and that the patients themselves could, with the support of the OTs, make changes in their everyday lives to enhance their well-being. The patients themselves did the work, but they needed the support from and reflection together with the OT to draw the conclusion about what they exactly had to do.

The patient as an agent in enhancing their own well-being

The OTs perceived that it was the patients themselves who steer the reflective conversations about well-being with BeWell^™. It was the patient who chose which photograph to send. And it was the patient who figured out the answers to their own questions, which the OTs perceived as positive for the intervention. ‘That is, they have to do all the thinking, they have to answer their questions, we don’t provide solutions for them. Because when we don’t do that, it is more enduring for the patient’. (OT #2) The OTs felt that lot of responsibility lay in the hands of the patient, which contributed to them being in focus and that the intervention is based on their own story, their conditions and wishes. ‘It’s about letting patients do the work themselves because that’s what becomes effective. ‘ (OT #2). At the same time the OTs experienced a need for the patients to have someone to exchange their ideas about their well-being with. It is difficult for the patient to reflect on their own hand.

OT 1. And you may never reflect on that level yourself unless you get asked those questions.

M: No.

OT 1: And then you can continue and elaborate on those questions when you take the next photo, and then you sort of think more about what makes you feel good. And then you kind of transfer that into other activities as well, I mean those reflections.

OT 6: Yes, we talk a lot about patient-centred care… but here it really becomes so, that the patient steers the conversation, and we are mostly just guiding along the way, that they are the ones who control the conversation, really.

M: Mmm.

OT 6: Because we receive a photo, but we don’t really know much more about it, no more than what we see, so it becomes very clear that way. I totally agree with what you’re saying that it’s anchored in a different way … the whole way of thinking.

(Focus group)

The focus on well-being in everyday life

The OTs experienced that BeWell^™ helped the patients to focus on activities that generate well-being. For the OTs, the intervention dealt with supporting the patients to reflect about activities that made them feel good. The OTs thought that the patients could have a preconceived idea about what they ought to feel good about and needed guidance as to which activities generated well-being for that specific patient. ‘Those activities are not the same for everybody, but we all have different activities that we enjoy and where we…. that are healing and salutary and relaxing and stimulating and fun’ (OT #2). It could concern the patient realising that seemingly small activities could enhance well-being, and that the patient sometimes needed to pause to discover what generated well-being and to prioritise and choose those activities. One OT had a patient stating: ‘It doesn’t have to be that I’m [i.e. the patient] going to organise a big family party gathering, but it can be when I’m sitting with my coffee cup and actually taking a break at the kitchen table. ‘ (OT #1). The OTs said that BeWell^™ not only helped the patients reflect upon what they do but also on how the patients perform activities. ‘ … we don’t just talk, but it’s about how you perform your activities and that you can also find well-being and rest in an activity’ (OT #2).

OT 6:[…] you can really focus here on what actually works or generates well-being in everyday life or gives energy and I think it’s been a way to make it a little clearer for the patient as well, just that it’s the small moments in everyday life, […], I think, that you become a little more attentive, both me as a therapist but also the patient, that they find those small moments in everyday life in a different way, I think.

OT 2: And it’s also that many people lower their own demands on themselves, I think, you find an acceptance in a completely different way […].

OT 5: Yes, you may have to re-evaluate an activity, as you say […] Maybe there are other values in the same activity, I think you find that out quite clearly with the photos, as you said. That you kind of get a different perspective on things, even if you talk about the same thing, you get a different angle on it. That reinforces why I am doing it and do I feel good about this and doing this.

(Focus group)

Contributing to one’s own well-being

The OTs liked using BeWell^™ and it also made them happy. Moreover, they considered that the intervention suited them as OTs, but they also became influenced by the patients’ reflective conversations about well-being, and using the intervention affected them in a unique way.

