The concept of hegemony, drawn from the Italian philosopher Antonio Gramsci, describes a situation in which a dominant group’s worldview becomes accepted as simple common sense, even by those it disadvantages. Crucially, hegemony does not depend on coercion. It operates through persuasion and passive acceptance, through the accumulated weight of policies, productivity targets, billing rules, and professional hierarchies that make one way of doing things feel inevitable. In healthcare settings, researchers have long described how medical discourse dominates decision-making, sidelining nursing and allied professions. For occupational therapy, whose entire identity rests on the therapeutic power of occupation rather than the treatment of impairment alone, this dominance creates a profound professional dilemma.

Earlier studies have documented the problem. In Australia, researcher Clare Wilding used action research to show that occupational therapists unconsciously complied with others’ expectations, focusing on medical diagnoses rather than occupational concerns and on productivity rather than client-centered care. She concluded that such hegemonic practices rendered occupational therapy an invisible and subservient profession. In Malaysia, investigators identified hegemony as a suppressor of the profession’s growth, producing occupational injustices. But until now, little attention had been paid to how therapists in the United States—particularly those working in acute mental health settings governed by risk-averse and biomedical ideologies—experience and respond to these forces in their daily work.

To answer that question, the researchers turned to practice-based enquiry, an action-oriented methodology in which clinicians become co-researchers of their own practice. In 2020, Gallagher, then practicing in a university-affiliated acute mental health facility in the southeastern United States, invited all of the occupational therapists at the hospital to join what the team called a community of practice scholars. All nine agreed. The group included therapists with one to sixteen years of mental health experience, spanning entry-level and advanced practitioners, some with international experience, and a diversity of gender and ethnicity. Following a structured three-stage facilitation model, the scholars met biweekly from May 2020 to June 2021, documenting their thoughts, emotions, and actions in written or audio reflections posted to a secure shared platform while collectively discussing their experiences of practice.

The analytic process was deliberately rigorous. Each reflection was read by at least two members of the analysis team, and the data were coded using three complementary schemes: in-vivo codes that preserved the therapists’ own words, process codes that captured their actions, and emotion codes that recorded their feelings. The team then assigned each reflection a descriptive title—names like ‘Good Trouble’ and ‘Staying the Course’—and through repeated discussion distilled the material into themes. Because the co-researchers themselves had generated the data and ultimately confirmed that the final analysis accurately reflected their experiences, the researchers argue the findings carry strong internal trustworthiness, even though a study of a single small community is not intended to be generalizable.

What emerged was a strikingly maritime metaphor for professional survival. The therapists’ shifting narratives resolved into three themes: making waves, staying afloat, and sailing away. Responses to hegemony varied by person, by moment, and by circumstance, and the overall story, the authors write, was one of challenge and survival, much like navigating difficult waters in the face of strong prevailing winds. For some clinicians, growing awareness of how the system constrained occupation and dulled their professional values ignited what one therapist called being ‘fired up’—a decision to make waves and, in a phrase borrowed from civil rights leader John Lewis, to make good trouble.

The acts of resistance were often small, subversive, and deeply humane. One therapist deliberately broke a unit policy by leaving a patient with her own hairbrush, reasoning that the woman needed some agency and self-care at a time when nothing in her life was within her control. Another took a patient to a courtyard coffee shop, following protocol but not waiting for permission, and described the moment as one of embodying her own values rather than adopting values that rang hollow. Others asserted themselves within the interdisciplinary hierarchy: one practitioner recounted telling a doctor to come back later so she could finish an evaluation, and described feeling empowered by it. Beyond individual defiance, some therapists pursued structural change, with one successfully advocating for a seat on the clinical leadership team to help redesign unit schedules and improve quality of care. These acts of counter-hegemony, the study found, left therapists feeling hopeful that change was possible, though sustained transformation would demand a long-haul approach.

Not everyone had the bandwidth for battle. The second theme, staying afloat, captured therapists who, worn down by the COVID-19 pandemic, personal circumstances, conflict avoidance, or relentless productivity demands, chose to work within the system rather than against it. One practitioner admitted feeling guilty for avoiding her unit because it was so physically and mentally taxing. Another spoke of prioritizing productivity over change, acknowledging she had little capacity for reform. Some gave up on educating colleagues or improving programming when staff would not follow through, retreating into a narrowly defined scope of practice. Yet staying afloat was not framed as failure. The researchers describe it as a valid protective state, and some therapists preserved their commitment by modeling small moments of occupational connection—organizing coffee and music on the unit so patients could pour for one another, share interests, and experience belonging—which they knew had the capacity to heal even if fleeting.

The third theme, sailing away, was the most sobering. Feelings of being undervalued, frustrated, and trapped by context pushed several therapists toward detachment, including literal departure from the setting—the first author among them. Others sought influence elsewhere, such as a state-level role in occupational therapy, or withdrew emotionally, with one noting that she wanted change at both individual and macro levels but was simply tired. As one reflection poignantly summarized, some colleagues traveled hundreds of miles to find fulfilling practice aligned with their values, others bided their time searching for jobs with less moral distress, and those unable to leave were left to work around whatever stood in their way.

