Exploring the professional experiences of mental health occupational therapists during a period of COVID-19

Abstract

Purpose

The COVID-19 pandemic has brought about disruption in the way health-care professionals carry out their day-to-day practices across communities. The purpose of this research paper is to explore the professional experiences of occupational therapists working in community and rehabilitation mental health settings during a period of the COVID-19 pandemic and to help gain an understanding of how their day-to-day work practices have been affected.

Design/methodology/approach

A qualitative phenomenological research study explored the lived experiences of ten occupational therapists working within Health Service Executive community and rehabilitation mental health services during the COVID-19 pandemic. Participants included eight community mental health occupational therapists and two rehabilitative mental health occupational therapists. Data was collected through semi-structured interviews and analysed using reflexive thematic analysis.

Findings

Three themes were identified: holding on to what we do; technology: friend and foe; and COVID as a catalyst to clarify the occupational therapy role. These themes capture the community changes, challenges and frustrations experienced by the occupational therapists while striving to provide quality mental health occupational therapy services during the pandemic.

Originality/value

The findings demonstrate the adaptive nature of the profession, the importance of traditional observation methods of community-based care, the experiences with telehealth approaches and an opportunity to clarify misconceptions of aspects of the profession’s role in relation to employment-related issues and occupational therapy group work within such mental health settings.

Citation

Culleton, B. (2022), "Exploring the professional experiences of mental health occupational therapists during a period of COVID-19", Irish Journal of Occupational Therapy, Vol. 50 No. 1, pp. 3-9. https://doi.org/10.1108/IJOT-04-2021-0012

Introduction

The public health measures introduced to contain the COVID-19 pandemic caused widespread disruption to many aspects of life across the world. The restrictions, which included “staying at home” and social distancing measures, resulted in people being unable to participate in what is meaningful in their lives as well as having to adapt to new and alternative ways to re-engage within society (Mynard, 2020). Many aspects of day-to-day living were out of personal control due to the pandemic, including the ability to meet others and engage in community life. For health-care professionals, this imposed occupational disruption and alienation affected both professional and personal lives, but also offered a chance to see the way in which to adapt in these unprecedented times (Bryant, 2021; Hammell, 2020). The pandemic enforced time to look at new ways of being able to do, to be and become, which can encourage a sense of belonging within our disrupted lives (Wilcock, 2006).

Occupational therapists working in community and rehabilitation mental health settings design interventions to help people gain a sense of belonging by participating in meaningful activities within their community to enhance their health and well-being. However, the lockdown measures and phased societal reopening plan implemented by the government to slow down the spread of the COVID-19 virus reduced access to everyday community resources. This included retail, education, cultural, social and economic activities (Government of Ireland, 2020). In the context of the pandemic, people with mental illnesses can become susceptible to relapse, impaired function or an increase in symptoms, so it is crucial that there is priority to reduce such mental health consequences for vulnerable groups (Gavin et al., 2020; O’ Connor et al., 2021). Within work settings, guidance from the Health Service Executive (HSE, 2020b) limited occupational therapy face-to-face contact with service users to curb the spread of the virus. This “postponement” of the ability to practice in the usual manner and deliver a service in the community impelled occupational therapists to seek alternative methods to carry out their professional duties. In response to the coronavirus pandemic, the World Federation of Occupational Therapists (WFOT) issued a statement to highlight that:

Occupational therapists will be working with people to develop strategies to facilitate continued access to their occupations. These will include, but will not be limited to individual, family, community, social and environmental adaptation, mental health, assistive technology and telehealth (WFOT, 2020, p. 1).

With fundamental changes to new ways of working, it is necessary to evaluate their effectiveness in comparison with traditional methods (Drummond and Lannin, 2020). Now more than ever we need to look after ourselves, reflect on the present and ensure we can achieve our professional role in these unprecedented times (AOTI, 2020).

This research will explore the professional lived experiences of occupational therapists working in community and rehabilitation mental health settings during a period of the COVID-19 pandemic. The purpose of this study is to understand how public health restrictions have led occupational therapists to adapt their day-to-day work and how they deliver professional services in mental health settings.

Methods

Research design

This study aims to explore the lived experiences of occupational therapists working within community/rehabilitation mental health settings through a period of the COVID-19 pandemic. A phenomenological approach was used to emphasise the lived experience (Creswell, 2014). Phenomenological research is an approach in qualitative research that tries to discover new awareness through personal reflections that can offer rich revelations (Finlay, 2011). Interpretive phenomenology acknowledges that interpretation of experience is influenced by the researcher’s background and pre-understanding of phenomena (Finlay, 2011). Fundamentally social constructivist in nature (Creswell, 2013), knowledge generation in interpretive phenomenology is a product of interaction between the participant and researcher. The researcher worked as an occupational therapist in a mental health community setting during the pandemic. Therefore, acknowledges they will not “bracket out” their understandings of their professional role and experiences of COVID-19. It is used to inform analysis of the participants understanding of their professional experiences during COVID-19.

