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

Delirium is often underrecognised and underdiagnosed, partially due to its enigmatic nature, fluctuating symptoms, and the complex interplay of factors that contribute to its onset. Recent research has underscored the frequency of delirium among older adults in various healthcare settings, revealing that up to 50% of older inpatients may experience this condition at some point during their hospitalization. The ramifications of untreated delirium can be severe, leading to longer hospital stays, increased mortality rates, and enduring cognitive decline. Therefore, understanding how different healthcare professionals perceive their roles in addressing this issue is crucial.

The research conducted by Pozzi et al. involved qualitative and quantitative methodologies, allowing for a rich tapestry of insights from both geriatricians and occupational therapists across multiple sites. By synthesizing their findings, the study contributes valuable knowledge to the discourse surrounding best practices in managing delirium. It reflects a growing recognition of the multi-disciplinary approach required to mitigate the adverse effects of delirium, thereby enhancing patient outcomes in long-term care facilities.

Occupational therapists, with their expertise in promoting independence and facilitating engagement in meaningful activities, play an indispensable role in the management of delirium. Their strategies aim to enhance cognitive stimulation, reduce environmental stressors, and promote social interaction, which are critical in preventing or ameliorating delirium. This study highlights the necessity of integrating occupational therapy into delirium care plans as a means of fostering a more holistic approach to geriatric patient management.

The geriatricians involved in the study expressed varying degrees of familiarity with occupational therapy’s contributions to delirium care. Some recognized the potential for occupational therapists to enhance cognitive functioning and improve overall quality of life for those afflicted with delirium. However, others exhibited a lack of understanding about the specific interventions occupational therapists can offer, potentially hindering interdisciplinary collaboration. This divergence in perspectives underscores the necessity for continued education and awareness within the healthcare community.

Aligning the viewpoints of geriatricians and occupational therapists is pivotal for developing cohesive treatment approaches. Improved collaboration between these two professions can ensure that patients experiencing delirium receive comprehensive and continuous care that is tailored to their needs. Such alignment fosters an environment where best practices are shared and implemented, ultimately leading to improved outcomes for geriatric patients.

Furthermore, the study draws attention to the environmental factors contributing to delirium within long-term care settings. High noise levels, lack of proper lighting, and limited social interaction can exacerbate cognitive decline in already vulnerable patients. Occupational therapists are often adept at creating therapeutic environments that mitigate these stressors. Structural changes, such as designing quiet areas for rest and crafting engaging communal spaces, can significantly reduce the incidence of delirium and promote the mental wellness of patients.

Monitoring and addressing the nutritional needs of older adults are also crucial in preventing delirium. Dehydration and malnutrition are known risk factors that can precipitate delirious episodes. Occupational therapists can contribute to this aspect by encouraging patients to partake in meals and hydration through engaging dining experiences. Strategies like meal preparation and involving residents in choosing their food options can enhance participation, increase caloric intake, and ultimately reduce the risk of delirium.

As technology continues to evolve, the integration of digital tools in occupational therapy interventions offers promising paths to enhancing delirium care. For instance, telehealth consultations can enable occupational therapists to conduct assessments and provide guidance remotely, overcoming barriers posed by distance or mobility issues. Additionally, virtual reality platforms can facilitate cognitive stimulation exercises, offering immersive environments that engage patients in ways traditional methods may not.

In conclusion, the multi-site study by Pozzi et al. shines a crucial light on the intersection between occupational therapy and delirium care within long-term settings. The insights gathered from geriatricians and occupational therapists underscore the importance of collaboration and communication in forming effective treatment strategies. As healthcare professionals continue to strive toward comprehensive approaches in geriatric medicine, integrating the perspectives of different specialists will be fundamental in addressing the complex needs of older adults experiencing delirium.

Ultimately, enhancing care for delirium may require a shift in organizational policies to prioritize interdisciplinary training, investment in environmental improvements, and leveraging technological advances. By embracing occupational therapy as a vital component of delirium management, the healthcare system can move closer toward optimizing the overall well-being and quality of life for older adults in long-term care settings. Future research will undoubtedly build on these findings, further refining the frameworks for delivering exemplary care as our understanding of delirium and its impacts evolve.

In contemplating the future, this study beckons a call to action for policy-makers, educators, and healthcare providers alike. Recognizing the invaluable contributions of all members of the care team is essential in forging a healthcare landscape that prioritizes patient-centred care. As we navigate this journey, a unified commitment to improving education, sharing knowledge, and fostering interdisciplinary partnerships will be paramount in reshaping the standards of geriatric care for years to come.

Subject of Research: Perspectives of Geriatricians and Occupational Therapists on the Role of Occupational Therapy in Delirium Care in Long-Term Care Settings

Article Title: Geriatricians and occupational therapists’ perspectives on the role of occupational therapy in delirium care in long-term care settings: a multi-site study

Article References:

Pozzi, C., Borgonovo, G., Segura, J.A.L. et al. Geriatricians and occupational therapists’ perspectives on the role of occupational therapy in delirium care in long-term care settings: a multi-site study. Eur Geriatr Med (2025). https://doi.org/10.1007/s41999-025-01282-0

Image Credits: AI Generated

DOI: https://doi.org/10.1007/s41999-025-01282-0

Keywords: Delirium, Geriatric Care, Occupational Therapy, Interdisciplinary Collaboration, Long-Term Care, Patient-Centered Care, Cognitive Functioning, Care Strategies.