SCOPING REVIEW

 

Occupational therapy practice in psychiatric day hospitals: A scoping review

 

 

July Masango^{I, II, IV,}; Daleen Casteleijn^II; Fasloen Adams^III; Tania Rauch van der Merwe^V

^IDepartment of Occupational Therapy, School of Therapeutic Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa. https://orcid.org/0000-0001-6982-003X
^IIDepartment of Occupational Therapy, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, 1 Bophelo Road, Gezina, Pretoria, South Africa. https://orcid.org/0000-0002-0611-8662
^IIIDivision of Occupational Therapy Department, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa. https://orcid.org/0000-0001-6742-3727
^IVPrivate practitioner, Masango Occupational therapy Services, Evexia Psychiatric Day Hospital, Mediclinic Midstream, Centurion, Pretoria
^VDepartment of Occupational Therapy, School of Therapeutic Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa. https://orcid.org/0000-0002-5751-2707

Correspondence

 

 

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ABSTRACT

INTRODUCTION: The aim of this scoping review was to explore whether clear guidelines for the practice of occupational therapists in psychiatric day hospitals exist, both locally and globally.
METHODOLOGY: Searches were conducted in January 2024; 38 articles were screened and 22 were identified for data extraction. Articles were imported onto Covidence software. Data charting was done, and data were exported into a Microsoft Excel sheet, where content analysis was performed based on the review's objectives. Synthesis of the results was done through discussion and reported according to the PRISMA for Scoping Reviews guidelines.
RESULTS: Thirty-eight articles were included but only 22 were relevant. Group therapy, individualised therapy, vocational and community workshops were identified as common modes of intervention in psychiatric day hospitals. Occupation-based activities are integral to intervention. However, there was no explicit definition regarding the role of occupational therapy and practice guidelines for psychiatric day hospitals.
CONCLUSION: The general scope of occupational therapy remains the same for overnight hospitals, day hospitals and community-based centres. It is mainly occupation-centred, function-orientated, and patient-centred. However, there remains ambiguity on specific practice principles and guidelines that clearly define the role of occupational therapists in day hospitals. There is a need for occupational therapy practice guidelines specific for psychiatric day hospitals.
IMPLICATIONS FOR PRACTICE
• The study provides valuable insights into the current knowledge and availability regarding the role and scope of practice for occupational therapy in the rapidly expanding psychiatric day hospital setting, emphasising areas for further development.
• Tangible evidence was identified on therapeutic principles, practice approaches, program content, and guidance for resource allocation in psychiatric day hospitals, which can be translated into practical guidelines.
• Ultimately, the results inform occupational therapy service delivery, solidify the profession's role in psychiatric care, and contribute towards National Health Insurance (NHI) policy development.

Keywords: evidence-based practice, mental health, scope of practice, principles and guidelines, day care centre, good health and well-being, therapeutic principles, practice approaches, programme content, resource allocation, good health and wellbeing

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INTRODUCTION

Mental health is an essential element to health and central to the well-being of individuals, and societies at large. As noted by the World Health Organization and highlighted in Prince et al.^1:1, "there is no health without mental health"^1,2. Globally, one in seven people has experienced and/or is living with a mental illness³. Generally, within healthcare, mental health interventions are notoriously low on budget and resource allocation⁴. This is especially so in low- and middle-income countries such as South Africa⁵. The South African healthcare system is socio-economically divided into public sector and private sector. The public healthcare sector, funded by the state, serves 84% of the South African population with 41% of its registered healthcare practitioners⁶. The private healthcare sector is a profit-driven healthcare system available to insured South Africans and caters for the remaining 16% of the population.

To address this unsustainable and unconstitutional divide, the South African government has embarked on a process of implementinga National Health Insurance (NHI)⁷.The NHI has now been signed into law and officially promulgated on the 15^th of May 2024. Treatment protocols that will be adopted by NHI need to be evidence-based. Central to the current and future healthcare systems in South Africa is the need for evidence-based practices. Both public and private healthcare systems require reputable evidence that justifies healthcare practices for remuneration, budget, and resource allocation. The South African healthcare system has also been burdened by the high prevalence of mental health care as reported in global literature; mental and behavioural disorders account for approximately 7.4% of the global burden of disease and are the leading cause of disability, accounting for 22.2% of the world's disability, yearly⁸. Thus, mental illnesses and disorders can be classified as a pandemic. This, however, has been greatly neglected, and should be considered in a new light⁸. It necessitates more accessible and innovative mental healthcare services, such as psychiatric day hospitals, to ensure continuity of care from inpatient treatment to outpatient treatment.