Participants

Participants were purposively recruited by email invitation using the occupational therapy service mailing list of the HSE mental health service in which the researcher is based. Inclusion criteria were occupational therapists working within community and rehabilitation mental health settings. Any staff who were not currently working in community/rehabilitation settings were excluded from the study. Ten occupational therapists responded within the timeframe of the recruitment period to take part in the study. Eight occupational therapists were based on community mental health teams and the remaining two were in rehabilitation mental health services. Ethical approval for this study was obtained from a Health Service Executive (HSE) ethics committee (06/2020).

Data collection

Although a pilot interview was not conducted, the interview schedule was modified through consultation with colleagues who did not meet the inclusion criteria. In-depth semi-structured interviews were conducted with each participant, which included questions related to their professional experiences and reflections gained from working during the COVID-19 pandemic. Research using phenomenology suggests that structured interviewing is generally not leveraged. Instead the interview is conversational based where questions can be produced from the dialogue (Richards and Morse, 2012). Interviews adopted a natural flow of conversation while guided by a semi-structured interview guide to provide prompts if needed (see semi-structured interview sample questions for sample prompt questions). Interviews were conducted from September to early October 2020. Nine of the interviews were carried out within the participants working environment, where social distance measures could be maintained in line with public health guidelines and one interview was conducted via teleconference. Written and verbal consent was obtained before interviews commenced.

Semi-structured interview sample questions:

Q1.

Can you tell me about your reaction when you first heard about COVID-19?

Q2.

Tell me how your day-to-day work experiences has changes since the onset of COVID-19.

Q3.

Can you describe any significant changes or adaptations in how to you carry out your occupational therapist role?

Q4.

Can you describe any changes in your physical environment and working with your other team colleagues?

Q5.

Would you like your pattern of work to return to the way it was pre-COVID?

Q6.

Do you think there is a need for change in the role of mental health occupational therapy going forward?

Data analysis

Analysis was guided by a reflexive thematic analysis (RTA) interpretative approach. RTA is an approach used to analyse qualitative data that highlights the researcher’s reflective and interpretive lens within the analytical process (Braun and Clarke, 2020). The researcher in this sense does not limit bias, but brings it to the forefront, with self-awareness that their own assumptions may impact on the analytical process and findings (Finlay, 2002; Mantzoukas, 2005). The researcher followed the format of thematic analysis’s six-phased method involving:

1. familiarising yourself with your data;

2. generating initial codes;

3. searching for themes;

4. reviewing themes;

5. defining themes; and

6. producing the report (Braun and Clarke, 2013).

Using Microsoft Word software, the researcher transcribed the recorded interviews and became familiarised with the data by re-listening and re-reading the transcripts to identify key experiences. Illustrative quotes and codes were highlighted and grouped onto separate documents. The coding process required the researcher to continuously reflect and query their interpretative assumptions of the data. Through the researcher’s reflexive approach, themes were produced by organising codes into core thematic sections that were interpreted from the data.

Trustworthiness

To establish trustworthiness in the study, peer debriefing and reflexivity was implemented throughout the study. The peer debriefing process involved discussing a sample of the research findings with an occupational therapy colleague. This allowed for questions for any assumptions made and helped limit the subjectiveness of data, enabling further analysis to take place, as recommended by Austin and Sutton (2014). Lincoln and Guba (1985) recommended that peer debriefing promotes an external check on the research process, which may increase credibility of interpretations against the raw data. To demonstrate dependability of this research, the process of implementing an audit trail and keeping records of the raw data, transcripts and field notes was applied. The approach to systemise, relate and cross reference data provided readers with evidence of decision rationale and choices made by the author (Nowell et al., 2017). Adopting reflexive analysis in the study allowed for in-depth self-evaluation, rich insight and its implementation as an analytic tool for evaluation. Through the continuous familiarisation of the narrative dialogue produced, the researcher reflected on their own experiences of working in a similar professional role and having direct experiences with COVID-19.

Findings

The purpose of this study was to understand how occupational therapists adapted their day-to-day work in mental health settings as a result of COVID-19 public health restrictions. Three themes were identified and include the following:

1. holding on to what we do;

2. technology: friend and foe; and

3. COVID as a catalyst to clarify the occupational therapy role.

The first theme highlights the desire to return to traditional methods of practice. Attitudes towards the transition of practice to online platforms are presented in the second theme, and the final theme focuses on some misconceptions and expectations of the profession. Each will be explored in more detail in the following sections.