The findings resonate with broader evidence of occupational alienation and burnout in healthcare. A Swedish national survey found that occupational therapists considering leaving the profession struggled for recognition, felt less valued than physical therapists, and reported working in constant headwinds when trying to justify occupation. The authors argue that practice-based enquiry itself can serve as a counter-hegemonic tool, fostering the critical reflexivity needed to see that feelings of isolation and discontent may stem from an oppressive biomedical and fiscal culture rather than personal inadequacy. They call for professional socialization and curricula that teach therapists how to advocate, ruffle feathers, and make good trouble—skills they believe could produce a healthier workforce and, amid a national mental health crisis, better care. The stakes, they conclude, could not be higher: if occupational therapy’s unique ways of knowing are to survive within hegemonic systems, therapists must be empowered not merely to stay afloat, but to change the course of the ship.

Subject of Research: Occupational therapists' experiences of hegemony in acute mental health practice

Article Title: Occupational therapists’ experiences of hegemony in a mental health setting: A practice-based enquiry

Article References: Gallagher, M., & Bagatell, N. (2025). Occupational therapists’ experiences of hegemony in a mental health setting: A practice-based enquiry. Scandinavian Journal of Occupational Therapy, 32(1), Article 2456462. https://doi.org/10.1080/11038128.2025.2456462

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2456462

Keywords: hegemony, occupational therapy, mental health, occupation-based practice, practice-based enquiry, occupational alienation, occupational justice, biomedical dominance, community of practice, burnout, professional identity, advocacy

Occupation-Based Practice, or OBP, is closely aligned with the purpose of occupational therapy: helping people participate in meaningful activities despite illness, injury, disability or changes in their circumstances. In practical terms, this can mean working with a person on dressing, preparing food, returning to employment, caring for family members or resuming community activities, rather than concentrating only on isolated physical or cognitive impairments. Impairment-based interventions remain clinically relevant, but OBP connects those interventions to the occupations that matter in a person’s life. That connection can make therapy more personally relevant and potentially strengthen engagement. The researchers note, however, that translating the principle into everyday hospital practice is difficult, particularly in environments shaped by time pressure, limited resources and established routines.

The investigators used a qualitative case-study design, collecting information at two points in the implementation process. In 2017, 95 occupational therapists and allied health assistants contributed to the research, while 39 participants took part in 2023. The data included eight focus groups in 2017 and three in 2023, together with multiple organisational documents. Researchers used descriptive thematic analysis to identify recurring ideas and patterns in how staff experienced the strategy. This approach did not produce a numerical estimate of treatment effectiveness. Instead, it allowed the team to examine changes in professional perceptions, the conditions that helped the strategy take hold and the pressures that made occupation-based work harder to sustain. Comparing the two time points also provided a view of implementation beyond the initial launch.

The analysis found that strategic leadership helped cultivate a culture in which OBP could become part of professional practice rather than remain an abstract concept. Leadership can influence implementation by establishing shared expectations, allocating attention to the strategy and signalling that occupation-centred care is a service priority. In this case, the strategy was supported by a broader organisational culture, allowing clinicians to encounter consistent messages about the value of OBP across their work environment. Such cultural reinforcement is important because clinical behaviour is shaped not only by individual knowledge but also by documentation systems, team communication, workload, supervision and the priorities visible in day-to-day decision-making. The case study therefore presents implementation as a systems problem, not simply as a question of whether therapists understand the underlying philosophy.

Professional development was identified as another important facilitator. Training and learning opportunities can help clinicians move from knowing what OBP means to recognising how it should influence assessment, goal-setting, intervention and review. An occupation-based assessment may explore what a person needs or wants to do, the context in which the activity occurs and the barriers that limit participation. Therapists can then use clinical reasoning to connect specific interventions with those real-world goals. For example, strengthening, cognitive strategies or environmental modifications become more meaningful when they are explicitly tied to a person’s ability to complete a valued task. The study indicates that, over time, staff perceptions shifted from conceptual understanding toward practical application, suggesting that repeated exposure and organisational support helped embed the approach in clinical reasoning.

Interdisciplinary support also helped the strategy develop. Occupational therapists work within teams that may include nurses, physicians, physiotherapists, speech pathologists, social workers and allied health assistants. When colleagues understand the purpose of occupation-based goals, they can reinforce them during discharge planning, rehabilitation and daily care. This can improve continuity between therapy sessions and the rest of a patient’s hospital experience. It also reduces the risk that occupation-focused work will be treated as an optional addition to medical care. The study does not claim that the strategy produced a specific improvement in patient outcomes, and its qualitative design cannot establish such an effect. Its contribution is different: it shows how shared professional values and cooperation across disciplines can create conditions in which an established therapeutic approach is more likely to be used consistently.

