Critical issues in interviewing people with traumatic brain injury

Experiences of adult stroke survivors and their parent carers: a qualitative study

OBJECTIVE

To explore the experiences of adult stroke survivors and their parent carers.

DESIGN

Qualitative methodology: interpretative phenomenological analysis.

SETTING

Six residential areas across England and south Wales.

PARTICIPANTS

Six adult stroke survivors (aged 27-46), six mothers (aged 59-76) and five fathers (aged 55-76).

METHOD

Semi-structured interviews to explore the relationship and interactions between parent and survivor prior to and after a stroke, with opportunities to explore both positive and negative changes. All interviews were transcribed and analysed by a six step interpretative phenomenological analysis process. Survivors, mothers and fathers were analysed as three separate groups and the results were synthesised.

RESULTS

Identical and interconnected themes emerged from the three groups, permitting synthesis into a single organising framework with four superordinate themes capturing the key issues for all three groups. The four superordinate themes were: 'emotional turmoil'; 'significance of parents'; 'negotiating independence versus dependence' and 'changed relationships'.

CONCLUSIONS

Parents reported adjusting to caring with relative ease. Survivors did not adjust to being cared for with such ease and felt positioned in a child role. Balancing independence and dependence was a challenge for survivors and parents and is considered within a systemic theory framework. Implications for service developments and guidelines are considered.

Perceptions of Long-term Community-based Support Following Severe Acquired Brain Injury

Many individuals require long-term community-based support following acquired brain injury (ABI). However, very few studies have examined individuals' perceptions of these support needs. The present exploratory study examined individuals' perceptions of community-based support following severe ABI. Participants included eight individuals (aged 20–48 years) with severe ABI, seven relatives and three case managers. The individuals were receiving long-term specialised lifestyle support ranging from 3–70 hours per week. A structured interview with open and closed questions was developed to explore perceptions of individuals' support needs across the areas of personal and home-based activities, community-based activities, self-organisation and vocational activities and social and psychological well-being. The questions investigated whether support was needed, the importance of support, the sources of support, the effectiveness of support and the need for change. A comparison of the three respondent groups' perceptions of support indicated a general consensus that community-based activities were the most important and most effective area of support. When the issues raised by the three respondent groups were compared and contrasted two main themes emerged from the data, which were labelled “relationships” and “individual choice versus support needs”. These themes are discussed in relation to the provision of long-term community-based support services following ABI.

Moving from aged care facilities to community-based accommodation: outcomes and environmental factors

OBJECTIVE

Nearly 3500 people under 60 years of age are living in residential aged care in Australia, a situation which is generally recognized as incompatible with optimum quality of life. The objective of the current study is to explore the transition experiences of young people with acquired brain injury who have lived in aged care facilities and moved into community-based settings.

RESEARCH DESIGN

Grounded theory, qualitative design.

METHODS AND PROCEDURES

Semi-structured interviews were conducted with seven individuals with very severe ABI, seven family caregivers and two disability support workers. Each interview was recorded and transcribed verbatim.

RESULTS

Participants identified a range of positive outcomes that resulted from the transition from aged care settings to community living environments including increased independence in everyday activities, improved well-being and a greater degree of social inclusion. Participants also identified environmental factors that they deemed as crucial to facilitating positive outcomes.

CONCLUSIONS

People with very severe ABI have the potential to increase their level of independence in community-based accommodation settings; a potential that is not fostered in most aged care environments. The findings inform the outcome variables and environmental factors that should be measured in studies of transition from aged care to the community.

A model for neurorehabilitation after severe traumatic brain injury: facilitating patient participation and learning

BACKGROUND

During intensive neurorehabilitation, it is a professional challenge that patients with severe traumatic brain injury may have changed abilities to learn.

PURPOSE

To develop, initially test, and evaluate a model for neurorehabilitation aimed at systematizing and facilitating professionals' efforts of promoting patients' participation and learning.

METHODS

Qualitative study inspired by action research. Empirical data were analyzed by a theoretical framework of "didactic relation model," "situated learning theory," and neurophysiologic/neuropsychological categories of learning premises.

