Patient Experience of Neurologic Rehabilitation: A Qualitative Investigation

"We can all relate": patient experience of an emotion-oriented group intervention after Acquired Brain Injury

Introduction

Group interventions are carried out routinely across neuropsychological rehabilitation services, to improve understanding of brain injury and aspects of impairment. Treatment provided in a group modality can bring additional perceived benefits, such as co-operative learning. However, there are very few studies which explore patient perceptions and experiences of such interventions. In the present study we investigated the experience of attending a group-based educational intervention for the consequences of acquired brain injury (ABI), which had a strong focus on emotion and emotion regulation.

Methods

Using qualitative semi-structured interviews (approximately 20 minutes), the study explores the lived experience of participating in the seven-session programme, the better to identify the perceived efficacy, salience and value of individual elements. Twenty participants with ABI took part in individual interviews, after completion of the group programme (the Brain Injury Solutions and Emotions Programme, BISEP). The study adopted a descriptive phenomenological philosophy, which focuses on lived experience to explore a phenomenon (i.e. the experience of BISEP). As regards methods, the study employed thematic analysis to cluster experiences into themes of meaning.

Results

Five themes were identified: (1) 'Long term consequences and psychological needs', which related to the persistent nature of direct consequences of injury and adjustment, and how these result in a need for interventions such as BISEP. (2) 'Positive experiences of participating in the programme', referred to participants' overall experience of the programme and valued elements within it. The remaining themes referred to the programme as (3) a social milieu; (4) a place to learn; and (5) a place to promote positive emotional experiences.

Discussion

Similar to previous studies, many people reported high acceptability and perceived value of the group programme, and its role in facilitating adjustment and understanding of injury. Of particular importance was the opportunity to socialise with people who "can all relate", in line with a growing emphasis on social rehabilitation. The findings especially highlight the relevance of emotion-focused group programmes for ABI, promoting emotion regulation, and practical tools that are delivered optimistically. Further implications for practice and future research include to focus on long term rehabilitation, a social milieu, and strategies to support adjustment.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study

BACKGROUND

Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes.

METHOD

A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ).

RESULTS/DISCUSSION

Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions.

CONCLUSION

This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

Quality Measure Concepts for Inpatient Rehabilitation That Are Best Understood From the Patient's Perspective

PURPOSE

The aim of this study was to identify inpatient rehabilitation quality-of-care concepts that are best understood from the patient perspective.

DESIGN

We conducted 12 focus groups with 95 former patients, caregivers, and rehabilitation clinicians and asked them to describe high-quality inpatient rehabilitation care.

METHODS

We independently reviewed the focus group transcripts and then used an iterative process to identify the quality measure concepts identified by participants.

RESULTS

Based on participants' comments, we identified 18 quality measure concepts: respect and dignity, clinician communication with patient, clinician communication with family, organizational culture, clinician engagement with patient, clinician engagement with family, rehabilitation goals, staff expertise, responsiveness, patient safety, physical environment, care coordination, discharge planning, patient and family education, peer support, symptom management (pain, anxiety, fatigue, sadness), sleep, and functioning.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

Rehabilitation nurses should be aware of the quality-of-care issues that are important to patients and their caregivers.

CONCLUSION

Important patient-reported domains of quality of care include interpersonal relationships, patient and family engagement, care planning and delivery, access to support, and quality of life.

The Person-Centered Rehabilitation Model: Framing the concept and practice of person-centered adult physical rehabilitation based on a scoping review and thematic analysis of the literature

OBJECTIVE

To develop a cross-professional model framing the concept and practice of Person-Centered Rehabilitation (PCR) in adult populations, based on a scoping review and thematic analysis of the literature.

DATA SOURCES

Key databases (PubMed, Scopus, CINAHL), snowballing searches, and experts' consultation were the data sources for English-language empirical or conceptual papers, published from January 2007 to February 2020.

STUDY SELECTION

Two independent reviewers selected adult-based papers addressing at least one of the six categories of PCR-related content, a priori specified in the published review protocol. From 6527 unique references, 147 were finally included in the analysis. Of those, 26 were exclusively conceptual papers.

DATA EXTRACTION

Two independent reviewers extracted textual data on what PCR entails conceptually or as a practice. No quality appraisals were performed as is typical in scoping reviews.

DATA SYNTHESIS

A thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by five external experts. PCR was framed as a way of thinking about and providing rehabilitation services "with" the person. PCR is embedded in rehabilitation structures and practice across three levels: 1) the person-professional dyad, 2) the micro-system level (typically an interprofessional team, involving significant others) and 3) a macro-system level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR.

CONCLUSION

The PCR model can inform both clinical and service organization practices. The PCR Model may benefit from further developments including obtaining wider stakeholders' input, determining relevance in different cultural and linguistic groups, and further operationalization and testing in implementation projects.