The researchers also identified substantial barriers. Resource limitations and systemic pressures can narrow the time available for detailed conversations about routines, roles and participation. Acute and tertiary services often prioritise immediate clinical needs, rapid turnover and measurable impairment changes, all of which can make occupation-based goals harder to articulate or document. Even when therapists support OBP, systems may encourage fragmented care or place greater visibility on tasks that are easier to standardise. These pressures do not necessarily reflect opposition to occupation-centred practice; they can arise from the structure of healthcare delivery. The findings suggest that implementation efforts must therefore address practical conditions, including staffing, workflows, documentation and communication, rather than relying on clinicians to compensate for system-level constraints through individual effort alone.

COVID-19 negatively affected occupation-based practice, according to the study, disrupting services and creating new demands across healthcare. The pandemic placed pressure on staffing, clinical routines and the ways professionals could interact with patients and colleagues. Those disruptions tested whether OBP had become sufficiently embedded to survive a major change in operating conditions. The researchers found that commitment to the strategy supported its re-establishment after the disruption. This recovery is significant because sustainability is more demanding than initial adoption. A practice can appear successful during a focused implementation period but fade when leadership attention changes or exceptional circumstances arise. In this case, the return toward occupation-based work indicated that the strategy had become part of the service culture, even though it remained vulnerable to broader operational pressures.

The case study offers a detailed example of how a health service can make a practice philosophy more durable, while also showing the limits of evidence from one setting. The participants were drawn from a large metropolitan tertiary service, so the findings may not transfer directly to smaller hospitals, community organisations or health systems with different resources and structures. The number of participants also differed between the two time points, and the study focused on staff experiences rather than directly measuring patient outcomes. Nevertheless, the six-year perspective provides evidence that implementation can progress from shared ideas to routine application when leadership, education, teamwork and responsive systems work together. For occupational therapy services seeking to strengthen OBP, the central lesson is that sustainability is built collectively: clinicians need practical support, teams need a common language and organisations need systems that make meaningful occupation a visible part of care.

The study is particularly useful for understanding implementation as an evolving organisational process. By examining the service at two time points six years apart, the researchers could consider whether occupation-based practice remained visible after the initial period of change. The later findings suggest that implementation involved more than introducing new terminology: clinicians increasingly described how the approach informed practical work. This distinction matters because a service may endorse a philosophy in policy documents without incorporating it into clinical reasoning, team discussions or routine decisions. The movement from conceptual endorsement toward application therefore provides an indication of cultural integration, even though it is not a numerical measure of fidelity or effectiveness.

The evidence was assembled from several qualitative sources, including focus groups and organisational documents. Using more than one source can help researchers compare staff accounts with the formal record of a strategy and its implementation. At the same time, the unequal participation across the two periods—95 participants in 2017 and 39 in 2023—means that the results should not be interpreted as a direct before-and-after measurement of the same group. The study is better understood as a comparison of perspectives within one service at different stages. Descriptive thematic analysis can reveal recurring experiences and implementation conditions, but it cannot determine how often particular behaviours occurred or establish that the strategy itself caused changes in practice.

These methodological features place the findings alongside, rather than above, other forms of evidence. The study does not test whether occupation-based interventions improve a defined clinical outcome, reduce length of stay or produce greater participation after discharge. Instead, it addresses a preceding question: what organisational circumstances make a practice approach feasible and durable? That question is important because outcome research may have limited influence when clinicians lack the time, tools or team support needed to deliver the model being evaluated. Future work could build on this case by linking implementation measures with patient-reported participation, goal attainment or other outcomes, while also examining whether similar strategies function in rural, community or differently resourced services.

The account also highlights why sustainability should be treated as an adaptive process rather than permanent completion. A strategy may need to be re-established after disruption, refined as clinical demands change and continually connected to the service’s operational systems. The reported recovery following COVID-19 suggests that shared commitment can help preserve a practice identity during upheaval, but it does not imply that occupation-based care is protected from future pressures. Ongoing leadership attention, learning opportunities and interdisciplinary communication may be needed to keep the approach active. For service managers, the implication is to monitor not only whether OBP appears in policy, but also whether everyday systems continue to make occupation-centred reasoning possible and visible.

Subject of Research: Implementation and sustainability of occupation-based practice in a metropolitan tertiary health service

Article Title: Implementation of an Occupation-Based Practice Strategy in a Metropolitan Health Service: A Case Study

Article References: Wort, J., Hitch, D., & Baxter, C. (2026). Implementation of an Occupation-Based Practice Strategy in a Metropolitan Health Service: A Case Study. Scandinavian Journal of Occupational Therapy. https://doi.org/10.1007/s44474-026-00004-4

Image Credits: AI Generated

DOI: 10.1007/s44474-026-00004-4

Keywords: occupation-based practice, occupational therapy, health service implementation, tertiary healthcare, clinical leadership, professional development, interdisciplinary care, practice sustainability, Implementation, Occupation-Based, Practice, Strategy