Day hospitals form part of primary healthcare, and a psychiatric day hospital is regarded as an effective, accessible and inexpensive way of meeting mental healthcare users' needs⁹. Although there is a lackof literature on day hospitals for mental health care, Heekeren et al.¹⁰ argue that day-hospital treatment closes the gap between outpatient care and hospital admission. In South Africa, a psychiatric day hospital is characterized by day to day attendance of therapy, where patients do not sleep over in the hospital. The benefit for mental healthcare users in such facilities is that they can receive comprehensive therapy without being institutionalised and isolated from their personal and social environments and the latter can be incorporated into treatment and intervention^10,11. Similar to an inpatient programme, the psychiatric day hospital is typically run by a multidisciplinary team comprising a psychiatrist, clinical psychologist, occupational therapist, professional nurse, social worker and dietician⁹.

Despite the involvement and featuring of occupational therapists in psychiatric day hospitals, evidence for occupational therapy programme development in psychiatric day hospitals in South Africa is not clear¹². Lack of published evidence that could guide practice is notoriously problematic in occupational therapy epistemology¹³. The increase and availability of evidence ensures the refinement of treatment techniques and the development of new therapeutic options¹³. Law et al.¹⁴ opine that evidence-based practice is important when discussing with other professionals; this attracts referrals. Moreover, the need for evidence is crucial when discussing healthcare spending and reimbursement¹³.

As more ground is slowly gained by occupational therapists in the psychiatric day hospitals, there is a need to clearly define the scope of practice and have guidelines that are evidence-based to inform the intervention programmes that are used. Evidence-based guidelines will enable occupational therapists to have a better and unified understanding of their scope of practice and be aware of their boundaries when working in a psychiatric day hospital. Furthermore, the guidelines may enable occupational therapists to avoid grey areas, scrutiny, criticism, and possible litigation, as they will have researched guidelines that are based on evidence, to use at the developing psychiatric day hospitals.

This scoping review explored whether clear guidelines for the practice of occupational therapists in psychiatric day hospitals exist, both locally and globally. The objectives were: to provide a focused overview of occupational therapy practice; and to identify and map content areas, principles and guidelines that need to be considered in the development of an occupational therapy programme that can be applied in a psychiatric day hospital.

 

METHOD

This scoping review was part of a larger PhD study that aimed at developing evidence-based occupational therapy guidelines for a programme that can be applied to a psychiatric day hospital in South Africa.

A preliminary search was conducted using Google Scholar, and no similar reviews were found. The Joanna Briggs Institute (JBI) scoping review framework was followed15. The stages of the scoping review are shown in Table I (below). Stage 1 entailed development of the scoping review protocol, which can be accessed through the corresponding author. An information specialist from the University of the Witwatersrand Health Sciences Library assisted with stage 2 (search strings and identification of literature), and also assisted with aspects of stage 3 (data searches). EndNote was used to collate full texts of articles. The relevant articles were uploaded into Covidence software for management and screening of selected articles (stage 4), and data extraction and charting (stage 5). A data extraction template was developed and used in Covidence. The extracted data were summarised and interpreted during stage 6. Data were exported from Covidence software into a customised Excel template, and manually analysed by the reviewers through content analysis.

 

 

Eligibility criteria

The eligibility criteria of the review entailed 1) global primary research that is published in English; 2) peer-reviewed journal articles; and 3) relevant grey literature, dating from 2000 to 2020. The first author started his PhD study in 2021 and had hoped to review papers of the then past 20 years, however, a further search was conducted up to March 2024. Some of the articles were traced from the references' lists and included as part of the reviewed papers.

