‘Safe as possible or as happy and well as possible,because they might not be the same thing.’ Occupational therapy perspectives of intermediate care risks during COVID-19

Abstract

Introduction:

Intermediate care involves managing risk and employing positive risk-taking. The COVID-19 pandemic introduced new risks; however, little is known about how this impacted services from the perspectives of those providing and receiving occupational therapy.

Method:

Semi-structured interviews were conducted with people who had experience of intermediate care during and following the pandemic, including occupational therapy practitioners (at novice, semi-expert and expert levels of experience), patients and carers. Themes in the data were developed using Framework analysis.

Results:

Fourteen participants were interviewed: nine occupational therapists (six experts, two semi-experts, and one novice), two students of occupational therapy (novices) and three members of the public (two carers and one patient). Six themes were developed: (1) Intermediate care perspectives; (2) COVID-19 impact; (3) Disruptive factors, difficulties, and dilemmas; (4) Safety creation and improvements; (5) Facilitators and benefits of occupational therapy; and (6) Personal impact. Positive risk-taking for all participants was impacted by problematic organisational and cross-boundary systems, role blurring, blame culture and, for novices, heterogeneous/unstructured ways of assessing risk.

Conclusion:

Positive risk-taking is challenging for practitioners, patients and carers/families, sometimes involving dilemmas and conflictive perspectives; and COVID-19 created additional complexity. Occupational therapy risk management could be better utilised in hospitals to support positive risk-taking in intermediate care.

Introduction

The first case of the novel acute respiratory syndrome COVID-19 was reported in December 2019 in Wuhan, China. The first case recorded in the UK was in January 2020 (World Health Organization [WHO], 2020a), with the global COVID-19 pandemic being announced on 11^th March 2020 (WHO, 2020b). This resulted in global efforts by governments to stop/slow the spread of COVID-19 through enforcing ‘stay-at-home orders’ (i.e. ‘lockdowns’); with the UK announcing its lockdown measures on 23 March 2020 (Cabinet Office, 2020). These were intended to protect people from catching COVID-19 and to manage increases in demand for hospital care and resources (Murray et al., 2024). Lockdowns in the UK included restrictions on people’s movements, requiring people to stay indoors with the exception of essential journeys, limited daily outdoor exercise, and food shopping, with the exception of key workers (including health professionals) (Murray et al., 2023). Family visiting was only permitted under specific circumstances, including caring relationships (being in a ‘bubble’). Hospital visitation was restricted, with visits being conducted via video calls rather than in-person. For patients, families and health and social care workers situated within intermediate care, this added challenges on top of an already complex situation.

There is a paucity of literature that has investigated practitioner’s perspectives on risk and positive risk-taking in occupational therapy intermediate care. Despite being used within Occupational Therapy practice and guidelines (College of Occupational Therapists, 2010; Royal College of Occupational Therapists (RCOT), 2018) there is no consistent definition of positive risk-taking (Field et al., 2024). In their review of positive risk-taking definitions within adult social care, Field et al. (2024) identified that there were three key concepts within practice-policy documents’ definitions and/or uses of positive risk-taking:

• (1) That positive risk-taking is a process, which identifies potential risks to a person and then weighs these risks against the potential benefits to the person.

• (2) That positive risk-taking aims to enable a person to exercise their choice and autonomy, including through setting goals.

• (3) That a plan and actions must be developed to mitigate the potential negative aspects of a risk taken.

As there is no unified definition at this time, we adopt the definition outlined by RCOT (2018): ‘Positive risk is when taking a risk achieves positive outcomes; taking a risk in order to benefit. The term ‘positive’ is not about the risk, but about the outcome of taking a risk’ (p. 3; Adapted from Morgan and Williamson, 2014: 5). We also add to this definition that positive risk-taking is a process of weighing potential positive and negative outcomes with the person, who has autonomy in the decision-making process (Field et al., 2024).

Intermediate care focuses on preventing unnecessary admission to hospital and supporting patients who are discharged (National Institute for Health and Care Excellence (NICE), 2017). Most people receiving intermediate care often have frailty and multiple long-term conditions, such as chronic obstructive pulmonary disease, heart disease and diabetes. Intermediate care is a non-means-tested, time-limited (short-term) support service, normally to a maximum of 6 weeks. In 2018, the average patient age in the United Kingdom was 79 years and older across all types of intermediate care (Fraser et al., 2024). Step-down intermediate care models support the National Health Service (NHS) discharge to assess (D2A) pathways with services that are focused on home-based, bed-based or reablement provision to rehabilitate, re-able and help people recover. Intermediate care also includes crisis response, which is a step-up model that focuses on providing an urgent and rapid assessment in someone’s own home in response to a crisis (e.g. a fall, infection, or exacerbation of an existing condition) to mitigate hospitalisation (NHS England, 2023).

Occupational therapists work in acute hospital settings, social care, and in community settings – including intermediate care – to adapt surroundings and tasks to help people live better with disabilities and recover from injuries or illnesses. Occupational therapy is integral to helping to keep people safe and for those who require support to avoid a hospital admission to bridge the gap between hospital and home. Operating within a multidisciplinary team, occupational therapists focus on hospital throughput to mitigate service pressure and operate D2A objectives for those that are clinically optimised; that being, the point at which care and assessment can be safely continued in a non-acute setting (NHS England, 2023).

One aspect of managing hospital throughput and safely transitioning care into non-acute settings is through effective assessment and management of risk. Risk management is a critical component of intermediate care provision, with the National Institute for Health and Care Excellence (NICE) policy mandating the completion and documentation of a risk plan with those accessing the service (and their family and carers, as appropriate) as part of the intermediate care planning process. The risk plan should include strategies to manage risk, for example positive risk-taking, and should consider the implications of risk-taking for the person and for those it might impact (NICE, 2017).