The method facilitates enjoying the work

The OTs were positive to the intervention. Carrying out BeWell^™ was described as making them happy, that it was fun, fascinating, and exciting to use the intervention with the patients. This method means a lot to the OTs. They experience a lot of joy in following the patients’ progress ‘A lot of joy, so a lot of joy in the meetings and yes, it gives… It’s really rewarding, so this is great fun. And when you see patients during a long journey, what happens to these people, it’s rewarding for me’ (OT#4). The method was described as easy to use, an intervention where the OTs do not feel they have to do a lot of preparation. It helps them cope with the rest of their work a little easier. It is similar to having a break for the OT as well, to be able to focus on the positive aspects.

Well suited for the professional role

Using BeWell^™ also strengthens the OTs’ professional identity. ‘I have longed for these meetings, because I think it’s been well … so very good, I can really go into my role as an occupational therapist, […] this becomes like a very sacred moment’ (OT #5). The OTs discussed whether BeWell^™ can be used by another profession or whether it should exclusively be for OTs. Some of them considered initially that a physiotherapist or a psychosocial counsellor would be suited but then these OTs also pointed out that the method focuses on occupation and patterns of everyday occupation and how one relates to what one does and concluded that the method should be kept within the occupational therapy field. This was, however, obvious from the start for others. ‘So, it becomes so clear for me about this method, that it’s an occupational therapist, and I haven’t considered whether any other professions could use it’ (OT #5) A requirement, according to the OTs, however, was experience of reflective conversations and experience as an OT.

OT 5: It’s a fairly unique way of working. And I think, as an occupational therapist, that we’re talking about activities and thus a solution-focused approach in that way, so that if all of a sudden, it’s going to be sort of smeared out on all sorts of different …

M: What do you lose then?

OT 1: Yes, but the gist of it.

M: Which is?

OT 1: Which is activity. Well-being in activity, activity value.

M: Yes.

OT 1: The focus that we have on that. And the other professions don’t, they don’t focus on that.

M: No.

OT 1: So, I absolutely believe what you say. Absolute. I think that’s really important. That if it is used by other professional groups, for example if it is a physiotherapist, they will direct it towards their focus, or if it is psychosocial resource, they will move it in another direction.

OT 6: Yes, and I’m also thinking so….

OT 1: In that they don’t have activity as a fundamental focus.

(Focus group)

Overall, the OTs felt that performing BeWell^™ worked well in practice in the primary health care centres that they worked at. The intervention demanded some technical conditions, but one OT expressed that ‘Yeah, sure, it’s a bit of a puzzle… but compared to other hassles at work, this [the preparations before a BeWell^™ session] is minimal’ (OT #4). They had room in their calendars to meet the patients once a week for 12 weeks. One of the OTs found it difficult to use the method on several patients at the same time. ‘…you shouldn’t have too many at once, I had three and it was too many. You kind of mix up the processes and kind of mix up the thoughts around the pictures and such’ (OT #4). Using the method on patients with stress-related ill health triggered thoughts about using the method for patients with other diagnoses. Depression, chronic pain, anxiety and neuropsychiatric diagnoses were some examples that were mentioned. There was also a desire to be able to adapt parts of the method. This especially concerned how many sessions to use and how frequent contact there should be. ‘I wish you could be a little more flexible with the number of sessions, not that there should be too few, but also that it doesn’t have to be twelve. So, there wasn’t much that happened between some sessions, so that both she [a patient] and I could feel a little that a week in between was a little too tight sometimes’ (OT #6). They also expressed an idea that using BeWell^™ for groups would give another dimension to the method.

The use of the intervention spills over to the OT

The effect of the method affected the OTs’ own well-being. They experience that they also become affected by the intervention. ‘I feel very good as a person myself, when I have at least one person in treatment with this [BeWell^™], because I also feel good about these sessions when we meet’ (OT #1) The OTs spoke of becoming more attentive to what generates well-being for themselves. They described being inspired by the patients’ stories of well-being, which the OT then can apply to their own everyday life. ‘It’s that we focus on well-being, I think, that it also makes me reflect on my situation and on me and sometimes I can imagine that, maybe I should also think about that. Because I still see that most of the people I met seem very positive afterwards’ (OT #1).