The inclusion criteria were peer-reviewed publications in English and non-English and that described day hospitals with mental health services which included an occupational therapy programme. Adolescent, adult and older patients receiving general, group or individual occupational therapy were included. Studies were excluded if translation of the non-English papers was not available, if there were no detail about the occupational therapy programme, if there was only one contact session per week or month, if overnight stay were offered and if the programme was not delivered by an occupational therapist

Population

For this scoping review, Population, Context and Concept (PCC) were as follows: the population was Occupational therapy clinicians', the concept was Occupational therapy practice', and the context was 'psychiatric day hospitals and facilities', globally. Therefore, the scoping review question was: what global published evidence is available on occupational therapy interventions and practice in psychiatric day hospitals and facilities?

Search strategy

Medical Subject Headings (MeSh), a thesaurus that assists with creation and refining of search strings and facilitates the searching process, together with the Participant, Context, Concept were used to develop the following search strings: "Occupational Therapy" OR "day hospital" OR "Art Therapy" OR "community centres" AND "outpatients AND practice" AND "guidelines". The search was conducted and completed in six databases (Google Scholar, MEDLINE, Embase, PsychlNFO, CENTRAL and Scopus International). For additional articles, the reference lists of all included sources of evidence were screened. After the search, all identified articles (22 articles), were collated and uploaded into End Note¹⁶.

Selection process

The first five included articles were screened together by the two reviewers (first and second authors), to refine the selection criteria and enhance inter-rater reliability. As part of this process, reasons for excluding articles were inductively developed and captured on Covidence. Reviewers jointly met and embarked on thorough screening (Titles and Abstracts) of articles, which were subsequently moved either into full text screening or exclusion. Duplicates were removed. Conflicting votes were discussed between the two reviewers until consensus was reached. Using the same format and selection criteria, full text screening commenced between the reviewers.

Data extraction and analysis

In Covidence, the finally selected articles were identified, and were ready for data extraction. Data were extracted from the articles by the reviewers using a data extraction template. The template was developed collaboratively on Covidence software, which was informed by the review objectives. The Covidence data extraction template entailed: title of the article, author(s) names, year of publication, name of the journal, country of origin, study population, diagnostic criteria group, programme content (client factors and performance skills, occupations, roles, habits and routines as stated in the Occupational Therapy Practice Framework edition 4 (OTPF4)¹⁷, programme process¹⁷ (evaluation, intervention mode and content), outcomes (clinician and patient reported), theoretical approach, programme principles (layout, number of clients and frequency), facility and context of practice, practice detail, equipment and resources used. The template was not modified or revised; however, when the reviewers could not find suitable data under any category of the template, they used "none stated". When all data were extracted, quantitative extracted data were moved to Excel for analysis with SPSS. The two reviewers frequently met and, through collaborative discussion, refined the categories, identifying themes by consensus. Results of the review are presented in tables, and figures.

 

RESULTS

Study selection

A PRISMA 2020 flow diagram18, with information on the selected and included articles is shown as Figure I (below).

 

Figure I - Click to enlarge

Demographics of articles

A total of 38 papers were identified during the database search. Four duplicates were identified and removed, while 6 papers were excluded as they did not contain relevant information. However, 12 papers were manually hand-searched through perusal of the articles' reference lists, which were included. Among the total of 38 papers, four were duplicates and removed, which led to a total of 34 papers undergoing initial screening. Out of the 34 papers, 6 papers were found to be irrelevant and did not contain necessary data and were removed, which led to a total of 28 papers. Of the 28 papers that were carefully screened, a further 6 papers did not meet the inclusion criteria and were excluded, resulting in 22 papers undergoing full-text review (see Figure 1, page 3 and Table II, below).

Table II - Click to enlarge

 

Terminology used for psychiatric day hospital

The review highlighted that there are different terminologies used in different countries, with regard to the naming of the psychiatric day hospital. Generally, there seems to be a consistent wording around 'day centres for people with psychiatric disabilities' in Sweden^{24,26,30,37,40} and they mostly seem to ascribe to this terminology. . However, Bryant et al.³¹ use 'mental health day services' in the article that reported on services in the United Kingdom, whereas an article from Canada uses 'psychiatric day hospital', as reported by Mackenzie et al.³³. In South Africa, Engelbrecht²⁵ noted the use of 'mental health day treatment centres'.