Receiving Bad News: A Thematic Analysis of Stroke Survivor Experiences

Background

Breaking bad news to patients may be required in service provision to stroke survivors. While challenging, it may be critical to the retention of optimism and participation in rehabilitation.

Objectives

To explore the experience of stroke survivors when receiving bad news (RBN) from medical practitioners.

Methods

Data were obtained via 1:1 interviews conducted at stroke support groups with survivors at least 12 months into recovery and subsequently transcribed for thematic analysis and coded using NVivo.

Results

Eight of 10 participants experienced RBN, and 2 participants did not. The themes of being "lucky to be alive" and waiting for "delayed information" were expressed by all participants early in the interviews. Three sub-themes emerged and were labelled alliance, dissent, and dissatisfaction, each with a further 3 contextual themes. The perception of RBN was marked amongst the dissent and dissatisfaction groups, with the latter reporting negative implications for their rehabilitation as well as negative emotions, such as anger and anxiety. The perception of a poor-quality relationship with medical practitioners was said to impede rehabilitation and recovery processes. The dissent group was characterized by initial disbelief after RBN and consequently poorer long-term outcomes, whilst the Alliance group experienced very good quality of care due to existing personal knowledge and therefore did not perceive RBN during their early medical meetings.

Conclusions

In the period soon after their stroke, survivors required their medical practitioners to not only communicate knowledge and information, but also needed validation of their hopes and fears for the future from an empathically attuned clinician.

'A good stepping stone to normality': a qualitative study of cancer survivors' experiences of an exercise-based rehabilitation program

PURPOSE

Exercise-based rehabilitation is not routinely offered to patients. We explored the experience of cancer survivors completing an exercise-based cancer rehabilitation program with and without motivational interviewing.

METHOD

A qualitative study using semi-structured interviews and thematic analysis was completed with a purposive sample of 26 cancer survivors (n = 17 female, n = 18 post-treatment) participating in cancer rehabilitation at a tertiary hospital. Interviews were recorded and transcribed verbatim. Coding was completed by two reviewers independently and confirmed by a third reviewer.

RESULTS

The main theme that emerged was exercise-based rehabilitation facilitated a return to normality after diagnosis which included positive changes in physical activity behaviour. Sub-themes were that rehabilitation is person-centred, challenges expectations, empowering and facilitated by expert staff. Common themes emerged whether participants received additional motivational interviewing or not. However, participants who received motivational interviewing were more likely to report feeling accountable for their physical activity levels. Transition to ongoing independent physical activity remained a challenge for some people who did not feel empowered or socially supported.

CONCLUSION

Exercise-based cancer rehabilitation is important in facilitating 'return to normal' including increased participation in physical activity. To challenge expectations and to empower cancer survivors, rehabilitation programs should be person-centred and led by expert staff.

Factors Influencing the Overall Satisfaction in Patients With Severe Brain Injury With Physiotherapy Services During Inpatient Rehabilitation

OBJECTIVE

To determine what influences the satisfaction of rehabilitation inpatients and their relatives with physiotherapy after severe traumatic brain injury.

DESIGN

A prospective purpose-designed survey of consecutive eligible patients discharged from a metropolitan brain injury unit.

PARTICIPANTS

A total of 65 patients with severe traumatic brain injury and 32 relatives.

RESULTS

The vast majority of patients (99%) and relatives (97%) reported being "satisfied" or "highly satisfied" with the service. Patients' overall satisfaction was influenced by the extent of actual and perceived improvement, satisfaction with certain aspects of service delivery, and quality of interaction with physiotherapy staff. Satisfaction with the amount of therapy was the key determinant for patients' overall satisfaction, whereas relatives' overall satisfaction was influenced primarily by how well they felt they were listened to by physiotherapy staff.

CONCLUSION

The high satisfaction of the patients and relatives suggests that our brain injury unit provides physiotherapy that meets their expectations. Promoting recovery, providing high-quality care, and ensuring good interaction are ways to maintain high satisfaction of patients and relatives with the service. In addition, staff may have to pay particular attention to patients' satisfaction with the amount of therapy and ensure that relatives' needs are listened to.

Extending the assessment of patient-centredness in health care: Development of the updated Valuing Patients as Individuals Scale using exploratory factor analysis

AIMS AND OBJECTIVES

To update and re-validate the Valuing Patients as Individuals Scale for use as a patient appraisal of received healthcare.

BACKGROUND

Healthcare in the United Kingdom and beyond is required to deliver high quality, person-centred care that is clinically effective and safe. However, patient experience is not uniform, and complaints often focus on the way patients have been treated. Legislation in United Kingdom requires health services to gather and use patients' evaluations of care to improve services.

