Recovery and adaptation after traumatic brain injury in New Zealand: Longitudinal qualitative findings over the first two years

A Look at Traumatic Brain Injury Community Programs in British Columbia: Barriers and facilitators of implementation

RESEARCH OBJECTIVES

1) Characterize the delivery of programs that support acceptance and resiliency for people with brain injury in the healthcare sector; 2) Understand the barriers and facilitators in implementation of programs to support self-acceptance and resiliency for people with brain injury.

DESIGN

Participatory focus groups were used to explore experiences of conducting brain injury programs and knowledge of the barriers and facilitators to their implementation. Focus group data were analyzed with manifest content analysis to minimally deviate from broad and structural information provided by participants.

SETTING

Four focus group sessions were conducted online through a video calling platform.

PARTICIPANTS

22 individuals from community associations conducting programs for people with brain injury. Participants were recruited from a public brain injury organization database.

RESULTS

Systemic challenges such as access to and allocation of funding require navigation support. Resource consistency and availability, including stable program leaders and a welcoming atmosphere, are important for program implementation and sustainability. Shared experiences promote connection with the community and personal development.

CONCLUSIONS

This study informs individual- and community-level approaches to promote meaningful life after brain injury. Findings highlight existing resources and support future programming for people with brain injury.

Rebuilding the self through valued action and group connections after acquired brain injury: Participant perspectives of the VaLiANT group intervention

Effective interventions that facilitate adjustment following acquired brain injury (ABI) are needed to improve long-term outcomes and meaningful reengagement in life. VaLiANT is an 8-week group intervention that combines cognitive rehabilitation with Acceptance and Commitment therapy to improve valued living, wellbeing, and adjustment. This study explored participant experiences of VaLiANT to optimize its ongoing development. This included characterization of individually meaningful treatment outcomes, mechanisms of action, and intervention acceptability. Qualitative interviews and quantitative ratings were collected from 39 ABI survivors (Mage = 52, SD = 15; 54% stroke) following their participation in VaLiANT. Participants reported diverse outcomes which resulted in three themes being generated following reflexive thematic analysis. "A fuller toolkit for life with brain injury" indicated increased strategy usage and better daily functioning; "The value of connection and belonging" captured the importance of social experiences in shaping recovery; and "Finding the me I can be" represented cognitive, behavioural, and emotional aspects of identity reconstruction post-ABI. The content and delivery of the intervention were rated highly but participants desired greater follow-up and tailoring of the intervention. Overall, VaLiANT appears to facilitate adjustment through several mechanisms, but greater intervention individualization and dosage may be required to enhance the treatment impact.

Biopsychosocial factors of quality of life in individuals with moderate to severe traumatic brain injury: a scoping review

PURPOSE

Individuals with moderate to severe traumatic brain injury (TBI) experience changes in their quality-of-life (QOL) post-injury. Given the vast literature that exists about QOL after TBI, a scoping review was performed to identify the different biopsychosocial factors that affect a person's QOL after a moderate to severe TBI.

METHODS

A scoping review was conducted using the following electronic databases: MEDLINE, CINAHL, Embase, and PsycINFO. Terms relating to TBI and QOL were used.

RESULTS

There were 7576 articles obtained from the databases, resulting in 535 full-text articles. Ultimately, 52 articles were extracted, which consisted of biopsychosocial QOL factors after TBI. The biopsychosocial factors of QOL after TBI included 19 biological factors (i.e., sex, TBI severity, cognition), 16 psychological factors (i.e., depression, self-efficacy, coping styles), and 19 social factors (i.e., employment, social participation, social support). Factors such as fatigue, self-awareness, transition, and discharge from hospitals are known issues in TBI literature but were minimally reported in studies in this review, identifying them as potential gaps in research.

CONCLUSION

Identifying biopsychosocial factors relating to QOL after TBI can enable health services to develop targeted rehabilitation programs for individuals with TBI.

