Understanding the meaning and use of occupational engagement: Findings from a scoping review

Abstract

Introduction

It is theorized that occupational therapy practice is underpinned by the construct of occupational engagement, with a focus on examining the subjective meaning of occupation. The theoretical definition of occupational engagement presents significant challenges to its use, evaluation, and measurement within evidence-based contemporary occupational therapy practice.

Method

A scoping review was conducted to examine how occupational engagement is defined within occupational therapy literature and how occupational engagement is evaluated.

Results

Twenty-six journal articles were identified. Definitions were fragmented and inconsistent across studies. Key themes relating to definitions of occupational engagement included active involvement in occupation, finding value and meaning, balanced engagement, subjective experience of engagement, developing identity through occupation, and social and environmental interactions. Measures seeking to understand occupational engagement were varied across studies, with a consistent measure applied only in the area of mental health.

Conclusion

The lack of consistency in definitions and measurement of occupational engagement presents significant issues for occupational therapy practice and evaluation. There is a need for a common definition of occupational engagement to be applied in the literature. Outcome measures seeking to understand occupational engagement are also required; however, these rely on a clearly defined construct.

Keywords

Occupation occupational engagement occupational therapy occupational science

Introduction

Engagement in occupations is considered a basic premise for health and wellbeing (Townsend and Polatajko, 2007), and is fundamental to the practice of occupational therapy (Wilcock, 1993). Although occupational engagement has become a central term in the lexicon of occupational therapists, the conceptual understanding of occupational engagement remains unclear, and its definitions vary greatly in both research and practice (Kennedy and Davis, 2017).

The construct of occupational engagement first arose in work by Wilcock (1993), who described occupational engagement as beyond the performance of occupations in a physical sense, including engagement in occupation at a mental and spiritual level. Although other definitions have emerged over recent decades, they are driven by the implication that engagement in occupation includes both objectively observable, and subjectively experienced outcomes (Wilcock, 1993). The definition of occupational engagement provided by the American Occupational Therapy Association is largely consistent with Wilcock (1993), describing occupational engagement as a multidimensional interaction of the body, mind, and spirit (American Occupational Therapy Association, 2014). Similarly, Kielhofner and Forsyth (2002) acknowledge the cognitive and emotional aspects of engaging in occupation alongside the physical completion of activity, whereas Polatajko (2013) posits the inclusion of characteristics such as personal interest, motivation, and meaning that may be associated with occupation.

The understanding that engagement extends beyond the mere performance of occupation to include subjective experiences is recognized in core models of occupational therapy (Kielhofner, 2002; Kielhofner, 2008; Polatajko et al., 2007). The Canadian Model of Occupational Performance (Polatajko et al., 2007) refers to both occupational performance and engagement, suggesting that these terms are distinct. Although occupational performance describes the active participation in an occupation, engagement refers to the broader emotional and cognitive factors that may be associated with occupation (Polatajko et al., 2007). In this model, performance of occupation may provide a means to engagement; however, it is not necessary for engagement, acknowledging that an individual may engage in occupation passively (Polatajko et al., 2007). The Model of Human Occupation (MOHO) (Kielhofner, 2002; Kielhofner, 2008) also takes into account the distinction between the performance of an occupation and the broader subjective aspects that may be associated. The MOHO defines occupational engagement to be ‘clients’ doing, thinking and feeling under certain environmental conditions in the midst of or as a planned consequence of therapy’ (Kielhofner, 2002: 290) implying that volition, habituation, and performance capacities are all involved in occupational engagement (Kielhofner, 2002). As clients use their performance capacities to demonstrate a skill, they draw on habits and feel a level of satisfaction with their occupational performance (Kielhofner, 2002).

Although it is generally agreed that occupational engagement extends beyond the active performance of an occupation or activity, occupational engagement is commonly used synonymously with terms related to occupational performance (Kennedy and Davis, 2017). The characteristics of occupational engagement are similarly inexplicit, with the necessary components of occupational engagement differing between definitions of the term. Cumulatively, these factors result in ambiguity relating to occupational engagement. Given that enabling engagement in occupation is core to the profession of occupational therapy, an inadequate understanding of the core terminology of the profession is likely to harm the identity of occupational therapy practitioners. Researchers seeking to investigate occupational engagement cannot be certain that they are targeting and measuring the same construct, and similarly, practitioners using evidence-based approaches must have an adequate understanding of the construct underlying intervention and evaluation in their practice.

Given that the notion of occupational engagement is a core tenant of occupational therapy practice, clearly defining the construct of occupational engagement, and understanding how it is evaluated in the current body of literature, is imperative to current and future occupational therapy practice. For this reason, a scoping review examining how occupational engagement is both defined and evaluated within the current body of occupational therapy literature was conducted.