Positive risk-taking involves mitigating risk whilst also promoting beneficial and appropriate risk-taking as part of occupational therapy intervention. Interventions may well involve dilemmas that require, for example, choosing between options of safety versus autonomy, or managing the tension that promoting risk-taking to support re-ablement will also increase the potential likelihood of an accident. So, in some cases, after surgery, a person may wish to not be physically active, remaining in a lying or seated position for extended periods. By engaging in activity, their health outcomes would most likely be better, but they perceive the activity as a risk. To promote positive risk-taking, a practitioner would work with the person to discuss the benefits of the perceived risk (in this example, physical activity) and the potential unforeseen risks to other choices (e.g. remaining seated for long periods), to develop an agreed plan, respecting the person’s concerns whilst emphasising the importance of taking a perceived risk for their recovery. These two ways of acting – choosing between safety or autonomy and promoting risk-taking – may appear similar. However, in the first, a practitioner must consider whether a person’s decisions or wants in a situation is most-likely going to harm the person’s safety, and in such a case, the practitioner would need to weigh whether following the person’s wishes (which may be a risk) would actually lead to a harmful outcome. The best option may be to err on the side of safety rather than taking action, working with the person to achieve this in a way that they are happy with, without removing their autonomy. In the second, promoting risk-taking, the person may be wary of engaging in an action or activity as they are fearful of a negative outcome; but, in not taking action, they are actually increasing their risk of a poorer health outcome.

Making positive risk-taking decisions requires weighing up the potential benefits and harms of exercising one choice of action over another (Morgan, 2004). Clinical reasoning is a complex skill which is multifaceted (Diamond-Fox and Bone, 2021) and much of the learning and skill development associated with this approach is carried out unconsciously and gained during practical experience rather than theoretically (Round, 2000). A full discussion on the cognitive structures underpinning the development of clinical reasoning (e.g. schema, heuristics, biases) is outwith the scope of the current paper, but the variation in how people use information to assess risk within their clinical reasoning is an important factor to consider in relation to the current study’s findings. There are common risks which require consideration within intermediate care (e.g. falls, pressure care, loneliness, nutritional care), and assessing these risks using a positive risk-taking lens should be considered in a manner which incorporates risk awareness and identification into the clinical reasoning process, with the overarching aim of improving safety and outcomes (Newman et al., 2022b). The aforementioned examples (i.e. falls, pressure care, loneliness, nutritional care) are commonly taught in both occupational therapy formal education and in clinical practice, and are well represented within the evidence base. For example, when considering risk of falls, there are myriad validated tools which can be applied within clinical practice and within formal teaching: in their systematic review of validated fall risk assessment tools for use with older adults, Ruggieri et al. (2018) identified 33 falls risk assessment tools which were validated at an international level. Despite there being a large sample of validated falls risk assessment tools identified within this study, the authors specified that ‘fall risk assessments have demonstrated greater utility when combined with sound clinical judgment’ (Ruggieri et al., 2018: 332). However, the ways in which clinical reasoning is taught as a skill vary across different education and practice-placement providers. In some formal education programmes, decision making as a skill may be taught from the practitioner/clinical perspective, whilst in others it may be taught from the psychology of decision-making perspective (‘decision science’); and students may therefore be taught either a more practice-focused or a more theory-focused approach. In all formal occupational therapy education, however, students will hone their clinical reasoning skills through practice placement experiences. This variation in approach to teaching clinical reasoning is important to note, as with variation in teaching and learning practices, we can only then expect there to be variation in clinical reasoning post-qualification.

Moreover, barriers to positive risk-taking, such as, ‘Limited Capacity’ of the patient to understand and carry out recommendations, and ‘No Support’ (from family or carers) have been shown to reduce the likelihood to recommend a home discharge at different experience levels (novice, semi-expert, and expert). As highlighted earlier in this paper and in previous work (Newman et al., 2023), patients having decision-making capacity is a prerequisite for understanding the implications associated with discharge-related decisions and weighing one choice of action versus another. Practitioners must also be able to understand and explain the implications and the choices available in a way that is understandable to patients to facilitate shared decision-making. Limitations in a person’s ability to do this can significantly impact the process of positive risk-taking for people using services and practitioners. Similarly, having ‘No Support’ from family or carers to make and implement decisions in relation to discharge are also likely to impact. These barriers have been found to have the greatest impact on novice occupational therapists (Newman et al., 2022a). Furthermore, ‘blame culture’ – where it is perceived by those within an organisation that they will be blamed for mistakes and errors – is also likely to inhibit practitioners’ willingness to facilitate creative solutions and thus can impede positive risk-taking. This has been found to impact semi-expert occupational therapists the most (Newman et al., 2022a). As highlighted, these are potential barriers to engaging in positive risk-taking for practitioners, having potential impacts on, for example, home discharge decisions, engaging in shared decision-making fully, and in willingness to facilitate creative solutions. It is also essential to highlight that this also has potential impact for the person at the heart of the decisions being made. Should there be a risk-aversive approach based on the aforementioned barriers, then the creativity in the approach to care may be stymied, slowing progress. There could also be a reduction in shared decision-making due to concerns over limited capacity and lack of support for engaging in positive risk-taking. These could then impact on a delay to being discharged to home, risking deterioration and reductions in independence whilst in hospital care. The challenges associated with engaging in positive risk-taking therefore present as a rich tapestry of potential cumulative impacts on patient care.