Intervention mode

Eighteen articles out of 22 (82%) mentioned that occupational therapy practice at psychiatric day centres is predominantly provided through group therapy format. In some settings, the patients and/or group members in the programme were grouped according to their different levels of function. As elucidated in Table III (below), the wording of a group is rendered differently in different countries, namely: 'group therapy'^{20, 25, 34} and 'group'^{19,24,28, 32, 35, 37, 38, 40.} It is noted that there is also mention of individualised therapy in the UK^20,31, the US³⁶, Canada³⁴, Netherland³⁵ and Sweden²⁸ while Gibson³⁶ and Flokén²⁸ expressed a need to complement group therapy with individualised sessions.

 

 

In Italy, Maone et al.¹⁹ noted that a specific mode and service offering includes vocational training, or is referred to as 'vocational rehabilitation'; and by Larivière et al.³⁴ as 'vocational programmes'. These are consistent with the services that are offered in Sweden as work-orientated programmes, as noted by Eklund et al.²⁷ from Sweden. Workshops, as an intervention, are also one of the modes of intervention that were mentioned in the reviewed articles, as noted in Supplementary File 1: Programme content; programme process; programme principles and guidelines; programme format-overview of occupational therapy practice and intervention mode. However, in some places such as Sweden, there are specific work-orientated programmes and meeting-orientated places, workshops and community-based centres, and there are also large groups of people, who may be working independently on the same programme ^23,24,37.

Programme content

Maone et al.¹⁹ identified social skills, instrumental activities of daily living and leisure as among the areas of focus for the day hospital programme. Eight out of twenty-two (37%) articles identified social interaction and social networking as a theme. Work, productivity and transitioning employment are listed under occupations in the content of the programme^23,24,2S. Eklund et al.³⁷ note that, in Sweden, the daily schedule of the programme and the demands of the activities that the patients participate in, are adjusted according to their functional capacities and needs, to improve their occupational balance. In the UK, Bryant et al.³¹ assert that there is structuring of time by engaging the patients in meaningful occupations in the organised programme. This is consistent with what is taking place in Canada, as noted by Larivière et al.³⁴, that the programme is structured as part of their daily routine. Lundqvist et al.⁴⁰ noted that there is a need to find the right type and amount of occupation and the right variation between occupations in the programme.

The reviewed articles show that among the client factors and performance skills¹⁷, anxiety management and confidence, relaxation and planning skills have been addressed in the programmes ^{24,27,30,32,34,38}. In South Africa, common client factors and skills such as problem-solving, self-esteem, cognitive abilities and life skills were identified by Engelbrecht²⁵, which is consistent in Swedish programmes²³. Furthermore, motivation through contributing and being entrusted with responsibility, structuring time and setting goals, self-mastery and self-esteem, formulating goals, and strategy to reach goals, were also reported to be part of contents for the programme³⁷. Larivière et al³⁴ mentioned several client factors and performance skills from their study in Canada which include being optimistic and hopeful, controlling impulsive behaviours, having self-acceptance, insight, and self-awareness, implementing life skills, and coping with losses.

Occupational therapy process

Engelbrecht et al.²⁵ noted that among the important aspects of the occupational therapy process, is the assessment of patients' needs, which should be differentiated (i.e. based on the unique needs, abilities, deficiencies, and environment of each mental health care user), by performing a functional assessment. Eklund et al.³⁷ noted the use of interviews and questionnaires to assess patients. This is consistent with the work of Bryant et al.³¹, who reported that there must be a systematic approach to evaluation and the use of different methods such as questionnaires and interviews. Cognitive and functional evaluations are also being used as part of the occupational therapy assessment at a day hospital programme, as indicated by Larivière et al.³⁴ With all the different assessment methods, Argentzell et al.³⁸ identified observation as one of the useful assessment methods in the evaluation process.

In addition to assessment in the occupational therapy process, as noted in the OTPF⁴, there are also intervention and outcomes¹⁷. Different components and ingredients of intervention are reported herein, however there was not sufficient evidence to harvest on outcomes and tracking change in performance in the reviewed articles.