Methods

Study design

A scoping review process was utilized to investigate firstly how the concept of occupational engagement was used and defined within the occupational therapy and occupational science research literature. Secondly, as a constructs definition will influence its evaluation, the measurements used to evaluate occupational engagement in the literature were also examined. The methodological framework for scoping reviews described by Arksey and O'Malley (2007) guided the process. This process involves the identification of the research question, identification of relevant studies, study selection, collating, summarizing, and reporting the results (Arksey and O'Malley, 2007).

Search process

Electronic database searches were conducted for papers published on the term occupational engagement between January 1993 and June 2017. This time period was used as the term ‘occupational engagement’ was originally coined in 1993 by Wilcock (1993). Eight electronic databases were searched, including ProQuest, Psycinfo, EMBASE, AMED, CINAHL, Medline, Science Direct, and Scopus. All databases were searched using the term occupational engagement, with this term required to appear in the title, abstract, or keywords of the article.

Study inclusion criteria

Studies were included if they were written in English, peer-reviewed, occupational engagement was the articles primary outcome or focus, and a definition of occupational engagement was provided. As this review aimed to determine how occupational engagement is defined and measured within the body of occupational therapy and occupational science research, theoretical papers and gray literature, including book chapters or letters to the editor, were excluded.

Data extraction and synthesis

Data extracted from the articles included the author, year, country, study design, participant demographics, definition of occupational engagement, study aims, and outcome measures. A data charting table was developed by the authors to ensure uniform extraction of data from the articles.

Thematic analysis (Braun and Clarke, 2006) was undertaken to identify key themes related to definitions of occupational engagement provided by the articles. In identifying key themes, the definitions of occupational engagement extracted from the literature were grouped according to common emerging themes (see Appendix for a full list of extracted definitions).

Following thematic analysis to identify themes related to the definition of occupational engagement, where possible, the study aims and outcome measures were examined to determine how occupational engagement was being measured within the current body of literature.

Study evaluation and methodological quality

In addition to scoping the literature, the authors felt it was important to also consider the methodological quality of the included articles. The Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields Checklist (Kmet et al., 2004) was utilized. This checklist consists of a qualitative form, comprising 10 items, and a quantitative form, comprising 14 items. For each criterion, articles are allocated a rating of ‘criteria met’ (2 points), ‘criteria partially met’ (1 point), or ‘criteria not met’ (0 points), with a higher score indicating greater methodological quality. The points allocated to each article were added and divided by the maximum possible score. The maximum possible score for a qualitative article was 20 points, whereas the maximum possible score for a quantitative article varied because 8 criteria were potentially not applicable. Ratings were reported using the method created by Lee et al. (2008) that equate percentage scores to qualitative descriptors: strong (score of > 80%), good (70–80%), adequate (50–70%), or limited (<50%).

Results

Search results

As shown in Figure 1, 1008 articles were identified from the database searches. Duplicate removal and the exclusion of articles that were not peer-reviewed resulted in 363 articles being forwarded to title and abstract screening. Fifty-one eligible articles were identified and their full texts were retrieved and reviewed. Following full-text review, 25 further articles were excluded as they did not provide a definition of occupational engagement, resulting in 26 articles being included in this review. Although both occupational therapy and occupational science literature were sought, all included articles were occupational therapy literature.

Figure 1.

PRISMA flow diagram of article selection (Moher et al., 2009).

Methodological quality of included articles

The methodological quality of the included articles ranged from adequate to strong (Table 1). The majority of studies were rated as strong (k = 17), followed by good (k = 8) and adequate (k = 1). Common strengths in the quantitative studies included good description of the outcome measures and participants, and large sample sizes. Common limitations included lack of study design description and not controlling for confounding variables. Common strengths in the qualitative studies included clearly stated aims and credibility measures, and limitations included no accounts for reflexivity and a lack of context.

Table 1.

Description of studies included in scoping review.