Discussion

This qualitative study aimed to describe occupational therapists’ experiences of using photo-supported conversations about well-being (BeWell^™) with patients diagnosed with stress-related illnesses. The first of the three main themes that emerged, discovering well-being through images, showed that the images were considered important for the OTs when they talked with the patients. The importance of the image for the conversation is emphasised by the OTs in several ways. The photograph supports the directing of the focus towards well-being during the conversation between the patient and the OT, while the OTs also appreciated the photograph as a concrete means to use. Using photos to speak on behalf of vulnerable groups and to convey their stories is part of the photovoice method [27]. Allowing individuals to photograph their everyday life and show it to someone else, can be used in many ways, for example in health promotion with different groups and communities, and for diverse public health issues, health treatment, and science [28]. The image was the starting point for the reflective conversations about well-being in this current study and is one of the core components of BeWell^™. The OTs expressed that the photos allow them access to the patient’s everyday life that they normally would not be able to see. The advantages of using images in interviews, according to Rose (2014), are that they can help put words to aspects of the patients’ everyday life that would otherwise remain implicit or taken for granted [29]. Furthermore, the image guides the reflective conversations to focus on the patient’s own perspective, because it is the patient who has chosen the subject. What the photo shows is what he/she is talking about, i.e. what is important to the patient. This also means that the OTs feel that it reinforces the patients’ own steering towards their well-being, enhancing the patient’s own efforts towards well-being. This has also been shown in previous research, where the use of photographs as a tool in clinical work facilitates the patient finding their own strengths through self-reflection [30] and where the use of photographs together with the patient’s narrative combine to enhance communication between the patient and the therapist in practice [31].

The OTs felt that it was the patient who ‘carried out the work’. This could be interpreted as something negative for the patient, but is instead something positive, a sign of people-driven care [32]. According to Goodwin et al. [33], there is a need for a shift from people-centred care, which often fails to achieve what it strives for, to people-driven care where the patient’s needs and goals, expressed by them, become the core driver. This shift was also described by the OTs in the present study, in which the patients had the power to steer in a patient-professional collaboration towards better health and well-being. This is also in line with one key element of the discourse among OTs in Scandinavia, i.e. creating partnerships to facilitate desires for change in the client and regard the client as an active and equal partner contributing with their wishes and needs [33].

Another finding in this study is how the OTs experienced the intervention as contributing to the OTs’ own well-being. They speak of their excitement about how they look forward to the BeWell^™ sessions, expressing that they felt joy during the BeWell^™ sessions. A joy grounded in the experience of working with the competences the OTs have, and that they were able to put their professional skills and knowledge into practice. Joy at work is a central part of experiencing a good quality of life [34] and a healthy work environment [35], which the present study could indicate. The workplace and how the employees feel at work have a major impact on our health and our life satisfaction. Being in a workplace where people experience joy and that enables them to work with what they are trained to do has a positive impact on occupational health [36]. Some of the traits of gaining energy at a workplace are; feeling that the work is meaningful, feeling happy when going to work, having a diverse and challenging job and a good work situation in terms of feeling comfortable in one’s professional role, an opportunity to use skills acquired for the occupation [37]. These traits were seen in the results of this current study. This may indicate that using BeWell^™ has a positive impact on the OTs’ own well-being and that the OTs may gain energy while using BeWell^™. It has also been shown that reward is important for sustainable working life among Swedish OTs [38]. Reward is not only spoken of in economic terms such as a higher salary but can also concern positive feedback and appreciation [39], which is what the OTs in this study experience from using BeWell^™. This is important knowledge when creating new interventions for OTs.