Programme guidelines and principles

The review found that the occupational therapy programme at a psychiatric day hospital should involve family members¹⁹ who play a critical role as a bridge between the hospital and the community³¹. Secondly, the programme should ensure that patients are engaged in social settings and actively participate in different occupations²³. There should be opportunities for emotional reactions in various settings to facilitate change; they should have occupational balance and structure in daily life and be mastering challenges and learning something new²³. The programme should facilitate a sense of belonging; it should cultivate motivation through contributing and being entrusted with responsibility; it should enable individuals to make choices and acknowledge their power and abilities to decide²³. In essence, the programme must be structured and presented at the 'just right challenge'²³. Hultqvist et al.²⁴ emphasised that programmes should address the needs of the users as that will ensure "autonomy and a feeling of social inclusion, which are concepts of importance for well-being and recovery"²⁴(p 205)

The emphasis of the programme should be on the "here and now"⁴¹ rather than on problems from the past. The rehabilitation that takes place at the day centre also needs to be individualised to account for individual differences within a general need to be actively engaged²⁸. Leufstadius et al.³⁰ and Tjörnstrand et al.²³ noted the importance of being together with others and belonging to a group to facilitate a process of recovery. Experiencing a high level of empowerment increased with a high level of perceived meaning in the domain of personal development³⁸. Argentzell et al.³⁸ noted that the programme should be client-centred and individually based. Eklund et al.³⁷ asserted that the programme should follow a set schedule, and this was as a comment from one of their participants, that doing things that were pleasurable were the strongest motives for coming to the day centre rehabilitation.

Programme format (structure, frequency, and length)

The format of the programme differs across different countries in terms of daily suggested operating times and frequency of group sessions in a day. The reviewed articles show that the occupational therapy programmes at the psychiatric day hospitals may take place every day, with daily attendance^19,37, every day of the week²³,or during workdays²⁴. Other reports included two to three days per week and that patients should be occupied throughout the day²⁵; four hours per week²³; 13 hours average per week³⁰; daily³⁷, with four occupational therapy services per day for at least three days a week³¹; four to five days per week, on average for eight weeks³⁴; one morning and/or one afternoon per week³⁵. Literature suggests that there are greater benefits from longer intervention, more intensive intervention,³⁶, all day each day of the week³⁸.

Theoretical approaches

Engelbrecht et al.²⁵ reported that the commonly used theoretical approaches in South Africa include family orientated approach; psychoeducation; and Person-Environment-Occupation (PEO) model. The psychoeducation programme was also reported by Flokén et al.²⁸, as commonly practiced in Sweden. In the UK, there is a structured approach that is followed³¹. Larivière et al.³⁴ assert that Canada subscribes to Cognitive Behavioural Therapy (CBT),Interdisciplinary approach, Fundamentals of Human Occupation and Psychodynamic approach. In the US, Gibson et al.³⁶ noted the Behavioural and/or Cognitive-Behavioural approaches, which are the basis of the intervention programme, whereas articles from Sweden also include the Activity-Based Rehabilitation approach³². From our results it is evident that a variety of theoretical approaches are used across different countries, reflecting regional preferences and practices, with common models including psychoeducation, cognitive-behavioural approaches, and occupation-based frameworks.

Despite one out of the 22 articles not reporting specific intervention content, all 22 (100%) articles report that there are occupation-based activities that are utilised in the occupational therapy programme, - client factors, performance skills and occupations -that form part of session content and focus of sessions, at the different psychiatric day hospitals and/or day centres. Table IV (page 7) elucidates the different activities, skills and occupations that were mentioned and captured from the articles. All articles agree that occupational therapy practice cannot be practiced without the use of activity, either as a means and/or as an end. Various occupations are also used such as cleaning, leisure and recreation, and work-like activities. There is also a consistent message around specific skills training and development and life skills, that are inherently facilitated as part of the programme. Therefore, by following the occupational therapy processes to select and analyse the necessary activities, patients can be meaningfully occupied and challenged to grow and increase their capacity for function.