Author, year, country	Study design	Participants	Theme	Aims related to occupational engagement	Measure/evaluation of occupational engagement	Methodological quality
Areberg and Bejerholm, 2013, Sweden	RCT	Individuals with severe mental illness n = 87 Intervention: n = 60 (28 males, 32 females), Age: mean 38 (SD 8) years Control: n = 60 (39 males, 21 females), Age: mean 38 (SD 8) years	Balanced, meaning, social/environment interactions	Examine the effect of individual placement support on occupational engagement for individuals with severe mental illness	POES	Strong (28/28)
Bejerholm and Eklund, 2007, Sweden	Cross-sectional	Individuals with schizophrenia N = 74 (49 males, 25 females), Age: mean 42 years	Active involvement, meaning, balanced, subjective, identity, social/environment interaction	Examine relationships between occupational engagement, personal factors, psychopathology and quality of life in individuals with schizophrenia	POES	Strong (21/22)
Bejerholm, 2010, Sweden	Cross-sectional	Individuals with schizophrenia N = 74 (49 males, 25 females), Age: mean 42 years	Subjective, identity, meaning	Examine relationship between occupational engagement and sociodemographic factors in individuals with schizophrenia	POES	Strong (21/22)
Bejerholm and Areberg, 2014, Sweden	Cross-sectional	Individuals with severe mental illness N = 120 (67 males, 53 females), Age: mean 38 years	Active involvement, meaning, identity	Explore relationship between return to work potential, clinical and sociodemographic characteristics, empowerment and occupational engagement in individuals with severe mental illness	POES	Strong (22/22)
Chard et al., 2009, Canada	Qualitative, descriptive phenomenological	Homeless men living in shelter, N = 8, Age: mean 37.25 years	Identity	Explore the meaning and experiences of everyday occupations for adult men living in shelter	Unstructured interviews and visual notebooks Factors influencing engagement in occupation	Strong (20/20)
Craik et al., 2010, UK	Qualitative, focus groups	Individuals detained in forensic units, N = 26 (21 males, 5 females)	Balanced, meaning, active involvement	Explore occupational engagement for individuals detained in forensic mental health units	Focus groups Engagement in everyday occupation within and outside of therapy, engagement in past, current and future occupations.	Adequate (12/20)
Edgelow and Krupa, 2011, Canada	Pilot RCT	Individuals with severe mental illness N = 18 Intervention: n = 10, Age: mean 44.6 (SD 8.38) years Control: n = 8, Age: mean 32.38 (SD 9.4) years	Meaning, social/ environment interaction, balanced	Examine efficacy of a time-use intervention in improving occupational balance and engagement for individuals with severe mental illness	POES	Good (21/28)
Engel-Yeger and Rosenblum, 2017, Israel	Cross-sectional correlational design	Older adults N = 180 (81 males, 99 females), Age: mean 57.87 (SD 5.28)	Active involvement, subjective	Examine relationship between sensory process and occupational engagement in older adults	ACS	Strong (18/22)
Hultqvist et al., 2015, Sweden	Cross-sectional	Day center attendees with mental illness N = 123 (56 males, 66 females), Age: mean 51 (range 24–27) years	Balanced	Investigate the factors that have the strongest relationship with empowerment when considering occupational engagement, socio-demographics and health related factors for day center attendees	POES-P	Strong (22/22)
Illman et al., 2013, Canada	Qualitative, constant comparative	Homeless individuals with illness N = 60 (40 males, 20 females), Age: median 44.5 (range 20–64) years	Active involvement, meaning, subjective	Investigate the nature of occupational engagement for homeless adults living with mental illness	Interviews, discuss nature of occupational engagement and contextual factors	Good (16/20)
Kelly et al., 2010, Australia	Qualitative, narrative approach	Members of a mental health support group N = 5 (2 males, 3 females), Age > 40 years	Active involvement, social/environment interactions	Explore the relationship between recovery and occupation in individuals with mental health problems	Interviews, discuss link between occupation and recovery and barriers to occupational engagement	Good (14/20)
Kennedy and Davis, 2017, Canada	Qualitative, descriptive methodology	Occupational therapists N = 9	Active involvement, meaning, subjective, social/environment interaction	Explore perspectives of occupational therapists on construct of occupational engagement	Semi-structured interview, discuss occupational engagement, therapeutic engagement, elements of occupational engagement and relationship to performance	Strong (20/20)
Lexén and Bejerholm, 2018, Sweden	Cross-sectional	Individuals with schizophrenia N = 39 (24 males, 15 females), Age: mean 38.2 (SD 7.7) years	Balanced, meaning, social/environment interactions, subjective	Explore relationship between occupational engagement and cognitive functioning in individuals with schizophrenia	POES	Strong (20/22)