FINDINGS

Our findings indicate that the model for neurorehabilitation expands and systematizes the professional's reflections and interventions aimed at facilitating learning among patients with traumatic brain injury.

Delusions and qualitative confusions: a dialogic collaborative exploration

In this article we describe the application of a dialogic collaborative process (DCP) to the exploration of issues arising from our own interview-based research in populations prone to delusions. We used the DCP to investigate and develop a shared understanding of ethical and epistemological tensions and their potential influence on the research process. Although our meaning making involved agreement to disagree in relation to specific issues, we are united in the view that full reporting and individual and team reflexivity are the hallmarks of quality for research with these populations. In a context in which qualitative research is increasingly conducted by multidisciplinary and hierarchical teams, we take the view that the DCP offers an effective and efficient means to construct evidence-based knowledge. However, we caution that to maximize benefits, the process must be underpinned by individual and collective active self-awareness and clarity about the commitment of each participant in the dialogue.

The experiences of treatment from other people as narrated by people with moderate or severe traumatic brain injury and their close relatives

PURPOSE

The aim of this study was to describe the treatment from other people as experienced by people with moderate or severe traumatic brain injury (TBI) and their close relatives.

METHOD

Twelve people with moderate or severe TBI and eight of their close relatives were interviewed. The interviews were analysed using thematic content analysis.

RESULTS

The results were described by the means of two themes: being excluded and missing confirmation. People with TBI and their close relatives had experiences of being avoided, being ruled by the authorities, being met with distrustfulness and being misjudged. They also searched for answers and longed for the right kind of help. People who listened to them, believed them and tried to understand and help them were appreciated.

CONCLUSIONS

This study showed a lack of treatment which promotes well-being of the people with TBI and their close relatives. They experienced bad treatment also from authorities. Therefore, we emphasize that authorities should continuously reflect on how to make their practice a place which promotes dignity. Treatment of people with TBI and close relatives may be improved by increased knowledge about TBI, living with it and being a close relative to a person with TBI. This is a challenge to health care and rehabilitation professionals.

Dizziness after traumatic brain injury: Results from an interview study

BACKGROUND

Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

OBJECTIVE

To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

SETTING

A community brain injury rehabilitation programme and a community access programme for TBI survivors.

METHOD

Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

RESULTS

The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

CONCLUSION

The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.

Returning to productive activities: Perspectives of individuals with long-standing acquired brain injuries

PRIMARY OBJECTIVE

The primary objective of this study was to understand how intrinsic and extrinsic factors influence productive involvement over time.

RESEARCH DESIGN

Given this relatively unexplored area of study, an interpretive research paradigm was incorporated using the grounded theory methodology.

METHODS AND PROCEDURES

Six participants were recruited based on inclusion criteria. They had been living with a brain injury for an average of 14 years. The primary method of data collection was semi-structured interviews, which was supplemented by programme reports to enhance methodological triangulation.

RESULTS

The results revealed that factors influencing involvement in productive activities over time were conceptually linked to learning about one's capacity. These factors involved: an opportunity to try, support and feedback from others, experimenting, and participants' appraisals of themselves.

CONCLUSIONS

Recommendations for clinical practice include incorporating the postulates of the social cognitive theory in rehabilitation and moving from a deficits approach towards a strengths model of practice.

Facilitating the participation of people with aphasia in research: a description of strategies

Background: People with aphasia are often excluded from research because of their communication impairments, especially when an investigation into the communication impairment is not the primary goal. In our research concerning social participation of people with aphasia, we wanted to include people with mild, moderate as well as severe aphasia.

Aim: To suggest strategies and techniques for research in people with aphasia based upon experiences in conducting research in this group of people.

Methods: We conducted a qualitative study and a quantitative study in people with aphasia concerning their social participation. In these studies different strategies were developed based upon the literature, conversations with people with aphasia and speech and language therapists, to facilitate the inclusion of people with aphasia, even those with severe communication problems. Several strategies were evaluated. The strategies used and our experiences are outlined in this report.