The COVID-19 pandemic introduced new risks at all public health levels, placing services and those accessing services under unprecedented pressure to incorporate added risks on top of a very risk-prone area, that is, the discharge of older people into intermediate care. Given that risk is notoriously difficult to evaluate and is known to have both cognitive and emotional dimensions (Murray, 2022, Paek and Hove, 2017), studying the experiences of risk-related decision making within intermediate care during a time of additional pressures (i.e. the COVID-19 pandemic) adds insight to the literature for future unforeseen public health emergencies which require agile changes in practice. To the authors’ knowledge, this is the first study to investigate positive risk-taking decisions made by practitioners, patients and their families/carers across intermediate care from the experiences of occupational therapy clients (including family and caregivers) and occupational therapists at different levels of experience (novice, semi expert, expert) relating to how risk was managed and how positive risk-taking was employed during and after the COVID-19 pandemic.

Methods

Study design

A qualitative design was used to better understand multiple participant perspectives. Semi-structured interviews with open questions were utilised to explore the lived experience of participants in the specific context of their lives. In addition, two vignettes were discussed during the occupational therapists and occupational therapy student interviews. These were drawn from previous related research (Newman et al., 2022a).

Ethics

Ethical approval was granted via Ethics Online System (reference 2529). Participants were allocated pseudonyms to uphold confidentiality, and identifiable information was removed. Informed consent in writing was obtained from all participants.

Public and patient involvement

The study benefited from a public and patient involvement (PPI) working group who advised on research design and activities, including completing the ethics application, interview topic guide construction, data analysis, data interpretation and dissemination. This group consisted of three members from the (Elders Council of Newcastle, researchers from Northumbria University), and an occupational therapist from clinical practice. Members had to have experience of receiving or delivering care during the COVID-19 period or be an active occupational therapy researcher.

Participant recruitment

Occupational therapists (including students) were recruited from The Royal College of Occupational Therapists Specialist Sections for Older People and Trauma and Musculoskeletal Health via their research and development administrator. Occupational therapy students were also recruited from pre-registration cohorts at Northumbria University. Social media (Facebook) was also used to recruit occupational therapists and occupational therapy students. Additional recruitment from other universities’ pre-registration occupational therapy programmes was attempted but with no participants coming forward.

Occupational therapy patients, family and caregivers were recruited via the Elder Council of Newcastle and their partnership organisation, Age Proud Network, with the cooperation and coordination of a recruitment gatekeeper.

To try to increase the number of participants from the patient and caregiver groups, the recruitment period for the study was extended with focus on additional recruitment via social media, our PPI group members’ networks, and via our gatekeeper carer/service user organisation and their partnership organisation.

Participant eligibility criteria

Occupational therapists and students were required to have experience in supporting discharge during or following the COVID-19 pandemic from the perspective of intermediate care or as part of an integrated community service focusing on short-term intervention. Due to the study focusing on individual and autonomous decision-making, rather than team and supported decision-making, occupational therapy assistants were excluded from recruitment and participation.

Occupational therapy clients (referred to hereafter as patients, due to this being the dominant language that participants used in this study) at 65 years old or over and adult care givers (18 years or over) were eligible for inclusion providing they had experience of occupational therapy services as a result of a hospital discharge during or following the COVID-19 pandemic. Participants did not undergo any specific cognitive capacity tests to consent to participate. As recruitment required participants to self-select into the study (i.e. reach out to the researcher to take part after reading an information sheet and completing a consent form), capacity to consent was assumed at this early stage. Before each interview, the researcher (an occupational therapist by background) re-discussed the key study information and re-consented with each participant verbally before beginning the interview. Should the researcher have had concern over a participant’s decision-making or cognitive capacity to consent prior to or during the interview, the interview would have been paused or stopped, as appropriate to the situation. This did not occur in any of the interviews, however.

Sampling

Purposive sampling was used to recruit the participants. Occupational therapists and occupational therapy students were asked to categorise their own expertise level (in occupational therapy with older people) into whether they believed they were novice, semi-expert or expert and to confirm which intermediate care service model they had experience of. Participants used their own judgement to rate their expertise level; an approach that is consistent with previous research (Newman et al., 2023).

Data collection and data analysis

Semi-structured interviews were conducted by one researcher (CN) between April 2023 and February 2024. Interviews were conducted either by face-to-face, telephone or video conference, depending on the participant’s preference. Interviews were scheduled to last 45 minutes, with extra time permitted at the participant’s discretion. Patient and carers were offered a further interview if it became apparent that they had performed both roles and wanted to provide further information for the study. During the occupational therapist and occupational therapy student interviews, two vignettes were discussed and scored using a five-point Likert scale (not likely to very likely). These vignettes presented different levels of complexity for the participants to decide how likely they were to recommend a home discharge. These vignettes were used in a previous study (Newman et al., 2023) and were designed based on the findings from a scoping review of the literature and a Nominal Group Technique with occupational therapists. The same vignettes were included in this study as an additional tool to facilitate discussion in the interview, to elucidate possible differences between different levels of expertise, and to also enable comparison with our previous research. As these vignettes were designed for a previous study, they did not focus specifically on aspects of the COVID-19 pandemic. Interviews were audio-recorded and transcribed verbatim onto Microsoft Word. For the interview questions, prompts and vignettes, see Supplemental Material (Table 1).

Data analysis was conducted concurrently with the data collection. The Framework method of data analysis was used. The Framework method provides clear steps to follow and produces highly structured outputs of summarised data (Gale et al., 2013). Two researchers (CN, JM) conducted coding independently and defined categories before producing an analytical framework, which could be iteratively modified until the last transcript was coded. Reflective discussion during dedicated analysis meetings between (CN, JM, WR, PW, TR) promoted the interrogation of patterns and concepts within the data and facilitated categorising the codes to form a framework. A Microsoft Excel spreadsheet was used to chart the codes and categories to develop a framework matrix to present to the research team and to the PPI working group to help interpret the data and to agree upon the themes reported. The vignette Likert scores were collated for each level of experience (novice, semi-expert, expert) and presented using descriptive statistics (mean and standard deviation (SD)). Where available, participant discussion points to support their vignette answers were recorded, included onto the framework matrix for team discussion and presented separately, see Supplemental Material (Table 2).

