Impact case study database

Occupational Therapists (OTs) are increasingly important to public health and wellbeing, and the role features on the UK’s ‘Shortage Occupation List’, a UK government list of occupations for which there are not enough resident workers to fill vacancies (S9). Within this context, the research has prompted changes to nationally recognised and accredited care practice and clinical guidelines, and stimulated investments in improving NHS services. Patients have directly benefitted from applying the research in practice, and training standards have been influenced internationally. Finally, the research has raised awareness about the unseen side of occupations, catalysing debate, dialogue and action amongst practitioners.

Impact 1: Changes to care practice and associated clinical guidelines for the Royal College of Occupational Therapists for OTs working in secure settings.

Between 2013 and 2018, Morris was a National Executive Committee Member (Research & Development Officer) of the Royal College of Occupational Therapists (RCOT) ‘Specialist Section for Mental Health’. Her work with the ‘Forensic Forum’ resulted in her research being provided as evidence to the RCOT’s Guideline Development Review Group. This group cited Morris’ research and evidence base as sufficiently robust empirical evidence for two of the ‘recommendations’ in a NICE-accredited RCOT Practice Guideline (2017, 2^nd edition) entitled ‘Occupational therapists use of occupation-focused practice in secure hospitals’. The two recommendations are that “occupational therapists facilitate meaningful occupational choices for patients” (No. 6) and that “occupational therapists consider the impact of the environment on quality of life and occupational engagement” (No. 17). These two recommendations feature in the following guidelines and tools for practitioners:

• The main guideline and evidence base (S1) which allows practitioners to understand the underpinning research and context for the recommendations, as well as background on process; evidencing how the research impacted on the updating of this clinical health guideline.

• ‘Quick reference and implementation guide’ (S2), which is practitioner-focused with key tips for implementation: “an easily accessible reminder of the recommendations for intervention and implementation”. As a condition of RCOT accreditation, practitioners would be expected to adopt this in their practice.

• ‘Secure hospitals and CPD session PowerPoint’ (S3), which has an overall aim to “support a continuing professional development session to explore the practice guideline”; contributing to CPD in secure units, and influencing training standards and expectation as expected and needing to be evidenced through RCOT accreditation.

• ‘Audit Form’ (S4) which is used and completed by practitioners to assist evaluation and evidence gathering of their ‘current practice’, with an opportunity to specify actions in response, including identifying a responsible individual and time frame for implementation.

The research-informed practice guideline and suite of resources is an essential evidence-based resource for OTs and practitioners working in secure hospitals within the UK, and the audit tool allows current practice to be evaluated and new practice to be adopted. NICE-accreditation means that it is the most trusted source of guidance for healthcare professionals, and the RCOT utilise the guideline in promoting OT standards in all secure mental health settings. The guideline is therefore also used to inform patients, together with other health professionals, managers and commissioners working in secure mental health services

In terms of scale, the guideline and resources could potentially influence the care and treatment provided to individuals representing the 7719 inpatient beds in secure mental health units in England (NHS Commissioning Board, 2013). On the basis of approximately one Occupational Therapist for 12 beds, there is an expectation that around 550-650 OTs are using the practice guidelines as condition of their accreditation. The guidelines are also produced in a patient friendly version to engage patients in developing the services on offer in any unit; increasing patient involvement in shaping and implementing their care and treatment.

Impact 2: Improved outcomes for ~100 patients at a mental health and disabilities trust

The research has been directly utilised at the Secure Care Unit for Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, and has had influence beyond the OT profession. The Trust’s secure care unit has around 24 Occupational Therapists covering Prison, Mental health, Learning Disability and Personality Disorder in Medium Secure, Low Secure and Community pathways, and approximately 100 patients in their care.

The Trust’s Associate Director of Allied Health Professionals, Secure Care, and Professional Lead Occupational Therapist, gave evidence of how Morris’ research on occupations changing over time has improved the patient experience and increased patient involvement in shaping the Unit’s practice and policy (S5): “[The research] has led us to be more project orientated in our approach to 1:1s and group work, with no group session running longer than 8 weeks without review. For example, the medium secure mental health service run an events group which organises events on behalf of the clinic for world mental health day, black history month etc; with the therapeutic aims of role development and contributing to the immediate environment/community.”