Main contribution: It is possible to conduct research in this group. Several strategies were helpful to make this mission possible: the use of pre-structured diaries, the use of in-depth interviews with attention to non-verbal communication, the use of existing measurements, adjusted for people with aphasia by: using pictograms, placing one question per page, bolding the key concepts in the question, using large font, visualizing the answering possibilities in words and in pictures, reducing the question length, and excluding negatives in the question.

Conclusion: Research in people with aphasia is possible when using strategies adjusted to the communicative impairment.

Helping young adult children with traumatic brain injury: the life-world of mothers

Few scholars have described the personal-social context of the maternal experience of helping young adult children who have survived a traumatic brain injury (TBI). Viewing context as life-world, we used a descriptive phenomenological method to explore the life-world of 7 mothers whose young adult children had suffered a moderate or severe TBI at least 6 months earlier. Conducting three interviews with each mother, we discerned five features of life-world: having a child who survived a TBI as a young adult, perceiving that life has really changed, having sufficient support/feeling bereft of any help, believing that my child is still able, and believing that I can help my child. Compared to the literature, findings led to more definitive practice implications about postinjury uncertainty and maternal role change. In studies with such mothers, researchers should focus on the continuity of mothering rather than the initiation of caregiving.

Continuity amid chaos: neurotrauma, loss of memory, and sense of self

In serious illness or disability, individuals commonly say that their sense of self has dramatically changed. One might expect that the experience of a radically altered sense of self would be even more profound in individuals after neurotrauma because it is the brain itself that suddenly, and often literally, becomes "strange." The aim of this study was to investigate how people left with autobiographical memory impairments--impairments that also affect the capacity to organize complex linguistic productions such as autobiographical narratives--experience themselves and, specifically, their sense of self. Seven adults who had primarily anterograde memory impairments for 1 year were interviewed. Regardless of the profound changes in their everyday functioning and lives, the stories the participants told evoke a surprising sense of a continuous self. Employing several narrative and discursive techniques, they emphasized sameness and an unbroken connection between their pre- and post-morbid lives. We believe that most individuals felt they did not have to recover their former sense of self because they subjectively seemed to have never lost it.

Methodological issues in interviews involving people with communication impairments after acquired brain damage

Qualitative research has made a significant contribution to the body of knowledge related to how people experience living with various chronic diseases and disabilities; however, the voices of certain vulnerable populations, particularly those with impairments that affect their ability to communicate, are commonly absent. In recent years, a few researchers have attempted to explore the most effective ways to ensure that the voices of people with communication impairments from acquired brain damages can be captured in qualitative research interviews; yet several methodological issues related to including this population in qualitative research remained unexamined. In this article, the authors draw on insights derived from their research on the experiences of adult survivors of stroke and traumatic brain injury to describe methodological issues related to sampling, informed consent, and fatigue in participant and researcher while also making some recommendations for conducting qualitative interviews with these populations.

Email-facilitated qualitative interviews with traumatic brain injury survivors: a new and accessible method

PRIMARY OBJECTIVE

To trial the method of email-facilitated qualitative interviewing with people with traumatic brain injury (TBI).

RESEARCH DESIGN

Qualitative semi-structured email-facilitated interviews.

PROCEDURES

Nineteen people (17 severe diagnosis) with a TBI participated in email interviews.

MAIN OUTCOMES AND RESULTS

Findings indicate that this method facilitates the participation of people with TBI in qualitative interviews. Advantages include increased time for reflection, composing answers and greater control of the interview setting. In addition, the data indicates that people with a TBI are capable of greater insight, reflection and humour than indicated by previous research.

CONCLUSION

Findings indicate that new technologies may advance data collection methods for people with cognitive-linguistic impairments who face participation barriers in face-to-face interviews.