When the OTs describe how the use of the intervention spills over to themselves, they speak of the patients’ endeavours to increase their well-being as a role model for themselves, how the patients’ stories of well-being in their life inspired the OTs to try similar things. In the more common relationships between patients and carers it is the therapist who is the role model for the patient or groups of patients in group therapy situations, or that a patient is the role model for another patient [40–42]. There are several different definitions of what a role model is. However, most definitions contain one or more of the following components: the role model is a behavioural model through which you can learn different behaviours and abilities, the role model represents what is possible and achievable, and the role model inspires affecting your perception of which goals are worth pursuing [41]. The patients in this study inspired the OTs to try new things and made the OTs themselves think about their own goals in life.

Even if the OTs feel that it is the patients who are ‘doing the work’, it is likely that the patients would find it difficult to do the same thing on their own. The OT is certainly needed here, with their knowledge about occupation, asking questions and acting as a sounding board for the patient. It is more that the patient’s choices matter in this context. It is the patient who chooses what to photograph and which photos they send to their OT. Stress-related illness is characterised by reduced motivation, fatigue, difficulties getting started with activities [43]. It is thus in these cases that you need your own choice to provide motivation [44]. Choice is crucial for motivation. The patient chooses what to photograph and what activity they choose to show to the OT. This valuable choice is important for the intervention. One of the cornerstones of occupational therapy is that the desire to perform activities, which are valuable to the individual, has an impact on and is affected by motivation [45]. Kielhofner and Taylor [44] maintain that if an activity feels meaningful, is interesting, provides a challenge to increase competence and is not controlled by something from the outside, then you become motivated [44]. No negative aspects related to the intervention was brought up by the OTs when specifically answered. The present study thus shows that the OTs experience the patients to be an active part while conducting the BeWell^™ intervention, which is in line with its key element, the use of photographs as a starting point for reflective conversations about well-being.

Methodological considerations

The research was guided by ‘reflexivity’, ‘validity’ and ‘trustworthiness’, terms used by Malterud [21] for scientific quality. Reflexivity is important while conducting qualitative studies [21]. The authors tried to identify their preconceptions so that bracketing could be imposed during the data analysis. The internal validity was strengthened by a description of the research progress and following the steps of systematic text condensation [21], which also explicitly prescribes recontextualization as a final step of the analysis, where interpretations and findings are validated against the initial data. The systematic text condensation procedure is suitable for limited sample sizes (fewer than ten interviews) and is described in detail thus making the method easy to follow [21]. To further strengthen the internal validity, the findings were supported by rich illustrating quotes. The trustworthiness was strengthened by researcher triangulation, when using data from both individual interviews and a focus group [25]. Moreover, to strengthen the trustworthiness, the authors who developed BeWell^™ were not the ones who conducted the interviews and the focus group discussion.

One limitation of this study was that it had a small number of participants. However, all the six OTs who have used BeWell^™ participated. To further strengthen the validity, the focus group discussion was added to the data collection. The interviews and the focus group discussion provided sufficient information power [46]. The aim of the focus group discussion was to stimulate interaction between the participants in order to generate as many opinions and viewpoints as possible and to strive for as rich data material as possible. It gives participants the opportunity to build on each other’s answers and generate thoughts and ideas that they otherwise may not have done [47,22]. The fact that they knew each other, or at least were not completely unknown to each other, may have affected the atmosphere and the conversation in the group. The advantage of having a group where the participants already know each other is that it is easier for them to start a discussion. The disadvantage is that there is a risk that they can take on the roles they usually have and may thus not express their opinions [47,22].

Conclusion

Taking photographs of what represents well-being in the patients’ everyday lives facilitates a dialogue with the OT. This becomes a co-creation, which contributes to patients working towards enhancing their own well-being. BeWell^™, which is a new intervention that OTs appear to like using, needs to be researched from other perspectives, for example, the patients’ experiences of the intervention.

Acknowledgments

The authors sincerely want to thank the occupational therapists who contributed to this study for their time and experiences.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Kronoberg County Health Authority under Grant RK-846931; the Medical Research Council of Southeast Sweden under Grant FORSS-847271 and FORSS-846931; and Open Access funding supported by the University of Gothenburg.