Holding on to what we do

A principal change that was experienced with the onset of COVID-19 was the dramatic loss of access to educational and supportive community resources, which mental health occupational therapists would normally avail of day to day. With social distance measures in place, the usual face to face occupational therapy interventions carried out in community and home settings to support the development of independent living skills came to an abrupt halt. This sudden loss experienced brought challenges in the way occupational therapists could carry out their practice as reflected:

[…] working as an occupational therapist, the links you would have with a lot of the other community services and resources […] like educational or social groups […] there has been a pause on that (P4).

In addition, the occupational therapists highlighted the dramatic change experienced in having to adapt to a more generic and supportive role across the service rather than the traditional role of the profession. This impact is noted by participant one in the comment: “the fact that all had to stop very dramatically and move to more telephone support really limited the role of OT” (P1).

Occupational therapists reflected on the challenges in adapting to use telecommunication methods and the implications it had on practice:

It depends, sometimes people can be very forth coming…but then there are others that are a little hesitant, because they aren’t seeing me, or my face, they don’t know who they are talking to on the other side [initial interview]… That part is challenging if you are offering things over the phone (P3).

Despite this change from standard practice, the occupational therapists highlighted their willingness for adapting as they used such methods of communication to continue to be able to provide intervention in some form:

We found other ways of tracking progress and building rapport over the phone. For example, somebody was doing a lot of meaningful engagement through sewing […] the project that she’s working on […] we did a lot of goal setting […] she then emailed me photos and so we were able to discuss the finished project [….] even though it was over the phone, it was really nice to be able to see it adapt (P6).

Despite phone call adaptations, there was a strong sense of desire among the occupational therapists to return to traditional observational methods normally used in such mental health settings. This was illustrated by the following comment:

And I think its highlighted how, the face-to-face contact as well, that everything can’t be replaced with phone calls or over the internet… And the value of that […] the therapeutic rapport with someone in the room (P4).

The value of observational methods carried out in occupational therapy practice and how traditional methods can provide more information for the therapist was reflected on:

From an observational point of view, you'll notice some challenges and that insight might not necessarily be there. So you're kind of relying on exactly what the person is saying and you're missing the whole observational piece of assessment (P5).

During the phased societal reopening plan, the easing of some restrictive measures gradually allowed traditional methods such as meeting people in public community spaces to be reintroduced to practice, once social distance measures could be maintained. The occupational therapists welcomed the ability to be able to re-engage in elements of traditional methods:

Yeah, I think it was really positive. Like at the start. I was just so happy to actually leave the building again […] being able to kind of start doing activities and living skill sessions […] (P7).

They reflected on the valued opportunities to develop strategies to use the environment and demonstrate pragmatic clinical reasoning skills to promote re-engagement: “We [occupational therapists] are in a good position with our skills and knowledge of adapting and analysing activity and using the environment as a resource” (P6). One such example of using the environment despite public health restrictions was the development of a garden group where one participant shared how:

A community garden [service] approached us and said to set it up and we jumped at it […] this is a bit COVID proof […] it’s outdoor […] it’s a big huge community garden, we can all maintain social distance […] I am really happy to be able to offer that to a couple of my service users and they are really happy to come to it (P1).

Technology: friend and foe

With the sudden change in how practice could be delivered, the option of using technology such as video conferencing as a method of communication was highlighted by the participants. The respondents voiced a desire to explore technology platforms to use in their daily practice. With limited access to meet people face-to-face, the occupational therapists were motivated to implement such technology into their everyday practice: “I think it definitely makes me think about technology. Even like doing your appointment by video… thinking of how to use it for that” (P8).

However, the participants recalled their frustrations with such alternative methods of communication due to the lack of resources within the service as a whole:

The challenge with IT, limited IT equipment within the service [….] delays in getting access to certain IT tools like video conferencing […] periods of time where we didn’t have those things in place (P4).

Frustrations were further increased when promised technological advances did not come into effect, as one participant reflected “it seems like there's been a lot of efforts to try and get stuff like tablets or Wi-Fi, but it's all come to nothing so far” (P7). Even when video conferencing advances were made, respondents highlighted knowledge or skill gaps in using such technological resources:

I just feel the technology was not ready […] it wasn’t at all ready on time and there was a lot of confusion over it as to what software we are allowed to use (P1).