Mahoney et al., 2016, USA	Qualitative, phenomological approach	Individuals with intellectual disability N = 10 (5 males, 5 females), Age: range 20 s–50 s	Active involvement, meaning	Explore and explain how occupational engagement is demonstrated by individuals with intellectual disability	Interviews using visual supports and observations using the Volitional Questionnaire	Strong (17/20)
McDougall et al., 2014, Australia	Qualitative, interpretative phenomological approach	Primary caregivers of individual with intellectual disability N = 8 (1 male, 7 females) Age: range 42–71 years	Active involvement	Explore impact of caring for a person with an intellectual disability living in remote rural farming location on primary carers’ occupational engagement	Semi-structured interviews, discuss experiences of caring and occupational engagement and influencing factors	Strong (18/20)
McGrath et al., 2017, Canada	Scoping review	Adults with age-related vision loss	Active involvement, meaning	Identify most effective interventions that facilitate the occupational engagement of older adults with age-related vision loss	–	Strong (18/20)
Nilsson et al., 2007, Sweden	Cross-sectional	Older adults N = 156 (48 males, 108 females), Age: range 85–98 years	Active involvement, subjective	Evaluate whether level of occupational engagement is related to life satisfaction	Modified NPS checklist, ADL taxonomy	Strong (22/22)
Nyman and Lund, 2007, Sweden	Qualitative, constant comparative	Individuals with rheumatoid arthritis N = 9 (3 males, 6 females), Age: range 45–64 years	Active involvement, social/environment interactions	Describe and enhance the understanding of how individuals with rheumatoid arthritis experience the influence of the social environment on occupational engagement	Unstructured interviews, discuss social environment influences in occupational engagement	Good (16/20)
Richards et al., 2015, Australia	Qualitative	Individuals with dementia N = 13, Individuals in traditional care facilities: n = 4 (1 male, 3 females), Age: mean 85.25 years; Individuals in non-traditional care facilities: n = 9 (5 males, 4 females), Age: mean 79.44 years; Employees of care facilities N = 4 Employees in traditional facilities: n = 2 (2 females); Employees in non-traditional facilities: n = 2 (2 females)	Subjective, social/environment interactions, meaning	Observe opportunities for occupational engagement for people with dementia in traditional compared to non-traditional facilities and investigate employee’s perceptions of occupational engagement	Residential Environmental Impact Survey	Good (16/20)
Sutton et al., 2012, New Zealand	Qualitative, interpretative approach	Individuals with mental illness N = 13 (5 males, 8 females), Age: range mid 20 s to late 50 s	Subjective, meaning	Explore the experience and meaning of occupation in recovery from mental illness	Interviews, discuss experience of occupation and associated dynamics	Strong (18/20)
Tjörnstrand et al., 2015, Sweden	Cross-sectional	Individuals with mental illness attending day centers N = 93 (59% males, 41% females) Age: mean 46 years	Meaning, balance, social/environment interaction	Investigate how factors related to day center attendance, motivation, sociodemographic and clinical factors relate to perception of occupational engagement in day center attendees	POES-P	Good (17/22)
Tsunaka and Chung, 2012, Japan	Qualitative	Individuals with dementia N = 14 (4 males, 10 females), Age: mean 81 (SD 6) years Caregivers of individuals with dementia N = 14 (2 males, 12 females), Age: mean 50 (SD 7.8) years	Identity	Examine activity patterns of individuals with dementia and caregivers’ perception of occupational engagement of their relatives with dementia	Semi-structured interviews, discuss occupational engagement using person–environment–occupation framework ACS	Good (16/20)
Watters et al., 2013, Canada	Qualitative, thematic	Ikebana practitioners N = 9 (9 females)	Active involvement, subjective	Discover meaning and experience of Ikebana among practitioners and explore how Ikebana may promote occupational engagement	Semi-structured interviews	Strong (18/20)
Williams and Murray, 2013, Australia	Meta-synthesis	Individuals who had experienced a stroke	Active involvement, subjective, meaning	Understand the experience of engagement in occupation after stroke	–	Strong (19/20)
Wimpenny et al., 2014, UK	Research Synthesis	Occupational therapists, clients and carers across a variety of contexts	Subjective, social/environment interactions	Identify the types of interventions used by occupational therapists from the perspective of clients, carers, and occupational therapists and the perceived therapeutic effectiveness	–	Strong (18/20)
Zingmark et al., 2014, Sweden	Exploratory RCT	Older adults N = 177 Control: n = 46 (82.6% females), Age: range 77–82 years Individual group: n = 41 (82.9% females), Age: range 77–82 years Activity group: n = 49 (81.6% females), Age: range 77–82 years Discussion group: n = 41 (82.9% females), Age: range 77–82 years	Active involvement, subjective, balanced	Evaluate three different interventions focusing on occupational engagement among older adults and identify the most effective interventions	Modified NPS checklist, ADL taxonomy	Good (21/28)