Results

Fourteen participants were interviewed, including nine occupational therapists (six experts, two semi-experts and one novice), two students of occupational therapy (two novices), and three members of the public (two carers and one patient). To promote anonymity, the patient and carers will be referred to as patient/carer. The patient was also interviewed separately as a carer. All participants confirmed that they had the relevant experience of intermediate care during and/or following the COVID-19 pandemic as per the inclusion criteria.

Six themes were developed:

• (1) Intermediate care perspective

• (2) COVID-19 impact

• (3) Disruptive factors, difficulties, and dilemmas

• (4) Safety creation and improvements

• (5) Facilitators and benefits of occupational therapy

• (6) Personal impact

As is consistent with the research discussed in the introduction, we found that many of the themes characterising intermediate care and positive risk-taking within the service were embedded and relevant prior to the COVID-19 pandemic. However, many of the problems that these characteristics describe were compounded during this time causing a spill-over of poor service provision between the interface of hospital and home. Whilst there were similar issues pre- and during COVID-19, these were felt as being more prominent during the pandemic period. As such, themes 1 and 2 explain the service provision characteristics that impact positive risk-taking. Themes 3, 4 and 5 involve factors associated with supporting or inhibiting positive risk-taking, and theme 6 describes the patient journey and outcomes through intermediate care and the (mal)adaptions during and following service provision.

Intermediate care perspectives

Intermediate care was described as complex cross-boundary care between the NHS and non-NHS providers that is, care homes and commonly referred to as transitional beds, home safe or urgent community response services. Most of the participant accounts focused on discharge as opposed to admission avoidance where existing service pressures, limited resources and COVID-19 created a perfect storm that negatively impacted the patient journey through the discharge process. This also narrowed the scope for occupational therapy to employ positive risk-taking, which in turn was perceived to inhibit patient rehabilitation and recovery.

Those providing occupational therapy felt that their role had been diluted within intermediate care and especially during the COVID-19 pandemic to expedite hospital discharges. An occupational therapist currently practising in the NHS reflected on their intermediate care experience:

We’re not going to be able to make people’s participation or their occupations perfect, but I don’t think that is what we’re here to do. I think we are here to get them out of hospital [P4. Occupational Therapist]

A community occupational therapist in the preceptorship phase of their career spoke of role blurring with physiotherapy, ‘I have found it a bit difficult in some ways to stick to more like occupation focused goals’ [P5. Occupational Therapist]. Many of those involved in occupational therapy provision described having little time. They felt more constrained when services emphasised 10-day or 21-day timescales as targets for more timely discharge of patients. Working under time pressures was not always conducive with providing holistic therapy and created issues relating to not having time to read referral information or devote time to sourcing and delivering assistive equipment. The latter was compounded when the intermediate care service covered a rural area.

Ineffective organisational systems and disintegrated working which introduced risk was a key barrier to effective positive risk-taking and the quality of occupational therapy care delivery. The introduction of risk at a system level infringed on the time that could be devoted to positive risk-taking, as the time needed for this was often eroded by time spent addressing mistakes and errors. An occupational therapist [P11] reflected on common medication errors, ‘I’ve found one of the things that have to be really careful about is actually medication because sometimes people are discharged without the correct medication. . .’ A patient/carer discharged for reablement at their home reflected on hospital pressure and their experiences relating to medication,

Nobody sat with me and said, well, this is what you need for your heart [medication]. This is what you need for the infection. This is what you need for[. . .] Do you know what you’re taking these for and, you know, would you be OK? [P7].

These examples demonstrate the challenges in balancing risks: on the one hand, it is positive that staff are spending more time reviewing and addressing medication errors and reducing risk; on the other, as demonstrated by P7’s experience, the time needed to explain the importance and assure understanding of what the medications are with a patient is lost, potentially introducing risks to medication compliance or patient-use error. Time with the patient is not infinite: if increasing time is being spent in identifying basic errors (e.g. medication errors prior to discharge), then this necessitates less time spent on positive risk-taking and/or occupational therapy-specific care discussions at this key transitional timepoint for patients.

Many participants felt that occupational therapy was more effective in a home environment compared to a hospital. However, some intermediate care facilities in care homes were associated with restrictive or non-existent therapy environments, through, for example, being highly risk-adverse, limiting a patient’s movement, access to space or certain activities. Sometimes patients were diverted to different services, not as a result of their needs but because of insufficient resources.

COVID-19 impact

The risk of contracting and transmitting COVID-19 was described in a range of circumstances which inhibited or prevented care and made occupational therapy more challenging. The occupational therapy participants relayed the need to mitigate infection risk but were also aware that other risk was introduced through not being able to engage in face-to-face contact to address normal safety concerns.

In many accounts, participants recalled psychological harm and emotional costs. These were most noticeable in the recollections of family and carers where intermediate care services and the scope to continue the provision of their care was inhibited. Social distancing and infection control whilst necessary detracted from the quality of care and occupational therapy and the focus on employing interventions that promoted rehabilitation with positive risk-taking.

Many experienced occupational therapy participants gave accounts that demonstrated resilience to the impact of COVID-19, in contrast to the recollections of those with less experience. An early career occupational therapist [P5] in an adult community therapy role recalled ‘I was quite anxious about the risks and have been and still am to an extent’; adding how their patients reacted, ‘we had lots of service users even cancelling their care packages because they were so terrified’. The majority of participants felt that hospitals presented a far higher infection risk compared to a home environment.