 

DISCUSSION

This review synthesised information on occupational therapy practice in psychiatric day hospitals and mapped content areas, principles and guidelines that need to be considered in the development of an occupational therapy programme for a psychiatric day hospital. Different fragmented yet invaluable parts of the occupational therapy programme have been harvested from the reviewed articles to serve as a base for building an occupational therapy programme for a psychiatric day hospital in South Africa. Starting with the naming of the hospital setting, words such as psychiatric centres for people with mental health disabilities, mental health day centres, and psychiatric day hospital were used. Engelbrecht et al.²⁵ was the only study that reported on mental health day treatment centres for the South African context.

Regardless of the differences in the terminologies, there is a common and consistent theme of providing occupational therapy services at a 'day' setting and/or programme, and not at an 'overnight' setting. They come to the day hospital on a day-to-day basis and return to their community and homes to be with family, which allows the exercising of learnt skills from the programme. It is also noted that these types of day centres, and/or day hospitals, render services to people with mental illness, psychiatric illness and/or psychiatric disabilities, as noted in the reviewed articles. Although there is variation in the naming of the programme in different countries, there are certain elements and components that were found to be common and consistent.

The OTPF4¹⁷ highlights the importance of operationalising the occupational therapy process when delivering occupational therapy services to patients. The first step of the occupational therapy process is evaluation. The evaluation comprises the occupational profile and the analysis of occupational performance, which are integrated to guide and shape the intervention plan. Despite the different methods of evaluation mentioned in the reviewed articles, there is no mention of specific standardised and/or non-standardised assessment tools that can be used at the psychiatric day hospital. Evaluation is crucial at a psychiatric day hospital and should inform intervention planning. This is consistent with the scope of the occupational therapy profession in South Africa⁴², It is concerning that there is no mention of tools in the reviewed articles pertaining to the evaluation process. In South Africa, the Board of Occupational Therapy, Medical Orthotics, Prosthetics and Art Therapy in the Health Professions Council of South Africa (HPCSA) guides occupational therapists to a list of Formal Assessment Instruments relevant for the South African population⁴³. This list may be helpful in identifying relevant tools for assessment in day hospitals.

Furthermore, the evidence from this review shows that certain patterns and frequencies of patient care are consistent with current occupational therapy practices at existing overnight psychiatric hospitals in the South African context. Patients are seen every day during their admission duration, at any psychiatric hospital (overnight and/or day hospital). This may vary between two to three groups a day, which are presented by occupational therapists. Although the context of overnight hospitals may be different from psychiatric day hospitals, the occupational therapists' capacity and patients' potential to handle the reported number of sessions should be similar. Therefore, there should be a minimum of two occupational therapy group sessions, with a maximum of three occupational therapy group sessions, for the entire week (Monday until Friday), at a psychiatric day hospital.

Intervention (planning, implementation and review) follows the evaluation phase of the OTPF4¹⁷. Group therapy, individualised therapy, vocational, and community workshops were identified as common modes of intervention in psychiatric day hospitals. Occupation-based activities are integral in the context of intervention. Group therapy was found to be the leading and common mode of intervention among the different countries, although the terminology was different. 'Group'/'groups', and 'group therapy' were among the terms that were utilised in the articles. The groups are reported on vaguely with fewer specific details regarding the layout of the group and principles of group therapy and/or how the sessions would be carried out. Furthermore, it was not clearly specified and explicitly unpacked in terms of group protocol, group layout, principles, style of facilitation, group structure and the contents of the group process and/or a typical group treatment session, with specific principles for treatment. The articles do not stipulate the style of group facilitation that should be used. Therefore, there remains a noticeable gap pertaining to group therapy and its principles for a psychiatric day hospital, which would explicitly enable occupational therapists to define their scope and role in these settings.

It is noted that 'group' may mean different things to different people in different countries. Patients who are 'grouped' do not automatically equate to and/or suggest that there is an inherent group cohesion and that there is intentional group formation. It is not explicitly clear in the articles how many people or group members are seen per group. In the South African context, Fouché, an occupational therapy group intervention expert, alluded to the fact that for the group to be interactive, have a good dynamic, and be experiential in nature, there should be a maximum of 12 patients. If there are more than 12 patients in a group, there will be less interaction and fewer experiential elements, especially for patients who function at least on a passive participation level of creative ability⁴⁴. These kinds of groups are regarded as medium to intense and focus on developing insight into own behaviour, abstract thinking, problem solving, planning own recovery and applications of coping skills in own life⁴⁴. This is valid for psychiatric day hospitals because the assumption is that these kinds of patients have consolidated the fundamental functional aspects as they are voluntarily admitted, and they bring themselves to the psychiatric day hospitals⁴⁵. Therefore, it can be concluded that this should predominantly be the suitable population of patients for these settings.