ACS: Activity Card Sort; ADL: Activities of Daily Living; NPS: Norling, Pettersson, Selander Interest Checklist; POES: Profiles of Occupational Engagement in People with Schizophrenia; POES-P: Profiles of Occupational Engagement in People with Severe mental illness- Productive occupations; RCT: randomized controlled trial.

Study design

Articles included in this review were both qualitative (k = 12) and quantitative (k = 11) in nature. Quantitative studies consisted primarily of cross-sectional studies (k = 8) and randomized controlled trials (k = 3) (Areberg and Bejerholm, 2013; Edgelow and Krupa, 2011; Zingmark et al., 2014). Three studies were scoping reviews and synthesizes (McGrath et al., 2017; Williams and Murray, 2013; Wimpenny et al., 2014).

Participants groups identified within the included studies

The most common participant group examined were individuals with mental illness (Areberg and Bejerholm, 2013; Bejerholm and Areberg, 2014; Craik et al., 2010; Edgelow and Krupa, 2011; Hultqvist et al., 2015; Kelly et al., 2010; Sutton et al., 2012; Tjörnstrand et al., 2015), including schizophrenia (Bejerholm, 2010; Bejerholm and Eklund, 2007; Lexén and Bejerholm, 2018). Three studies were conducted with older adults (Engel-Yeger and Rosenblum, 2017; Nilsson et al., 2007; Zingmark et al., 2014), with two consisting of participant groups with dementia (Richards et al., 2015; Tsunaka and Chung, 2012). Individuals with intellectual disability (Mahoney et al., 2016) and their primary caregivers (McDougall et al., 2014) were examined in two studies. The perspectives of occupational therapists on occupational engagement were examined in two studies (Kennedy and Davis, 2017; Wimpenny et al., 2014). Other participant groups included Ikebana practitioners (Watters et al., 2013), adults with age-related vision loss (McGrath et al., 2017), individuals who had experienced a stroke (Williams and Murray, 2013), individuals with rheumatoid arthritis (Nyman and Lund, 2007), and individuals who were homeless (Chard et al., 2009; Illman et al., 2013).

Definitions of occupational engagement

As shown in Table 2, studies drew from a range of sources to form the basis of their provided definition of occupational engagement, with 37 different sources used across the included studies. Twelve studies referred to multiple sources when providing their definition of occupational engagement, and one study did not appear to draw from any citation in their provided definition (Wimpenny et al., 2014). The most frequently used source (k = 4) was provided by Bejerholm and Eklund (2007), followed by Bejerholm and Eklund (2006) (k = 3), Polatajko (2013) (k = 3), Townsend and Polatajko (2007) (k = 3), and Wilcock (2006) (k = 3).

Table 2.

Citing literature used to define occupational engagement.

Citation	Number of studies
Bejerholm and Eklund, 2007	4
Bejerholm and Eklund, 2006	3
Polatajko et al., 2013	3
Townsend and Polatajko, 2007	3
Wilcock, 2006	3
American Occupational Therapy Association (2002)	2
Kielhofner, 2002	2
Reibero and Cook, 1999	2
Baum, 1995	1
Bejerholm and Eklund, 2004	1
Bejerholm et al., 2006	1
Bruner, 1990	1
Canadian Association of Occupational Therapists, 2002	1
Christiansen, 2005	1
Chugg and Craig, 2002	1
Cohen-Mansfield et al., 2009	1
Csikszentmihalyi, 1993	1
Doble and Santha, 2008	1
Egan et al., 2014	1
Ek and Isaksson, 2013	1
Hasselkus, 2002	1
Hayward and Taylor, 2011	1
Hitch, 2009	1
Kielhofner, 2008	1
Kramer et al., 2003	1
Law et al., 1996	1
Mee and Sumision, 2001	1
Nilsson et al., 2012	1
Reibero, 2001	1
Stav et al., 2012	1
Vrkljan and Miller-Polgar, 2001	1
Wilcock, 1998	1
Wilcock, 1999	1
World Health Organization, 2001	1
Yerxa, 1998	1
Yerxa et al., 1990	1
Zuffrey and Kerr, 2004	1

Thematic analysis of occupational engagement definitions

Thematic analysis seeking to understand how occupational engagement was defined in the literature revealed six core themes: active involvement in occupation, finding value and meaning, subjective experience of engagement, social and environmental interactions, balanced engagement, and developing identity through occupation.

Active involvement in occupation

The majority of definitions (k = 15) referred to occupational engagement as including the active involvement, participation or performance of occupation. Within this theme, physical aspects of occupational engagement are described using terms such as performance (Bejerholm and Areberg, 2014; Bejerholm and Eklund, 2007; Kennedy and Davis, 2017; Nyman and Lund, 2007), participation (Edgelow and Krupa, 2011; Illman et al., 2013; Zingmark et al., 2014), doing (Kelly et al., 2010; McDougall et al., 2014; Watters et al., 2013), or being active (Craik et al., 2010). Involvement in activities (Mahoney et al., 2016), occupations (Illman et al., 2013), and life situations (Nilsson et al., 2007) were described, whereas Williams and Murray (2013) describe performance or participation as the physically or objectively observable aspects of occupational engagement.

Finding value and meaning

Definitions provided by a number of studies discussed occupational engagement as the engagement in occupations in which an individual found meaning, value, or personal significance (k = 15). Within this theme terms such as ‘meaningful activity’ or ‘meaningful occupation’ (Areberg and Bejerholm, 2013; Bejerholm and Eklund, 2007; Edgelow and Krupa, 2011; Lexén and Bejerholm, 2018; Mahoney et al., 2016; Richards et al., 2015) were used to describe the meaning or personal significance ascribed to occupations. Craik et al. (2010) referred to occupational engagement as ‘doing meaningful things’, whereas other studies referred to occupational engagement as having meaning associated (Kennedy and Davis, 2017; McGrath et al., 2017; Williams and Murray, 2013).