Some occupational therapy participants stated that roles, tasks and activities required of them changed. They had to adapt to new ways of working, for example, Medical Administration Record management, where they had to create, check or sign off the record of medications administered to a patient. This created a training need for those with less or no experience in this duty. Incorporating carer roles was also apparent in one participant account to reduce footfall and mitigate COVID-infection risk, ‘we took on the care calls. So instead of a carer going at lunchtime, we’d go at lunchtime, and we’d do a bit of therapy and combine it. So, we ended up doing more care. . .’ [P2. Occupational Therapist].

Many participants relayed that patient contact either stopped or that there had to be sound justification to visit a patient at home at the height of COVID-19. An occupational therapist in reablement [P3] described some alternatives to patient contact which were not appropriate for reablement,

so going out to physically see the patient was, I guess, the last resort [. . .] we were needing to look at other ways of treating patients. So be it Zoom calls, be it phone calls. But it didn’t seem to fit with reablement.

A patient/carer [P13] reflected:

I did have quite a lot of safety concerns because the biggest concern was that was if she was discharge [. . .] how would that be impacted by the situation as we know there was a period of time that the care wasn’t available.

Participants acknowledged that there were numerous factors that contributed to an inappropriate discharge, including staff resources, not contacting families with discharge locations and times, patient transport and issues relating to large equipment delivery and installation without home environment assessments. All this was occurring in a context, especially at the start of the pandemic, of enormous pressures on the NHS to more rapidly discharge patients. Many of these problems have continued, where resources have driven care and risk-related decisions,

a few years into COVID and we did have huge problems with attaining equipment and attaining carers, you know, there’s huge vacancies for carers, [. . .] So we had those problems, but if we couldn’t support positive risk, we couldn’t support it. [P8. Occupational Therapist].

Likewise, many participants believed that the COVID-19 pandemic continues to shape the culture of the NHS and intermediate care services in relation to the impact to waiting lists for post-discharge services and how rapid discharge objectives have been normalised.

Disruptive factors, difficulties and dilemmas

The participants articulated difficult situations and many factors that affected their feelings, approaches to occupational therapy and care and presented barriers to managing risk and making risk-related decisions. In many accounts of the complexity of the patient, multifactorial risk factors seen in falls prevention, cognitive impairment or a difficult episode of care was associated with higher levels of risk and was considered in relation to carrying out activities of daily living safely. Both falls and cognitive impairment risks were recounted in the context of intermediate care and commonly considered in a patient’s home environment. In contrast, hospital-acquired pressure injuries, deconditioning, occurrences of infection, malnutrition, dehydration and social isolation were seen as risks associated with hospitalisation and often made worse the longer a person stayed in hospital. As such, an occupational therapy patient’s presentation was considered to be volatile at the point of discharge and not optimal for positive risk-taking. A community occupational therapist [P5] compared the pressure which hospital services are under to patient deconditioning and immobilisation, and considered these as associated factors which could lead to poor patient outcomes,

‘Deconditioning is actually a big problem and I think especially with the pressure the acute hospitals are under and the therapy staff there, the patients aren’t getting that input early in their journey.’

A patient/carer [P7] reflected on hospital deconditioning, ‘absolutely, because it became more difficult to, you know, to make those movements that you need to support yourself.’; adding how detrimental bed care is psychologically, ‘what they don’t think about is helping your mind to recover, because without any decisions to make. All you can think about is I’m lying in a hospital bed.’

Barriers to decision-making, managing risk and communication issues were seen as potentially impacting positive risk-taking. These barriers were diverse in nature and, from the experiences of those providing occupational therapy, were mostly extrinsic factors, that is, not directly related to a patient. These extrinsic factors included inexperienced practitioners that in some cases lacked confidence, one occupational therapist [P1] with expertise in frailty recalled ‘. . .inexperienced staff are planning the discharges, which are really complex frailty patients and that’s why I’m going up there [hospital wards], because we just weren’t getting people on the right pathway really.’ Occupational therapy students and those in the early stages of their career expressed the need for support on risk-related decisions in relation to complex care. Students/early career participants did, however, acknowledge the support they were getting through supervision and multidisciplinary team meetings. One occupational therapy student [P14] explained, ‘I find it quite challenging, I guess because I’m not as experienced . . .’

Miscommunications or a lack of communication between those involved in the discharge process was mostly related to hospital processes and service pressures. Those employing positive risk-taking linked organisational and team culture as important to nurture confidence and effective professional reasoning. The professional reasoning of positive risk-taking was seen as sometimes involving a dilemma between safety versus a patient’s right to autonomy and especially difficult when a patient’s capacity was in question. In this context, an occupational therapy student [P5] stated, ‘because you then feel that duty that we maybe do need to protect them a little bit more but without taking away their sort of autonomy at the same time.’ This was also seen as difficult when recommendations were not followed, and risk was taken by the patient which (whilst mitigated) was not advisable. One occupational therapist [P1] reflected upon conversations with family members emphasising the safety versus autonomy conflict and that autonomy was directly linked to wellbeing, ‘Safe as possible or as happy and well as possible, because they might not be the same thing.’

Blame culture was a common issue and was seen as part of a whole system and not just one organisation, including blame from family and carers who disagreed with the positive risk-taking elements of occupational therapy intervention. A patient/carer [P7] related blame culture to the lack of staff and their stressful duties, ‘The fact that they are very stressed, if they allow people to take risks without being monitored, I understand somebody would be to blame for that. But there wasn’t the resources there’. There were no explicit examples of how risk (or positive risk-taking) was communicated with patients or carers within therapeutic conversations, and no examples of how positive risk-taking was reviewed or altered (if required) during intermediate care provision.