In the South African context, closed groups are conducted in many overnight hospital settings and a few day hospitals, although they are not well reported. Meyer et al.⁴⁶ asserted that there is a strong correlation between closed groups and group dynamics, which hold power for healing. Although the reviewed articles report on the need for frequent contact sessions and the sense of belonging experienced by patients in the programme, they do not account for the consistency of group membership or how to develop a sense of group belonging. It is unclear whether the patients remain constantly, in the same group for the duration of admission at the psychiatric day hospital, or if they are placed in different groups every time and every day they attend the programme. Considering Yalom's principles on group therapy, there is power in constant group membership, which permits certain therapeutic factors (group cohesion, altruism, universality, impartation of information) to develop and ensure healing⁴⁷.

In the South African context, there is also an Interactive Group Model (IGM) which is commonly used with patients when facilitating groups, in mental health⁴⁴. This group model was strongly highlighted and reported by the participants (occupational therapists) in phase one of this research study; it is a group model that is used at the few existing psychiatric day hospitals in South Africa. The IGM model is based on Yalom's principles of group psychotherapy⁴⁷, and it employs engagement in activities and "here and now" interactions to promote healing in interpersonal relationships and social skills⁴⁴. It fosters group cohesion and encourages therapeutic elements such as the feeling of universality^44,47, which are crucial group principles for any groups-based programme^44,47 and setting such as a psychiatric day hospital.

Occupational therapy literature provides evidence of the different types of groups that occupational therapists are qualified to offer and facilitate¹²·⁴¹·⁴⁴. These include functional groups; activity groups; tasks groups; social groups (including role play); life skills groups; psychoeducation groups; socio-emotional groups and support groups^46,48,49 among others. The reviewed articles did not specify which types of groups should be presented at the psychiatric day hospitals. However, it was noted that there are various themes and topics that are facilitated with patients at the psychiatric day hospital settings, such as: occupations (leisure and recreation, self-care, work or prevocational skills, instrumental activities of daily living, domestic tasks, rest, and community living); performance patterns (structure and routine, structured time and structured programme); performance skills (life skills, anxiety management, and interpersonal skills); client factors (motivation, problem-solving, self-esteem, and cognitive abilities); and in consideration of patients' contexts (community, workshops and hospital contexts)¹⁷. Therefore, when considering these interventions from the review articles, although not all aspects of the occupational therapy domain are mentioned, the message is clear that the occupational therapy services at the psychiatric day hospitals should be deeply rooted and grounded on the OTPF⁴ principles.

The literature lacks comprehensive descriptions of the occupational therapy process and explicit guiding principles for psychiatric day hospitals. Despite this, the role of occupational therapists in mental health remains essential, as indicated by the time allocation for patient interaction and the frequency of contact. The review offers valuable insights into the structure and delivery of programs, particularly in terms of session frequency, duration, and format. It suggests that patients should be seen daily, both in the morning and afternoon, five days a week, for a total of four hours each day. In the South African context, this equates to two 90-minute group sessions and one 60-minute session, aligned with current Medical Scheme billing codes⁵⁰.

Evidence-based practice is essential in occupational therapy, particularly in mental health, where it not only guides interventions but also justifies the cost implications of services. Mental health services involve both direct costs, such as healthcare delivery, and indirect costs like lost income and employment opportunities⁵¹. Given that inpatient care in South Africa accounts for 86% of mental healthcare expenditure, with nearly half of the total spending at the psychiatric hospital level⁶, the cost-effectiveness of day hospitals becomes critical. Frequent readmissions, extended hospital stays, and the need for specialized treatments drive these high costs, especially when physical comorbidities are present⁵². This underscores the value of occupational therapy in day hospitals as part of an integrated care model. By offering early intervention and preventive strategies, day hospitals can reduce hospitalisations, improve patient outcomes, and lower healthcare costs. Occupational therapy, with its focus on functional recovery, coping strategies, and life skills development, plays a key role in this outpatient approach⁵³, providing a cost-effective solution that addresses both mental and physical health needs. Therefore, evidence-based occupational therapy in day hospitals not only enhances patient outcomes but also helps alleviate the financial burden on the healthcare system by reducing costly hospital readmissions and resource use.