Although the majority of studies acknowledged the inclusion of meaning in occupational engagement through the participation or performance of personally meaningful or significant occupations, definitions provided by some studies discussed the experiences or sense of meaning obtained through engagement in occupation (Bejerholm and Areberg, 2014; Bejerholm, 2010; Tjörnstrand et al., 2015), describing occupational engagement as a means of constructing a ‘meaningful life’ (Illman et al., 2013). One study made reference to the role of occupational therapists in discovering or understanding this meaning (Sutton et al., 2012).

Subjective experience of engagement

Thirteen studies acknowledged subjective components of occupational engagement in their definitions. Subjective experiences refer to the psychological, cognitive, and emotional aspects of occupational engagement, with studies describing the subjective experiences of being involved in occupation (Illman et al., 2013; Kennedy and Davis, 2017; Sutton et al., 2012; Watters et al., 2013; Williams and Murray, 2013; Zingmark et al., 2014).

Bejerholm and Eklund (2007) and Richards et al. (2015) both describe how the processing of external and environmental stimuli influence how individual experience engagement in occupation. Similarly, the interpretation, comprehension, and reflection processes involved in occupational engagement are discussed by Bejerholm (2010) and Lexén and Bejerholm (2018).

In the definition provided by Kennedy and Davis (2017), a range of subjective factors are recognized as being influential to occupational engagement, including factors such as individuals interests, self-perceived efficacy, motivation, and feelings of responsibility or choice. Nilsson et al. (2007) further discussed motivational aspects underlying engagement, whereas Engel-Yeger and Rosenblum (2017) discusses the role of individual interests and attention. Wimpenny et al. (2014) acknowledges the ability for engagement in occupation to fulfil personal needs or wants.

Social and environmental interactions

The influence of the broader social and environmental context on occupational engagement were discussed by 10 studies. Within this theme studies discussed occupational engagement as interactions between individuals, occupations, and the environment (Bejerholm and Eklund, 2007; Lexén and Bejerholm, 2018; Nyman and Lund, 2007; Richards et al., 2015; Wimpenny et al., 2014), and acknowledge that occupational engagement is embedded within a broader environmental context (Edgelow and Krupa, 2011). A number of definitions contained components suggesting that occupational engagement involves being able to interact and move within society (Areberg and Bejerholm, 2013; Bejerholm and Eklund, 2007; Edgelow and Krupa, 2011; Lexén and Bejerholm, 2018). Kennedy and Davis (2017) and Tjörnstrand et al. (2015) acknowledge that occupational engagement may occur with other individuals within a social environment, whereas Kelly et al. (2010) discussed occupational engagement as having the capacity to influence ones’ culture.

Balanced engagement

Several studies provided definitions that included elements referring to balance in occupation (k = 8). Within this theme definitions referred to engagement in a range or variety of occupations (Bejerholm and Eklund, 2007; Tjörnstrand et al., 2015; Zingmark et al., 2014).

Bejerholm and Eklund (2007) defined occupational engagement as including a balance between various occupations but also between both activity and rest: ‘… a balanced rhythm of activity and rest, a variety and range of meaningful occupations and routine’. A number of definitions provided by other studies draw from this definition (Areberg and Bejerholm, 2013; Edgelow and Krupa, 2011; Hultqvist et al., 2015; Lexén and Bejerholm, 2018) to describe aspects of balance involved in occupational engagement. In the definition provided by Craik et al. (2010), occupational engagement is referred to as ‘doing this in a balanced way’.

Developing identity through occupation

Five studies discussed the connection between occupational engagement and an individual’s sense of self or identity. Within this theme, occupational engagement was discussed as having the capacity to influence or create identity (Bejerholm, 2010; Bejerholm and Areberg, 2014; Chard et al., 2009), and provide a means of maintaining a sense of self over time (Bejerholm, 2010; Bejerholm and Eklund, 2007). Tsunaka and Chung (2012) referred to this concept as engagement in occupations as part of an individual’s ‘life role’.

Measurements/evaluations of occupational engagement

The measures used to evaluate occupational engagement in 23 of the included studies were examined. The remaining three studies were not included as they were meta-synthesis or reviews.

A variety of different measures were used to examine occupational engagement. The most common means of evaluating occupational engagement consisted of qualitative analysis (k = 12). Within the studies using qualitative analysis methods, a number of methods were used, including unstructured interviews, focus groups, and semi-structured interview (Chard et al., 2009; Craik et al., 2010; Illman et al., 2013; Kelly et al., 2010; Kennedy and Davis, 2017; Mahoney et al., 2016; McDougall et al., 2014; Nyman and Lund, 2007; Richards et al., 2015; Sutton et al., 2012; Tsunaka and Chung, 2012; Watters et al., 2013). This qualitative data was analyzed according to the study aims, and most commonly referred to the experience of occupational engagement and factors influencing occupational engagement.