Safety creation and improvements

There was a diverse account of methods which were used to optimise safety and identify, assess and manage risk with many occupational therapy practitioners using screening tools, risk assessments, care planning, support services and remote monitoring (Telecare), and educational and collaborative approaches in their interventions. Risk assessments broadly fit into two categories: standardised or unstandardised. Standardised assessments were mostly related to preventing falls, cognitive assessments, or were described as a generic template that could be used holistically and with flexibility. However, the majority of accounts involving risk assessment were described as informal or unstandardised with many participants using observational approaches to assessing risk. In this context, observation was used in the continuous evaluation of the patient, and for one occupational therapist [P8] was part of an intuitive process, ‘I am constantly evaluating risk, I suppose, almost without realising it.’ Another occupational therapist [P4] explained their risk assessment in more practical terms,

so making sure they can do basic washing, dressing, and again, that’s not necessarily through assessment, that’s through more observational things, you know, if you can reach down to pick something up off the floor, you can probably wash your feet.

For one occupational therapist [P10], reflection was a key component of risk assessing, ‘sort of having to sit and think about actually what do we need to do [. . .] to get them to feel safe.’

Some occupational therapists felt therapeutic conversations were integral to mitigating and sharing risk, ‘. . .it’s not just doing a risk assessment, it’s about working out which risk it is to own, because that breaks things down into a much more manageable way of doing it.’ [P4. Occupational Therapist]. Most participants viewed communication as a main area for improvement, especially between the NHS and non-NHS providers during the discharge process. Many occupational therapists felt that more hospital-based preparation and early intervention would reduce risk. Additionally, more frequent follow-ups for those leaving hospital and better joined up working with social care services would help to mitigate the risk of readmission and facilitate the reviewing of positive risk-taking goals.

Facilitators and the benefits of occupational therapy

The topics of effective communication, team support, collaboration, rapport and transparency were often described within the same situations when the participants referred to what facilitated positive risk-taking. Those providing occupational therapy saw family support and working with the family as a key facilitator to a successful patient outcome. When families were understanding and aware of risk, the job of the occupational therapist was made easier. An occupational therapist [P2] in reablement, reflected on their recent patient/family interactions, ‘I think there’s less of that these days [risk avoidance]. I think that used to be more of a thing. I think people are much more aware of the need to keep moving and positive risk-taking.’ Many described supporting families to make decisions pertaining to risk and an occupational therapist [P6] described transparency in conversation as key, ‘I think it’s, yeah, that family or carer being open and understanding of the benefits of engaging in risk.’ A patient/carer perspective [P13] added elements of trust and rapport to promote working relationships, ‘. . . if you get someone who is really very open and honest with the conversation and the situation, you can work with that person much better with somebody who just says, well, this is what I’ve got to do.’

It was apparent that being proportionate and considered through the application of professional reasoning in the face of managing risk was a key facilitator for positive risk-taking; countering being overly cautious or reactive. One occupational therapist [P5] provided an honest account of their inner conflict with risk, ‘It’s something I don’t always get right. I think there’s definitely occasions where I’ve been over cautious, and I think I’ve kind of hopefully learned a bit from that to be a little bit braver sometimes.’ This recollection emphasises reflection and self-awareness as powerful tools in developing risk-related professional reasoning. Advanced professional reasoning for many occupational therapists was acquired through experience which facilitated automaticity in their approach, tacit knowledge and developed intuition which could be supported by analytical approaches. One occupational therapist [P11] encapsulated this, ‘I suppose it because the more you do of it, the more automatic it becomes. So, in your head you’ve got a little kind of checklist that you need to run through.’

The benefits of occupational therapy were seen as providing a holistic approach, which was focused at enabling people and the skills involved were very unique to the discipline. Those involved in providing occupational therapy saw their role as problem-solving using creative and ‘blue sky’ imaginative solutions to enable people to engage and perform the activities they needed or wanted to do. By the same token, such objectives were subject to service pressures and time constraints. A patient/carer [P7] described how receiving such support built their confidence with assistive equipment, ‘I did feel more confident and also the fact that they talked to me about it and told me the benefits of each piece of equipment.’ Occupational therapists were also viewed as taking a care for a carer approach. A patient/carer [P9] described the occupational therapy service during a discharge of a family member:

So, there was a handover and then I had to take up the reins with the occupational therapist. And I think what the service did as a whole there, they seemed to recognise immediately how to connect the dots for somebody in my circumstances. Very compassionately and very efficient.

Personal impact

Some occupational therapists expressed the limitations of their role and were philosophical about their work not always fulfilling the ideals of positive risk-taking. This caused inner conflict and impacted them professionally and personally. At an empathetic level, many occupational therapy participants were aware of the personal impact to those accessing their services post-discharge, highlighting the reality that positive risk-taking is a selective process not always appropriate when patients are dependent on support.

Positive risk-taking was hard to reconcile with complex needs that required more ‘dependency-oriented’ support, and when confidence and dignity were impacted especially in a patient’s home. An occupational therapist [P2] explained,

It’s one thing being stripped of your dignity and having people wash and dress you when you’re in hospital but to have people coming into your home [. . .] and that dignity is quite a challenge.

The participants felt that occupational routines, skills and performance capacities were eroded during hospital stays with minimal therapeutic input being the norm and psychosocial risks (e.g. loneliness) impacting those referred onto their services, ‘. . .sometimes people are really lonely, and they miss having human beings around them.’ [P11. Occupational Therapist]. This in turn impacted a patient’s ability to engage with positive risk-taking post discharge.