Remembering without a past: Individuals with anterograde memory impairment talk about their lives

This paper describes the linguistic resources people with anterograde amnesia draw on in conversational narratives. Because of their problems in recollecting post-morbid memories, it is particularly challenging for such individuals to refer to personal experiences. Seven patients with anterograde memory impairments due to neurotrauma were interviewed one year post-event. Among other topics, they were asked to talk about their new lives and selves, which was expected to be a precarious affair given that they did not have many or any autobiographical memories. Microanalyses of their narratives identified three readily available linguistic resources that participants used to facilitate their storytelling. These were categorized as "memory importation" (transplanting a past memory into the present), "memory appropriation" (taking another's memory as one's own), and "memory compensation" (searching for memories). It is argued that although these resources were not always efficiently used by participants and their use often violated conversational expectations, these linguistic techniques provided a helpful means to sustain the production of personal narratives, even in the absence of autobiographical memory.

Awareness of disability after acquired brain injury and the family context

The dimension of family context for awareness of disability following acquired brain injury (ABI) is examined through a qualitative discourse analysis. Three participants with ABI, who were identified by clinicians and relatives as demonstrating difficulties with awareness of disability, and three relatives were interviewed. The findings highlight important contextual parameters influencing the emergence of families' accounts for disability after ABI: (1) availability of sense-making resources and use of pre-injury meanings, and (2) incongruity within family sense-making and resultant orientating, disputing and contesting of accounts within families. These findings are discussed in relation to pre-existing literature, and applications are suggested for family intervention following ABI.

Psychotherapy Following Traumatic Brain Injury

Psychotherapy is now an approach used within several models of neurorehabilitation. However, a core theoretical model to guide psychotherapeutic practice is lacking. This article attempts to illustrate how the Generic Model of Psychotherapy of Orlinsky and Howard, which emphasizes the common factors shared by many psychotherapies, can be applied in neurorehabilitation settings. A case report is presented to illustrate how this model can potentially inform psychotherapeutic practice. The use of a theoretical model to underpin psychotherapeutic interventions in neurorehabilitation settings has the potential to facilitate our understanding of the psychotherapeutic process following traumatic brain injury in this evolving area of professional practice.

Conducting qualitative interview research with people with expressive language difficulties

Despite the increasing application of qualitative interviewing and analysis approaches, individuals with expressive language difficulties are still frequently excluded from such research. In this article, the authors seek to clarify the role for and importance of conducting qualitative interviews with respondents with impaired expressive language. They review current research with reference to studies conducted with individuals with intellectual disabilities or dementia, or those who have experienced stroke or traumatic brain injury, and identify deficits within existing research. They consider the challenges and difficulties that contribute to the limited inclusion of individuals with impaired expressive communication in qualitative interviews and discuss the way forward with suggestions of possible means of overcoming these obstacles. They argue that a willingness to adapt methods appropriately and to modify expectations is an important factor in ensuring that researchers hear the voice of respondents with expressive language deficits.

Technology in the Lives of Women Who Live With Memory Impairment as a Result of a Traumatic Brain Injury

A large number of individuals who have experienced a traumatic brain injury are women; unfortunately, there is a lack of literature focusing on their treatment preferences. Electronic memory aids have the potential to offer tremendous assistance to increase the independence of individuals with memory impairment; however, the use of electronic memory aids with this female population has not been explored. The objective of this study was to investigate the perceptions and use of electronic memory aids in women with memory impairment as a result of a traumatic brain injury to further their use of this technology to enable their independence. Two focus groups were conducted, each with five women who self-reported a moderate to severe head injury. The primary theme that emerged was the willingness and interest of this sample to use this technology when provided with an appropriate introduction and learning environment. The results reaffirm current literature supporting the use of electronic memory aids with a population with a head injury. Individuals not currently using this technology were motivated to employ electronic memory aids in their daily lives. Further research must be conducted to develop strategies to enable this population's use of electronic memory aids.

Experiences of Onset and Diagnosis of Low-grade Glioma From the Patient's Perspective

The aim of this study was to describe adult patients' experiences of falling ill and being diagnosed with low-grade glioma. Information concerning such experiences is lacking in the literature. The study population were adults identified within a well-defined population. Interviews were conducted with 27 patients. The interview texts were analyzed using inductive content analysis. Illness onset was described as a sequence of events. Nineteen patients narrated rapid onset and 8 patients prolonged onset. The most commonly described symptoms in both types of onset were headache, epileptic seizures, vomiting, and vision changes. Racing thoughts, depression, and tinnitus were 3 of the more uncommon symptoms. The most prominent negative experiences regarding healthcare included disrespectful encounters and a lack of opportunity for participation. The salient negative life-situation consequences included a lack of social support and attitudes expressing a lack of understanding. However, to some extent, positive experiences also emerged in the interviews concerning healthcare and life situation despite the onset of the illness. In conclusion, most of the patients in the study experienced the illness onset as stressful. Healthcare staff need particular knowledge to understand the vulnerability of the patient in the onset of low-grade glioma.