Within the context of mental health, the Profiles of Occupational Engagement in People with Schizophrenia (POES) was often used (k = 6) (Areberg and Bejerholm, 2013; Bejerholm, 2010; Bejerholm and Areberg, 2014; Bejerholm and Eklund, 2007; Edgelow and Krupa, 2011; Lexén and Bejerholm, 2018), with a further two using an adapted version designed for productive occupations (Tjörnstrand et al. 2013), Profiles of Occupational Engagement in People with Severe mental illness (POES-P) (Hultqvist et al., 2015; Tjörnstrand et al., 2015). The POES is a measure of occupational engagement based on time-use diaries consisting of nine items, including daily rhythm and rest, variety and range of occupations, place, social environment, social interplay, interpretation, and extent of meaningful occupation, routine, and initiating performance (Bejerholm and Eklund, 2006; Berholm, Hansson and Eklund, 2006).

The Activity Card Sort (ACS) (Baum and Edwards, 2001), and the ACS Hong Kong version (Chan et al., 2006) were used in two studies (Engel-Yeger and Rosenblum, 2017; Tsunaka and Chung, 2012). One study used the ACS Hong Kong version to examine the occupational engagement of adults with dementia (Tsunaka and Chung, 2012), whereas the other sought to examine the relationship between sensory processing and occupational engagement in older individuals using the ACS (Engel-Yeger and Rosenblum, 2017). The ACS is a tool commonly used to measure an individual’s participation in activities across several domains, including leisure, instrumental activities and social activities. Participants are required to sort labelled photographs into categories based on whether the individuals perform the activity currently or in the past (Baum and Edwards, 2001). In the study by Tsunaka and Chung (2012), ACS was used to investigate activity patterns in individuals with dementia and was supplemented by interviews conducted with care-givers based on a person-environment-occupation framework.

Two studies used both the Modified Norling, Pettersson, Selander (NPS) Interest Checklist (MNPS) and activities of daily living (ADL) taxonomy (Nilsson et al., 2007; Zingmark et al., 2014), which provided a measure of both performance as well as subjective factors of occupational engagement, such as motivation. The MNPS includes 20 leisure activities rated on four dimensions, including interest, performance, motivation, and wellbeing (Nilsson and Fisher, 2006). The ADL taxonomy examines 42 ADL categorized into 12 domains. Participants are required to rate whether they perform these activities independently, the quality of this performance, and level of assistance where required (Sonn et al., 1999).

The Residential Environmental Impact Survey (REIS) was used by one study (Richards et al., 2015). The REIS is based on the MOHO and was developed to provide a means of evaluating a care home’s ability to provide opportunity to participate and meets the needs of residents. The REIS consists of a walk-through observation, observation of task and activities, and interviews with residents and staff (Fisher and Kayhan, 2012).

Discussion

This scoping review identified that there is no commonly used definition of occupational engagement in the current body of occupational therapy research literature. Similarly, measures seeking to evaluate and measure occupational engagement were largely mixed, with a commonly used measure appearing only in studies conducted in the area of mental health.

Although a number of theoretical definitions are provided to describe occupational engagement, it is clear that these definitions are not applied within the clinical and research based literature, with definitions of occupational engagement appearing fragmented. When considering occupational engagement in relation to the six themes identified in this review, only one study included all elements (Bejerholm and Eklund, 2007). The majority of included studies included heterogeneous combinations of two or more elements, with several definitions encompassed by one element alone (Chard et al., 2009; Hultqvist et al., 2015; McDougall et al., 2014; Tsunaka and Chung, 2012). Inconsistency in the elements used to define occupational engagement contribute to ambiguity in the definition and a weakening of the construct of occupational engagement.

Occupational engagement was confounded with other key terms of occupational therapy practice. Several studies defined occupational engagement as including the balance of occupation or routine (Areberg and Bejerholm, 2013; Bejerholm and Eklund, 2007; Craik et al., 2010; Edgelow and Krupa, 2011; Hultqvist et al., 2015; Lexén and Bejerholm, 2018; Tjörnstrand et al., 2015; Zingmark et al., 2014). However, definitions of occupational engagement provided by seminal sources do not allude to this element (American Occupational Therapy Association, 2014; Kielhofner, 2002; Townsend and Polatajko, 2007; Wilcock, 1993). It is possible that other key terms of occupational therapy such as ‘occupational balance’, defined as in individuals experience of balance between occupations (Wagman et al., 2012), may provide a more appropriate alternative for this concept.