DESIGN

This study uses scoping literature reviews, cognitive testing of questionnaire items with patient and healthcare staff focus groups, and exploratory factor analysis.

METHODS/SETTING/PARTICIPANTS

Data were collected from 790 participants across 34 wards in two acute hospitals in one National Health Service Health Board in Scotland from September 2011-February 2012. Ethics and Research and Development approval were obtained.

RESULTS

Fifty six unique items identified through literature review were added to 72 original Valuing Patients as Individuals Scale items. Face validity interviews removed ambiguous or low relevance items leaving 88 items for administration to patients. Two hundred and ninety questionnaires were returned, representing 37% response rate, 71 were incomplete. Thus 219 complete data were used for Exploratory Factor Analysis with varimax orthogonal rotation. This revealed a 31 item, three factor solution, Care and Respect; Understanding and Engagement; Patient Concerns, with good reliability, concurrent and discriminant validity in terms of gender. A shortened 10 item measure based on the top 3 or 4 loading items on each scale was comparable.

CONCLUSIONS

The Updated Valuing Patients as Individuals Scale is sufficiently developed to capture patient appraisals of received care.

RELEVANCE TO CLINICAL PRACTICE

The short scale version is now being routinized in real-time evaluation of patient experience contributing to this United Kingdom, National Health Service setting meeting its policy and legislative requirements.

Comparison of FIM™ communication ratings for English versus non-English speakers in the traumatic brain injury model systems (TBIMS) national database

OBJECTIVE

To examine the effect of primary language on admission and discharge FIM™ communication ratings in a sample of individuals with moderate-to-severe traumatic brain injury (TBI).

DESIGN AND METHODS

Secondary data analysis of rehabilitation admission and discharge FIM™ communication ratings of 2795 individuals hospitalized at a Traumatic Brain Injury Model Systems (TBIMS) centre between 2007-2012.

RESULTS

Individuals who spoke no English were rated worse on functional communication outcomes at inpatient rehabilitation discharge relative to individuals whose primary language was English.

CONCLUSIONS

These findings may reflect systematic bias in FIM™ communication ratings of non-English-speaking individuals with TBI and/or TBI-induced communication difficulties in non-English-speaking individuals. Clinical and research implications are discussed.

Medical treatment decision making after total avulsion brachial plexus injury: a qualitative study

OBJECT

Complete avulsion traumatic brachial plexus injuries (BPIs) can be treated using nerve and musculoskeletal reconstruction procedures. However, these interventions are most viable within certain timeframes, and even then they cannot restore all lost function. Little is known about how patients make decisions regarding surgical treatment or what impediments they face during the decision-making process. Using qualitative methodology, the authors aimed to describe how and why patients elect to pursue or forego surgical reconstruction, identify the barriers precluding adequate information transfer, and determine whether these patients are satisfied with their treatment choices over time.

METHODS

Twelve patients with total avulsion BPIs were interviewed according to a semi-structured guide. The interview transcripts were qualitatively analyzed using the systematic inductive techniques of grounded theory to identify key themes related to the decision-making process and long-term satisfaction with decisions.

RESULTS

Four decision factors emerged from our analysis: desire to restore function, perceived value of functional gains, weighing the risks and costs of surgery, and having concomitant injuries. Lack of insurance coverage (4 patients), delayed diagnosis (3 patients), and insufficient information regarding treatment (4 patients) prevented patients from making informed decisions and accessing care. Three individuals, all of whom had decided against reconstruction, had regrets about their treatment choices.

CONCLUSIONS

Patients with panplexus avulsion injuries are missing opportunities for reconstruction and often not considering the long-term outcomes of surgery. As more Americans gain health insurance coverage, it is very likely that the number of patients able to pursue reconstruction will increase. The authors recommend implementing clinical pathways to help patients meet critical points in care within the ideal timeframe and using a patient- and family-centered care approach combined with patient decision aids to foster shared decision making, increase access to information, and improve patient satisfaction with decisions. These measures could greatly benefit patients with BPI while reducing costs, improving efficiency, and generating better outcomes.

Patients’ perspectives on person-centred participation in healthcare

The aim of this article was to critically analyse the concept of person-centred participation in healthcare from patients’ perspectives through a review of qualitative research findings. In accordance with the integrative review method of Broom, data were retrieved from databases, but 60 studies were finally included in the study. The diverse attributes of person-centred participation in healthcare were identified and contrasted with participation that was not person-centred and analysed through framework analysis. Person-centred participation in healthcare was found to be based on patients’ experiences, values, preferences and needs in which respect and equality were central. It manifested itself via three intertwined phases: the human-connection phase, the phase of information processing and the action phase. The results challenge in many aspects earlier concept analyses of patient participation in addition to illuminating patient participation that is not positively valued by patients.