There was a regular use guidance policy for video conferencing to maintain licencing, however it was not systematically embedded as standard daily practice in the mental health setting which drove further dissatisfaction: “Advice around that seemed to change […] unless you’re going to use it [HSE Attend Anywhere video software] often, you can’t get it […] that was the message” (P7). The occupational therapists also reflected on the resource issues of even using such virtual platforms within their mental health standard practices, highlighting the discrepancy of how not all have access to such technological advances that are used in everyday life: “some of them [service users] don’t have smartphones […] it just really varies according to different people (P10)”.

The experiences voiced also reflected on the professional knowledge and the importance of considering a service user’s level of comfort when trialling such alternative technology methods in mental health settings:

I know going forward, we're probably going to have to embrace the whole telehealth side, but it is how the service users feel about it […] I think in the first instance they preferred the face-to-face where possible (P10).

The experiences reflect the possibilities and advantages that video conferencing could bring the service users:

I mean, it solves the problem of being able to look at someone and see if they look dishevelled or see their facial expressions […] at the same time, I think it’s a bit awkward […] people might not be as natural as they would be when you see them in person (P9).

As voiced in the first theme, participants reflected on the value of meeting people at face value: “The actual coming to the appointment is part of OT […] getting to an appointment. With some people with a video call… kind of takes away that part” (P8). The occupational therapists describe a requirement of more knowledge in using such technological methods in practice: “It’s highlighted the need for kind of more input with technology and you know even that skills-based training for people” (P5).

COVID as catalyst to clarify occupational therapy role

Due to the limited access of community resources and the increased use of remote working, the occupational therapists described spending more time with other team members due to the impact of COVID. There was a sense of working collaboratively: “[…] as a team we probably have ended up gelling together better […] more time together than we wouldn’t have had previously” (P10). The value of this was recognised by another participant: “[…] peer support is important for all the staff health and well-being and also for teamwork. We function better as a team when we get to know one another” (P1).

However increased interactions with colleagues brought some misunderstanding of aspects of the occupational therapist role to the fore, in particular the expectations of other team members within mental health settings: “There was a lot of trying to manage other people’s expectations and frustrations when they wanted a service user to access occupational therapy” (P6). This was despite the limited opportunities for occupational therapists to engage with service users in the community and the loss of community resources.

One participant describes this feeling of frustration with expectations and misconception of the role of occupational therapy in regards to people obtaining a job:

People losing jobs left, right and centre [….] they [team members] were almost expecting me to have a magic wand to get them a job […] and get around all the pandemic and just find this person a great job (P9).

With the difficulties imposed by the pandemic on employment and work roles, the participant highlighted an opportunity for others to understand the professional role of occupational therapy in this regard:

I suppose it opened up a conversation about what is an appropriate occupational therapy referral for? Somebody lost their job because of something […] or because of a mental health problem that they would struggle to find another one. It's brought up that kind of maybe misconception that some team members have about what occupational therapy is (P9).

The pandemic provided an opportunity to reflect on groupwork, in particular, the expectations of other team members on occupational therapists to run groups as one participant described: you just kind of get pushed in to “are you doing groups” (P2). The postponement of group work due to the public health restrictions presents an opportunity for occupational therapists themselves to reflect on the purpose of groups:

But we have taken it on […] running groups and maybe it’s time to let that go a bit and just work with people on their individual goals and then look for groups that are already happening in the community as opposed to running and becoming stagnated in a group ourselves. So it gives us an opportunity and also think how other professions view us (P2).

Discussion

The findings highlight the dramatic changes that were experienced by the occupational therapists due to the loss of community resources and face- to-face communication methods that would usually be core of their day-to-day practice. The first finding highlights an eagerness among the participants to return to their traditional methods of delivering services. It brings to the forefront the importance and value of community-based care and being able to observe and understand how people are functioning in their natural communities within mental health services. As voiced by interviewees, the pandemic had certainly led to a postponement of the traditional methods of practice they were accustomed to. They expressed their challenges in moving on from the “doing” in Ann Wilcock’s – doing, being, becoming and belonging (Wilcock, 2006). Their normal day- to-day professional role had been disrupted where they could not “do” their meaningful duties with service users in the pre-pandemic traditional fashion. There was an understanding that traditional methods must make room for new approaches and methodologies, such as using telehealth. Yet it is important to hold on to the traditional methods of providing quality of care that were in place before the crisis (Scott, 2020).

The therapists further described that positive feeling of re-“doing” when the aspects of the community began to reopen. As a profession, occupational therapy recognises the value of accessing and undertaking occupations. The findings demonstrate the committed and creative ways in which occupational therapists can adjust in such challenging times, for example exploring pragmatic ways to adapt community environments to support and encourage service users to re-engage in meaningful activities in a safe manner. Under the circumstances presented by public health restrictions, occupational therapists can use their core skills by developing and searching for creative strategies that can influence change and develop new ways of working within the profession (AOTI, 2020).