Ambiguous and fragmented definitions of occupational engagement present significant concern for the practice of occupational therapy. A shared understanding of the discourse of occupational therapy is essential for the professional identity of occupational practitioners and researchers (Wilcock, 2000). An understanding of core terminology is essential not only for occupational therapists to share knowledge, but also in explaining practice to clients and members of the interdisciplinary team. Without a shared understanding of the discourse of occupational therapy, practitioners and researchers are at risk of losing their identity and status in the multi-disciplinary team (Turner and Knight, 2015). A lack of a clear definition of occupational engagement also presents challenges in developing the evidence base of occupational therapy. A clear understanding of the constructs and terminology of occupational therapy is required to improve the validity and reliability of evidence for occupational therapy practice, thus researchers seeking to empirically investigate occupational engagement must be cautious of the way in which this construct is defined.

A clear understanding of occupational engagement as a construct is essential to ensuring that measures seeking to evaluate this construct are accurate, valid, and reliable. When examining the measures used to evaluate occupational engagement, similar inconsistency was observed. Heterogeneity in the measures used to examine occupational engagement is likely resultant from the incongruity and confusion the in definitions of occupational engagement found in the included studies. The ACS, for example, was used to provide a measure of occupational engagement in two studies (Engel-Yeger and Rosenblum, 2017; Tsunaka and Chung, 2012); however, the ACS was developed to provide a measure of participation in activities rather than occupational engagement. The use of the MNPS checklist and ADL taxonomy in two of the included studies (Nilsson et al., 2007; Zingmark et al., 2014) provided some form of subjective measure (such as motivation), comparatively providing a measure more closely related to occupational engagement; however, these measures may still be considered to provide a measure of participation as opposed to occupational engagement as traditionally defined. Several studies conducted qualitative analysis of occupational engagement using interviews and focus groups. The use of such evaluation enables a thorough and in-depth exploration of the meaning and subjective experiences of occupational engagement. Despite the relative strengths of qualitative investigation, limits exist in regard to generalizability and measurement of change.

Consistently used measures of occupational engagement were observed only in the area of mental health. These studies used the POES (Bejerholm, Hansson and Eklund, 2006) and POES-P (Tjörnstrand et al. 2013), designed for use with individuals with schizophrenia and severe mental illness. These assessment provides a measure of not only participation in occupation, but also the meaning underlying occupation, the subjective interpretation of experience, and the broader context in which the occupation occurs (Bejerholm, Hansson and Eklund, 2006). This measure has been used in various cross-sectional and randomized controlled studies included in this review demonstrating its potential efficacy (Areberg and Bejerholm, 2013; Bejerholm, 2010; Bejerholm and Areberg, 2014; Bejerholm and Eklund, 2007; Edgelow and Krupa, 2011; Hultqvist et al., 2015; Lexén and Bejerholm, 2018; Tjörnstrand et al., 2015). The POES arguably provides the most accurate and rigorous measurement of occupational engagement included in this review. There exists a need to develop similar valid and reliable measures of occupational engagement for other populations.

Future studies investigating occupational engagement should seek to use a definition of occupational engagement that reflects the intended meaning of the construct to ensure the development of a common shared understanding of occupational engagement among researchers and practitioners. Theoretical understandings of occupational engagement and definitions provided by seminal sources of literature such as the American Occupational Therapy Association (2014), Wilcock (1993), or Kielhofner (2002), in addition to the themes presented within this paper, may provide a basis to understand occupational engagement; however, further empirical evidence must be conducted to support the construct of occupational engagement and its measurement. Researchers seeking to investigate occupational engagement have a responsibility to be clear when discussing the construct of interest and to ensure that the measures used adequately evaluate their chosen construct.

Limitations

Limitations of this review must be considered. Firstly, as this study sought to understand occupational engagement in the context of how it is employed in the current body of literature, it is likely that weaknesses in the definition of occupational engagement presented in the included studies will contribute to limitations in the current review. Potential for researcher bias in extracting and interpreting the data must also be acknowledged (Krefting, 1991). In developing the themes, the researchers subjectively determined the themes encompassing the included studies. However, the potential for this bias was reduced by the authors collaboratively discussing and determining the themes.

Conclusion

It is imperative for occupational therapy practice that occupational therapy practitioners and researchers have a clear understanding of the core principles underlying the practice and have measures that are accurately able to evaluate occupational engagement. Although the articles included in this review presented largely incongruous definitions of occupational engagement, the identification of the six themes may provide insights to guide the development of a common definition for occupational engagement.

Key findings

No commonly used definition of occupational engagement exists.

Similarly, no consistently used measure of occupational engagement was found.

A clear definition of occupational engagement is required.

What the study has added

This review highlights a need for a shared understanding of occupational engagement among occupational therapy practitioners and researchers. Measures designed to accurately and reliably measure occupational engagement are also required.

Footnotes

Research ethics

Neither ethics approval nor consent were required or relevant for this scoping review.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Contributorship

All authors contributed to the design of the study. Melissa Black, Kyle Desjardins, Victoria Sylvester, and Kimberley Parrant undertook searching of the literature and extraction of data and all authors contributed to the synthesis and interpretation of the results. All authors were involved in continued revisions of the manuscript.

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