The reviewed articles highlight key foundational principles of occupational therapy, particularly the focus on restoring function and fostering a sense of meaning and purpose through active engagement in meaningful occupations⁵⁴. These principles are rooted in the belief that humans are inherently occupational beings, and that health and well-being are supported through participation in purposeful activities⁵⁵⁵⁶. However, despite the strong theoretical foundation, the review revealed a significant gap: there are no clear, evidence-based guidelines or comprehensive programs specifically tailored for occupational therapy in psychiatric day hospitals. This gap underscores the need for further research and development to support effective occupational therapy practices in these settings.

 

CONCLUSION

This scoping review explored and examined the practice of occupational therapists in psychiatric day hospitals. Occupational therapists have a special role to play in mental health, particularly in psychiatric day hospitals. Their language and terminologies may be different depending on the country, but the scope of work and core goals for therapy remain the same. The occupational therapy practice framework domain and process emerged alongside certain theories, frames of reference, models, and approaches, which affirm that quality service and evidence-based practice are crucial for occupational therapists.

Group therapy emerged as the main mode of intervention at the psychiatric day hospitals, although this was not vigorously unpacked in detail, for example, in terms of group structure, format and principles. The review findings reveal that there is a noticeable gap, and lack of a clearly defined occupational therapy programme for a psychiatric day hospital with specific guiding principles, despite the reported components and scope-specific related ingredients. Nevertheless, this scoping review provided a basis to consider when developing evidence-based occupational therapy guidelines for a psychiatric day hospital.

Strengths and limitations

Methodological rigour and a collaborative team approach were the key strengths of this scoping review. The protocol was developed using the latest evidence in scoping review methodology from the Joanna Briggs Institution (JBI)¹⁵, and the PRISMA-ScR guidelines were used to report the findings⁵⁷. Regular discussions and peer debriefing with co-authors have enhanced credibility and ensured the trustworthiness of the study. The results of the review informed the development of evidence-based practice guidelines for occupational therapists working in psychiatric day hospitals in South Africa.

A limitation of this scoping review was that non-English sources were excluded. The authors recognise the fact that this may have excluded some evidence from countries similar in context to South Africa. It is noted that there was a lack of published articles and evidence on the occupational therapy practice in psychiatric day hospitals, globally. Although this was one of the limitations, it also dictates the need for further research on psychiatric day hospitals.

Acknowledgements and conflict of interest declarations

The University of the Witwatersrand Medical School Librarian, Mr Nakedi Mphago is acknowledged for his assistance during the search and data charting processes. All authors declare that there is no conflict of interest to report in this project.

Author contributions

Mr July Masango was involved in the scoping review design, methodology, data collection and analysis, results and discussion, and finalisation of the scoping review research proposal, including as part of the conceptualisation of an overall PhD research proposal; critical review and writing up the article. Prof. Daleen Casteleijn assisted with writing up of the study, methodology, results and discussion, review of final drafts. Dr Fasloen Adams was involved in scoping review design in all drafts, and finalisation of the scoping review research proposal, including as part of the conceptualisation of an overall PhD research proposal; critical review and input to the writing of drafts and text to completion. Dr. Tania Rauch van der Merwe was involved in scoping review design in all drafts, and finalisation of the scoping review research proposal, including as part of the conceptualisation of an overall PhD research proposal; critical review and input to the writing of drafts and text to completion.

 

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Correspondence:
July Masango
Email: julymasango76@gmail.com

Submitted: 3 August 2024
Reviewed: 12 August 2024
Revised: 30 September 2024
Accepted: 1 October 2024

 

 

* PhD occupational therapy candidate at Department of Occupational Therapy, School of Therapeutic Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa at the time of study
Editor: Hester van Biljon https://orcid.org/0000-0003-4433-6457
Data Availability: Upon reasonable request from corresponding author
Funding: No funding was received for this research