Illness-related problems and coping among persons with low-grade glioma

The literature reveals no qualitative study concerning the consequences of low-grade glioma in adults. The aim of the present study was to describe perceived illness-related problems in persons with low-grade glioma and the coping used in everyday living. The study was cross-sectional within a well-defined population. A semi-structured qualitative interview was conducted with each of 39 persons, and the data were subjected to inductive content analysis. There was a wide range of perceived problems, mainly concerning bodily functions, memory, cognition, emotion, communication and perception. Several coping strategies emerged, the most frequent being searching for a solution, which was often related to memory and communication problems. One characteristic of communication was the creation of new words. Other common strategies were refraining from and avoiding and laughing and joking. Caring about self involved prioritizing of personal needs. A striving to feel a sense of solidarity within seeking social affinity was coping with a novel content. The study provides vivid narratives about previously unreported phenomena, conveying a deeper understanding. The variety and endurance of problems revealed verifies the need of support from several professionals, including in the form of out-patient post-medical care.

Giving people a voice: reflections on conducting interviews with participants experiencing communication impairment

AIM

The aim of this paper is to describe the various strategies employed to mitigate communication impairments and to argue that illness experiences may be captured through methods other than audio-tape recordings of spoken words.

BACKGROUND

This paper explores issues surrounding the collection of interview data from participants experiencing communication impairments. It derives from a qualitative interview study, which enquired into experiences of living with a percutaneous endoscopic gastrostomy. This is an artificial route created directly into the stomach for long-term delivery of nutrition to people who are unable to take nutrition via the normal route. However, in many cases the physical impairments that led to their requirement for this form of feeding also made speech, and hence interviewing, very difficult.

DISCUSSION

Capturing illness experiences from participants with impaired communication requires a reconsideration of both practical strategies and broader methodological issues. In addition to the adaptation of data generation strategies a re-examination of the complexities inherent in the meaning of 'patient experience' is required. This paper explores the utility of verbal and other interactional input from carers to explore further dimensions of this experience.

CONCLUSION

Qualitative research that seeks to capture the meanings of illness from the patient's perspective needs to be adapted to embrace different modes of communicating the illness experience.

Grief, Self-Awareness, and Psychotherapy following Brain Injury

Brain injuries result in complex losses for an individual. Impairments of self-awareness are common following brain injury. The losses associated with brain injuries are often difficult for a person to comprehend because of impaired self-awareness. It is likely that there is a dynamic relationship between self-awareness and the grief that follow brain injury. Grief and impaired self-awareness, unless resolved, are likely to hamper rehabilitation efforts. Psychotherapeutic approaches specifically addressing grief and loss following brain injury are discussed. Ideally, attempts to address grief following brain injury should take account of the problem of impaired self-awareness. This article aims to bring together the concepts of both self-awareness and grief following brain injury and the role psychotherapy may have in assisting people adjusting to loss and grief following brain injury.

Beyond the "fetishism of words": considerations on the use of the interview to gather chronic illness narratives

The author explores the technique of interviewing chronic illness patients to obtain narratives of their illness experiences. It is argued that the perspective that interview responses are accurate reflections of experience (the "fetishism of words") hampers the understanding of patient voice and agency. Discussions of chronic illness and narrative are followed by an examination of the interview based on the work of Charles L. Briggs. The author then uses the concepts of self-presentation and social support to examine what interviewers and interviewees contribute to the coconstructed discourse that is produced by the interview and addresses the question of how these concepts contribute to the beneficial outcomes of constructing narratives. The author offers specific suggestions for future research.