Patients value patient-therapist interactions more than the amount or content of therapy during inpatient rehabilitation: a qualitative study

QUESTION

How do patients receiving inpatient rehabilitation experience physiotherapy and does their experience differ if they receive extra Saturday physiotherapy?

DESIGN

Qualitative study using in-depth interviews and thematic analysis. Interviews were audio-taped, transcribed, member checked and coded independently by two researchers. Data were triangulated using published quantitative data.

PARTICIPANTS

Nineteen adults undergoing inpatient rehabilitation for neurological and musculoskeletal impairments who received either usual care (Monday to Friday therapy) or additional Saturday therapy.

RESULTS

One main theme (personal interactions), and five sub-themes (empathetic and caring physiotherapists, socialisation with other patients, alleviated boredom, changed perceptions of the weekend, and contentment with amount of therapy) emerged from the data. Patients valued interacting with physiotherapists and other patients. Patients were content with the amount of physiotherapy whether or not they had additional Saturday physiotherapy. However, having additional Saturday physiotherapy changed the patients' perceptions of Saturdays; patients who received Saturday physiotherapy viewed Saturday as a day where they would be working towards improving their function, while patients who did not receive Saturday physiotherapy expected to rest on the weekend.

CONCLUSION

The patient-therapist interaction was more important to the patient than the amount or content of their physiotherapy, but Saturday therapy changed patients' perceptions of weekends in rehabilitation.

Research priorities of patients with neuromuscular disease

PURPOSE

This paper describes a study in which patients with neuromuscular disease (NMD) were engaged to list top-priorities for scientific research in order to complement the researchers' agenda.

METHOD

A dialogic model for research agenda setting was used. Interviews, focus groups and expert meetings with patients were held to identify research topics. Research topics were prioritized via a questionnaire. Agendas were integrated in a dialogue meeting with professionals and patients.

RESULTS

The research agenda of NMD patients is divided in four research domains, with a total of 24 research topics. These domains include (1) health; (2) quality of life; (3)quality of care and support, and (4) basic issues. Among the research domains highest priority was given to research on health, followed by research on quality of life.

CONCLUSIONS

Both patients and professionals agreed a proper balance needs to be found between fundamental research and research on symptomatic treatment and quality of life. They concluded that more attention is required for research on the effective treatment of symptoms, quality of life and implementation of knowledge about NMD in regular care.

Reliability and Validity of the Neurorehabilitation Experience Questionnaire for Inpatients

Background. Patient-centered measures of the inpatient neurorehabilitation experience are needed to assess services. Objective. The objective of this study was to develop a valid and reliable Neurorehabilitation Experience Questionnaire (NREQ) to assess whether neurorehabilitation inpatients experience service elements important to them. Methods. Based on the themes established in prior qualitative research, adopting questions from established inventories and using a literature review, a draft version of the NREQ was generated. Focus groups and interviews were conducted with 9 patients and 26 staff from neurological rehabilitation units to establish face validity. Then, 70 patients were recruited to complete the NREQ to ascertain reliability (internal and test-retest) and concurrent validity. Results. On the basis of the face validity testing, several modifications were made to the draft version of the NREQ. Subsequently, internal reliability (time 1 α = .76, time 2 α = .80), test retest reliability ( r = 0.70), and concurrent validity ( r = 0.32 and r = 0.56) were established for the revised version. Whereas responses were associated with positive mood ( r = 0.30), they appeared not to be influenced by negative mood, age, education, length of stay, sex, functional independence, or whether a participant had been a patient on a unit previously. Conclusions. Preliminary validation of the NREQ suggests promise for use with its target population.

Feasibility of web-based decision aids in neurological patients

Decision aids (DAs) may be helpful in improving patients' participation in medical decision-making. We investigated the potential for web-based DAs in a rehabilitation population. Two self-administered DAs focused on the treatment of acquired ankle-foot impairment in stroke and the treatment of arm-hand function in cervical spinal cord injury (SCI). Data collection comprised a telephone interview and a self-reported paper questionnaire. Of the patients who agreed to participate, 39 stroke patients (44%) and 38 patients with SCI (78%) returned a questionnaire. More than 75% of patients expressed a need for more information about the treatment of disease-related impairment. The DAs were highly appreciated by both patient groups. Nearly all patients expressed a positive attitude towards the use of the web-based DAs in general practice. The DAs had a positive effect on the knowledge about the treatment alternatives in the stroke patients (P = 0.001), although not in the patients with SCI. The DAs reduced patients' conflict about treatment (P < 0.05). The effect of the DAs on patients' desired role in decision-making was limited. Web-based aids are feasible in the rehabilitation population with access to a computer and can improve the knowledge gaps in patients.