Positive risk-taking is subject to mitigating the risk of harm and those involved in the provision of care were very aware that psychosocial factors are extremely complex and sometimes conflictive, with interventions focused on maintaining safety. One patient/carer [P13] described negativity around using a falls’ pendant, ‘at the back of her mind, she was convinced that as she pressed that. An ambulance would come out and she would be taken to hospital, and she never wanted to go to hospital.’ Carers described maladaptive approaches that were not always optimal or made explicit within their care to save time, promote safety and keep the person they were caring for happy. In the relationship between carer and the recipient of the care and to counter emotional risks, new occupations evolved which were akin with positive risk-taking. These new occupations amounted to coping mechanisms for those involved during emotionally demanding episodes of care and created alternate realities to counter stress,

It was a much more loving, caring, less shocking environment to be in [. . .]You know, yeah, this was play acting at its best to make the situation work. [P9. Patient/carer]

In addition, risk was seen as having many moving parts and as being a dynamic process, where reducing risk of falls in favour of more bed-based care caused other issues, ‘when up and moving about could get a drink but when it became bed based introduced the risk of dehydration.’ [P9. Patient/carer]

Vignette responses

Eleven occupational therapists and occupational therapy students answered two vignettes during their interviews. Six expert occupational therapists responded to vignette one (Mean = 6.8, SD = 0) and vignette two (Mean 5.8, SD = 1.3). Two semi-expert occupational therapists responded to vignette one (Mean = 6, SD = 1.4) and vignette two (Mean = 5, SD = 0). Three novice occupational therapists responded to vignette one (Mean = 5.3, SD = 1.5) and vignette two (Mean 3.6, 1.5). The participants provided real-time rationale for being less likely to recommend a home discharge and these factors were: patient cognitive/lack of capacity to understand recommendations; unsupportive team; blame culture; lack of support; the family not accepting risk; and a patient’s risk of falling, see the Supplementary material (Table 2). These factors affected the decision-making of the participants differently, where experts were impacted the least, followed by semi-experts and then novices, and this was consistent with a previous study (Newman et al., 2022a).

Discussion

The COVID-19 pandemic introduced many challenges for hospital patients and their caregivers pre- and post-discharge and introduced new ways of working for occupational therapists. The impact on psychological wellbeing was apparent throughout this study. There were examples of inappropriate discharges that were unsafe, and the COVID-19 pandemic added complexity and risk to the already risk-prone area of practice, intermediate care. However, this study found very few examples of how the COVID-19 pandemic impacted how those providing occupational therapy thought about positive risk-taking or employed it as a risk strategy. As mentioned previously, whilst the characteristics of risk and positive risk-taking within intermediate care were similar pre- and during the COVID-19 pandemic, many of the problems associated with these characteristics were compounded during the COVID-19 period, which exacerbated the quality of service provision between hospital and home. The current study identified three main areas which were impacting positive risk-taking: (1) organisational and cross boundary systems created problematic conditions which narrowed the scope for positive risk-taking; (2) role blurring and the dilution of the occupational therapy role also reduced the scope for positive risk-taking; and (3) unaided and heterogenous ways of assessing risk can make positive risk-taking difficult or a less desirable option for novice occupational therapists. These will each be discussed in turn.

Organisational and cross-boundary systems

Occupational therapy is a complex intervention, in part because of the need to engage with risk (Pentland et al., 2018). How and when risk is employed is subject to an organisation, team and an individual’s propensity to support it (or not), and create conditions where it can be used successfully. A key finding in this study is that hospital mistakes (e.g. medication errors) associated with poor communication across boundaries of care and time pressures all impact the quality of a discharge. Errors in hospital care complicate ongoing care (Reeves et al., 2011) and narrow the scope for comprehensive occupational therapy and positive risk-taking as such errors take time for occupational therapists to rectify at the expense of providing therapy. Supporting positive risk-taking at an organisational level is not a new concept, and working cultures shape how risk is managed (Department of Health, 2009).

This study further highlights that blame culture is prominent, especially across boundaries of care, and extrinsic risk factors originating from organisational or cross-boundary systems are not always subject to a risk assessment. This supports the notion that risk assessment as a precursor to optimising positive risk-taking should be conducted prior to discharge to highlight potential organisational or cross-system risk factors and to promote a safe transition in care through effective risk communication. Moreover, the participants in this study felt that occupational therapy should be introduced earlier on in the pre-discharge process not only to facilitate such a risk assessment and communication thereof but to counteract the impact of hospitalisation on physical and psychological wellbeing.

Role blurring and the dilution of the occupational therapy role

In an intermediate care context, risk assessment requires navigating and prioritising many risk factors, reconciling these with a patient’s wishes and needs, whilst accommodating the views of family and carers (NICE, 2017; RCOT, 2018). This requires advanced professional reasoning and negotiation skills, especially when there is conflicting information or risk-avoidant views. Risk avoidance was associated with blame culture and in relation to family or carers’ perspectives in a positive risk-taking context. Open and honest conversations with family are necessary and may mitigate risk avoidance and apportioning blame. The statement, ‘safe as possible or as happy and well as possible, because they might not be the same thing’ encapsulates such transparency in a therapeutic conversation. Moreover, it highlights that positive risk-taking can become a complex dilemma, in that a patient’s independence and autonomy are at conflict with dependency and surrendering self-governance; and such choices are difficult to make as they can present equally undesirable outcomes.

