Exploring the impact and implementation of occupation-based groups in inpatient rehabilitation.

Abstract

This thesis explores the use of occupation-based groups in adult inpatient rehabilitation. When people are admitted to hospital following a medical event, this can often be associated with a decline in function and reduced ability to carry out their everyday activities, or occupations. Occupational therapists working in the hospital setting use a range of interventions to support their patients’ recovery and return to performing, participating, and engaging in their valued occupations. One of these is occupation-based interventions. Occupation-based interventions use repetitive practice of part or whole of an intended occupation as a therapeutic agent of change. Occupation-based groups involve the practice of occupations using semi-supervised practice. There is a growing body of research on the use of occupation-based groups in the inpatient rehabilitation setting. Despite the therapeutic benefits of occupation being well understood theoretically within the profession and occupation-based interventions aligning with the profession’s Contemporary Paradigm, no previous research has critically reviewed the available evidence for occupation-based interventions (delivered both individually and in a group). Existing research is limited by underpowered and uncontrolled studies with limited exploration of the factors influencing the impact and implementation of these interventions. It is also unclear whether delivering occupation-based interventions in a group offers comparable outcomes to delivering them individually (usual care).

Four studies were developed and undertaken where findings from one study were used to shape and direct the next. Firstly, a systematic review of occupation-based interventions delivered in the hospital setting was undertaken to critically review the available evidence for this intervention. Thirty-three articles (26 experimental, five non-experimental, and two mixed methods) with n=1646 participants were included in the narrative synthesis. Following this, a Nominal Group Technique Design was used to develop an occupation-based group intervention for implementation across geriatric, general, and neurological rehabilitation wards at the University of Canberra Hospital. Several sources of knowledge were considered to inform the development of an evidence-based intervention. These included the available research evidence informed by the systematic review completed in study one, the experiential expertise of patients (n=4) as consumers of healthcare, the clinical expertise of occupational therapists (n=4), and the contextual experience of other key stakeholders including management and other allied health professionals (n=4) providing site-specific insights and considerations to help inform the design of the intervention. Finally, two studies were conducted concurrently, examining the outcomes, impact, and implementation of the occupation-based group intervention developed in study two. A quasi-experimental pre post design with non-equivalent control group and mixed methods process evaluation were conducted with 21 participants (n=11 control group, n=10 intervention group). The quasi-experimental study compared goal attainment and occupational performance and satisfaction outcomes for a cohort of patients either receiving occupation-based interventions delivered individually (control) or in a group (intervention). The process evaluation explored the context, mechanisms of impact, outcomes, and implementation of the occupation-based group intervention.

Findings from study one revealed good evidence for occupation-based interventions in the inpatient rehabilitation setting with research in acute and mental health settings scarcer. Qualitative findings exploring both patient and clinician perspectives enhanced understanding of the potential benefits of occupation-based interventions in this review. These included improving self-efficacy and independence to discharge home and increasing motivation for therapy. When occupation-based interventions were delivered in a group, additional benefits including connecting with co-participants through shared experiences and facilitating peerbased learning were identified. Heterogeneity and methodological weaknesses across the included studies in the review limited the overall conclusions that could be made regarding the impact of occupation-based interventions. In study two, an occupation-based group intervention using patient-centred, goal-directed practice of domestic-based occupations was developed. When the occupation-based group intervention was piloted across three inpatient rehabilitation wards using a quasi-experimental pre post design with non-equivalent control group, feasibility for a larger scale clinical trial was confirmed with initial outcomes suggesting that occupation based groups offer comparable outcomes to occupation-based interventions delivered individually. Mixed model analysis found a significant change over time for all participants on COPM Performance (F = 83.77, p = <0.001), COPM satisfaction (F = 59.60, p = <0.001), and GAS (F = 101.80, p = <0.001) scores. There were no significant differences between the groups for COPM performance (F = 1.52, p = 0.23), COPM satisfaction (F = 3.16, p = 0.09), or GAS (F = 3.35, p = 0.08). There were no significant time by group effects for COPM performance (F = 1.65, p = 0.21), satisfaction (F = .46, p = 0.51) or GAS (F = 1.02, p = 0.33). Further examination of the occupation-based group intervention using a process evaluation uncovered additional insights and considerations for using occupation-based groups. Challenges to implementation and participation in the intervention included fluctuations in patient eligibility, managing competing ward demands and staffing, equipment and environmental resources. Despite these challenges, qualitative exploration of the impact of the occupation-based group intervention with patients and clinicians highlighted the positive impact on the patient experience, patient outcomes, and perceived resource efficiency.

The overall findings from these studies contribute to the growing evidence for occupation-based groups in inpatient rehabilitation. Further research is necessary to confirm whether occupation based group interventions offer comparable outcomes to occupation-based interventions delivered individually. A larger scale clinical trial (i.e. multisite randomised controlled trial) is recommended. Furthermore, future research endeavours should also focus on cost effectiveness analysis and establishing the effect of targeted, site-specific, implementation strategies to support the sustainable implementation of occupation-based groups into practice. It is recommended that patients, clinicians and other key stakeholders are involved in the design, implementation, and evaluation of future occupation-based groups.

Date of Award	2025
Original language	English
Supervisor	Stephen ISBEL (Supervisor), Claire PEARCE (Supervisor) & Diane GIBSON (Supervisor)