The Associate Director (S5) also reported that Morris’ research on the value and consequences of occupational choices has influenced practitioners to “become more explicit in [their] therapeutic goals and care plans in order to support service users to link their occupational routines, choices, wants and needs to their overall recovery, transition into the community and sustaining their pro-social occupations when discharged from hospital.”

The research also prompted this Trust to take decisions on moving to a psycho-occupational model, and on staffing. This includes creating one band 7 Advanced Occupational Therapist and two band 6 Clinical Specialist Occupational Therapists. This has increased the amount of occupational therapy support available to patients. Links between this development and the research are elucidated by S5: “I would, in part, credit the practice guidelines as a key contributor to the trend because it has given us a clear evidence base to articulate our contribution and reasoning.” More widely within this Trust, the research-informed guidelines have raised awareness about the importance of OT within these contexts, facilitating a “broader recognition of the need for occupational therapy within the secure care population.”

Impact 3: Engagement with patients and other health care professionals to establish a local framework which improves care, and is used by practitioners.

For occupational therapy in secure settings, there is a careful balancing act between the needs of society, the responsibility of the service and the preferences of the individual they are engaging in assessment and treatment (R3). The Secure and Specialist Learning Disability Division of the Mersey Care NHS Foundation Trust serves 370 patients, and the Lead Occupational Therapist (S6) has stated how R3 and R4 have supported the Division to identify methods to 1) engage patients in meaningful occupation whilst in long term seclusion environments, and 2) to assess treatment needs or effective interventions with a cohort of patients detained in forensic services.

In an effort to improve Trust services, the Lead OT (S6) is developing a locally co-produced framework to support OTs and other disciplines which will be used to support progress on care pathways for patients in forensic mental health services. Through a series of workshops, the framework enabled patient involvement in shaping and implementing the division’s policy and practice, developed in collaboration with 12 service users as well as 30 staff members from different health care professional disciplines in the high secure environment. R3 and the conceptual framework “informed the development of this long term segregation focused project” which “has resulted in clinicians proactively reflecting and thinking critically re their practice in terms of what constitutes active engagement, factors that may influences participation in a positive/negative manner and methods in order to develop their understanding of how service users experience participation” . This framework has initially been implemented in two high secure pilot wards, impacting six patients and being used by 12 clinicians within the multidisciplinary teams across both wards (S6).

Impact 4: Influencing OT education in Denmark and Sweden

A Professor in Occupational Therapy and Occupational Science at the University of Southern Denmark (also Associate Professor at the Karolinska Institute, Sweden, ranked by Times Higher amongst medical Universities as 38^th in world and 10^th in Europe) states how: “[the] framework is an important step forward in our knowledge building” (S7) . This is in particular relation to training standards for occupational therapists: “I use it very much in my teaching on all levels, bachelor, master and PhD-courses”. The research has therefore influenced educational programmes at two institutions in Denmark and Sweden, prompting a new focus on the qualities of experience in occupation, rather than specific areas of occupation.

Impact 5: Increased understanding and awareness of occupational meaning

Finally, the research was featured on Episode 49 of the ‘OCCUPIED’ Podcast produced by Brock Cook, a lecturer at James Cook University in Australia and previously an occupational therapy Practitioner (prior to May 2019). His podcast has been running since 2013, and in Episode 49 ‘Meaning and Occupational Engagement’ (S8), Brock discusses how Morris’ research can contribute to our understanding about occupational meaning, and how this meaning needs to originate from the individual patient, rather exclusively from the practitioner. It has been downloaded over 1800 times since September 2019. The ‘OCCUPIED’ Podcast is evidence of enhanced public awareness about the ‘meaning’ of occupation: “Meaning is arguably the most important aspect of a person’s occupation. Yet, in my experience, it is also one of the most neglected or least understood areas of our practice.”