This study found that occupational therapy incorporates different roles and areas of responsibility, making positive risk-taking and decisions relating to it (dilemmas) even more challenging. Workforce structuring, blurring of roles, limited funding, cost containment of practice settings, junior clinicians not being supported by senior clinicians, and role creeping (other professions assume roles traditionally associated to occupational therapy) are threatening professional identity (Walder et al., 2022; Wilding and Whiteford, 2008). Work-related burnout is well-reported for those who have an unclear professional identity, experience a lack of professional recognition or are unable to practice in a manner congruent with their professional values and philosophy (Lloyd and King, 2001). Moreover, those who experience a crisis in their professional identity may feel undervalued with a potential outcome being that employers are impacted by staff attrition (Edwards and Dirette, 2010; Walder et al., 2022). As such, this has ramifications to the quality and holistic practice of occupational therapy including employing positive risk-taking potentially forgoing all the benefits it brings to those accessing intermediate care services.

Unaided, heterogeneous risk assessment

Risk assessment is a complex process to evaluate the severity of harm and estimate the probability of its occurrence in relation to each risk factor identified (Breakwell, 2007). A key finding in this study is that risk assessment was not a standalone process or even an explicit part of an occupational therapy intervention with the findings supporting that no universal method (or discernible shared approach) of conducting a risk assessment is used to inform positive risk-taking. Moreover, there was no explicit way of estimating or evaluating risk given by those providing occupational therapy, or contained within the recommendations for those who received their services including how any risks were communicated. Also, there were no examples of how risk was reviewed as part of a risk plan or how positive risk-taking was monitored and readjusted (if needed). As such, this would suggest that the RCOT (2018) risk enablement guidance has not been fully absorbed into practice. However, risk communication was described as effective amongst occupational therapists and their team colleagues.

The majority view of those providing occupational therapy in this study was that risk is always being assessed and that risk-related decision-making and judgements are made using unaided approaches, such as by observation, to support professional reasoning. Moreover, managing risk was inherent in the nature of occupational therapy itself to adapt environments, modify activities or behaviours to minimise disruption to a person’s occupation whilst maximising their safety. Unaided risk assessment is a common approach, it is more time efficient than using a structured professional judgement tool, and it is adaptive when risk is unclear making it an appealing approach to assessing risk. These approaches evolve and are refined over years of experience. However, unaided approaches are highly subjective and idiosyncratic to the assessor and therefore are not transparent or easy to replicate to inform others, and they may be subject to unconscious bias (Murray, 2022).

Occupational therapy students in the current study gave examples of lacking confidence, which is consistent with previous research (Newman et al., 2022a). Furthermore, and in the vignette part of this study, novices, semi-experts and experts were very similar in identifying risk within the vignettes, although accepting risk increased with experience. This finding suggests that experts have acquired advanced professional reasoning skills, experience, confidence, and resilience to problem solve complex care and justify their risk-related decisions. In short, novice occupational therapists have shown that they are risk-averse compared to higher levels of experience, and this affects their ability to employ positive risk-taking (Newman et al., 2022a). It is possible that the current approaches to risk within occupational therapy and intermediate care, being unstandardised and built from on-the job experience and reliant on observation, are the reasons for such results and explain why the novice occupational therapists in this study identified the need for support to build their confidence.

Conclusion

This study was conducted at an optimum time for participant reflection in relation to the COVID-19 pandemic and benefited from a diverse range of occupational therapists within intermediate care at different levels of experience. The study also benefited from a strong patient and public voice, which mitigated a low recruitment response and subsequent participation of patients and caregivers as originally intended.

Preventable hospital errors, organisational blame culture, poor communication across boundaries of care and time pressures are detrimentally affecting the quality of occupational therapy and the scope for occupational therapists to provide holistic interventions, including positive risk-taking. This study also found that positive risk-taking is implicit and seen as part of the occupational therapy process. However, unstructured risk assessment approaches, crisis in professional identity, and underdeveloped organisational approaches to risk present a harsh landscape for novice occupational therapists to acquire the risk planning and positive risk-taking skills required in intermediate care. This study highlights that positive risk-taking decisions do sometimes involve dilemmas where pursuing safety may not always equate to promoting wellbeing (safety and wellbeing might not be the same thing). Early occupational therapy intervention pre-discharge has the potential to increase the scope for positive risk-taking in intermediate care, join-up services, and facilitate better risk communication with patients and carers to promote mutual understanding and counter unhelpful risk-avoidant perspectives.

Key findings

• Preventable hospital errors, blame culture, poor communication, the loss of professional identity and time pressure risk reducing the potential opportunities, situations and activities considered to employ positive risk-taking for occupational therapists in intermediate care.

• The reliance to acquire ‘on the job’ skills and underdeveloped organisational approaches to risk present a harsh landscape for novice occupational therapists to acquire risk planning and positive risk-taking skills

What the study has added

This study has found that the COVID-19 pandemic added complexity to positive risk-taking in intermediate care for occupational therapists and, as a risk strategy, positive risk-taking requires many considerations, particularly reconciling conflictive perspectives, before it can be employed successfully. This study also highlights opportunities to improve risk assessment between boundaries of care – including earlier involvement pre-discharge, supportive team culture, and reflective, transparent, communication – and emphasises the importance of supporting novice occupational therapists to develop risk management skills.

Supplemental Material

sj-docx-1-bjo-10.1177_03080226261424820 – Supplemental material for ‘Safe as possible or as happy and well as possible, because they might not be the same thing.’ Occupational therapy perspectives of intermediate care risks during COVID-19

Supplemental material, sj-docx-1-bjo-10.1177_03080226261424820 for ‘Safe as possible or as happy and well as possible, because they might not be the same thing.’ Occupational therapy perspectives of intermediate care risks during COVID-19 by Craig Newman, Jennifer Murray, Winifred Anne Raffle, Steph Drake, Phillip Whitehead and Tim Rapley in British Journal of Occupational Therapy