The second finding captures the respondent’s mixed feelings toward aspects of their occupational therapy practice migrating to more online platforms. The COVID-19 pandemic has certainly caused rapid changes in methods of providing health care. However, the occupational therapists in this study were frustrated about the lack of the service readiness in terms of providing such telehealth supports, especially the lack of access to technological infrastructure for the majority of the participants. Not only were the occupational therapists limited in access, service users had similar limitations. Access to smartphones, tablets, Wi-Fi, laptops and high-quality IT infrastructure is an issue in many service areas (O’ Connor et al., 2021). The lack of devices and internet access – resources that would be considered the norm for most people in society – reinforces the disadvantages that can be experienced by people with mental health needs. As Social Justice Ireland (2020) highlights, those on welfare dependent schemes due to illness or disability can experience higher levels of poverty. For telehealth services to work effectively there needs to be a priority given to address and develop high-quality digital health systems (Alvarez-Jimenez et al., 2014). The HSE has made advances in information technology infrastructure such as “Attend Anywhere” – “a web-based platform for patients with pre-arranged video consultation appointments” (HSE, 2020a). Yet, as this study has shown, both the service providers and service users potentially missed the opportunity to engage in such services initially due to the lack of IT resources. Going forward, there is a need for community mental health teams to be strengthened by the upscaling of technology within services that can provide people with severe mental health illnesses improved access to health services by such technological methods (O’ Connor et al., 2021; Kelly, 2020).

Possibly due to the lack of exposure to telehealth advances as outlined, the occupational therapists experienced a feeling of apprehensiveness in providing such technological methods in their practice. This shift from a traditional setting into a virtual one can have an impact on both the provider and service user, where both are transitioning into a new environment. Individuals that are well prepared can understand the context of their new “environment”, allowing them to engage more effectively (Gomez, 2020). Supporting transitions is an invaluable role within the profession. Therefore, if occupational therapy programmes/interventions are to transition into a virtual environment it will require the occupational therapist to strengthen their capabilities to deliver such services (Gomez, 2020). According to Cason and Cohn (2014):

Telehealth is an appropriate delivery model for occupational therapy services when in-person services are not possible, practical or optimal for delivering care and/or when service delivery via telehealth is mutually acceptable to the client and provider.

By having the necessary IT technological advances in place for both the service provider and service user, there may be a decrease in the apprehensiveness of their use. Additionally, occupational therapy could provide a role in the delivery of efficient digital health interventions in such mental health community settings. As much as there are possibilities to execute engagement in a virtual setting, the consensus from participants in this study was that it is optimum to engage in person. Changes to service delivery were triggered by a crisis situation, and therefore, careful consideration in adopting an evidence based approach is recommended (Gustafsson, 2020).

The role of occupational therapy has a history of often being poorly understood by members of the multidisciplinary team (Simpson et al., 2005). The third finding in this study echoed this for community/rehabilitative mental health settings. Occupational therapists working in mental health settings can often experience issues in maintaining their clear professional identity, where there can be a shift from specific professional roles towards more generic roles, which can undermine their sense of professional identity (Scanlan and Hazelton, 2019). Occupational therapy has had, for a long time, an established role in group work. However, the suspension of groups because of COVID-19 provided the profession with time to reflect on their purpose. Although groups have value, their role, especially if other disciplines consider them as a “one size fits all” approach, should be questioned. There may now be an opportunity for service users and the wider team to have a better understanding of individual needs and how groups may best meet them.

Conclusion and directions for further research

This research offered the opportunity for occupational therapists to share how their professional role has dramatically changed within mental health community and rehabilitation settings from the onset of the pandemic. The disruption experienced within their professional roles has highlighted a strong desire to return to traditional methods of practice in the community. It has also highlighted the importance of meeting others face to face and how observation methods are vital for occupational therapy practice within such mental health settings. A frustration was expressed in having potentially missed opportunities to fully explore alternative technological means of practice due to the lack of IT infrastructure and limited access within the mental health service during the pandemic. It has indicated the need to improve and upgrade technological resources across services. The findings also suggest how the pandemic has offered an opportunity for occupational therapists to address some misconceptions of their role which can impact on professional identity.

Despite the limitations in carrying out aspects of the occupational therapy role as a result of the pandemic, there is an opportunity for the profession to reflect on how services are provided going forward. Further research of occupational therapy practice at a later point or after the pandemic would be advisable to review how occupational therapy practice has evolved in the mental health field since carrying out this study.