Bifactor analysis of the Hospital Anxiety and Depression Scale (HADS) in individuals with traumatic brain injury

Anxiety and depression symptoms are commonly experienced after traumatic brain injury (TBI). However, studies validating measures of anxiety and depression for this population are scarce. Using novel indices derived from symmetrical bifactor modeling, we evaluated whether the Hospital Anxiety and Depression Scale (HADS) reliably differentiated anxiety and depression in 874 adults with moderate-severe TBI. The results showed that there was a dominant general distress factor accounting for 84% of the systematic variance in HADS total scores. The specific anxiety and depression factors accounted for little residual variance in the respective subscale scores (12% and 20%, respectively), and overall, minimal bias was found in using the HADS as a unidimensional measure. Further, in a subsample of 184 participants, the HADS subscales did not clearly discriminate between formal anxiety and depressive disorders diagnosed via clinical interview. Results were consistent when accounting for degree of disability, non-English speaking background, and time post-injury. In conclusion, variance in HADS scores after TBI predominately reflects a single underlying latent variable. Clinicians and researchers should exercise caution in interpreting the individual HADS subscales and instead consider using the total score as a more valid, transdiagnostic measure of general distress in individuals with TBI.

A 'Network of Understanding and Compassion': A Qualitative Study of Survivor Perspectives on Unmet Needs After Traumatic Brain Injury (TBI) in Regional Communities

OBJECTIVE

This qualitative study aimed to identify the service and support needs of people with a recent history of traumatic brain injury (TBI) living in the community.

METHODS

A postal survey was sent to 662 people 6-18 months after hospital admission for a mild-to-severe TBI. The survey included an open-ended item ('wish-basket') for collecting ideas about important unmet needs.

RESULTS

Responses from 53 individuals were coded and processed using thematic analysis. Five themes (n = 39) were identified, three of which were related to personal needs. These personal wishes were about being symptom-free, independent and emotionally supported by, and connected to, loved ones. The remaining themes were about the wished-for changes to the health system and society, such as wishing for health care continuity (as opposed to being abandoned), and for greater understanding and support by society.

CONCLUSIONS

There is scope to improve the services and support for people living with TBI in the community. This includes reconsidering the way that discharge occurs, addressing the personal needs that remain when living in the community and promoting greater social awareness of TBI to counteract disadvantage.

Randomised pragmatic waitlist trial with process evaluation investigating the effectiveness of peer support after brain injury: protocol

INTRODUCTION

Traumatic brain injury (TBI) is an important global health problem. Formal service provision fails to address the ongoing needs of people with TBI and their family in the context of a social and relational process of learning to live with and adapt to life after TBI. Our feasibility study reported peer support after TBI is acceptable to both mentors and mentees with reported benefits indicating a high potential for effectiveness and likelihood of improving outcomes for both mentees and their mentors.

OBJECTIVES

To (a) test the effectiveness of a peer support intervention for improving participation, health and well-being outcomes after TBI and (b) determine key process variables relating to intervention, context and implementation to underpin an evidence-based framework for ongoing service provision.

METHODS AND ANALYSIS

A randomised pragmatic waitlist trial with process evaluation. Mentee participants (n=46) will be included if they have moderate or severe TBI and are no more than 18 months post-injury. Mentor participants (n=18) will be people with TBI up to 6 years after injury, who were discharged from inpatient rehabilitation at least 1 year prior. The primary outcome will be mentee participation, measured using the Impact on Participation and Autonomy questionnaire after 22 weeks. Primary analysis of the continuous variables will be analysis of covariance with baseline measurement as a covariate and randomised treatment as the main explanatory predictor variable at 22 weeks. Process evaluation will include analysis of intervention-related data and qualitative data collected from mentors and service coordinators. Data synthesis will inform the development of a service framework for future implementation.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the New Zealand Health and Disability Ethics Committee (19/NTB/82) and Auckland University of Technology Ethics Committee (19/345). Dissemination of findings will be via traditional academic routes including publication in internationally recognised peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12619001002178.

Indicators of life success from the perspective of individuals with traumatic brain injury: a scoping review

PURPOSE

The purpose was to synthesize qualitative literature and identify indicators of life success (positive life outcomes and experiences) that can help in understanding resiliency in the context of traumatic brain injury (TBI).

METHODS

This scoping review involved searching nine online databases for population (TBI) and context (qualitative literature). Searches retrieved 42 852 articles and, after two-stage screening, 76 articles met the inclusion criteria of reporting indicators of life success from the perspective of individuals with TBI.

RESULTS

Most studies were conducted in North America, Australia, or Europe. Participants were people living with TBI (mild to severe), of all age ranges. Positive life experiences were organized within four domains: understanding of oneself and one's life, social relationships and interaction, doing (engagement in activities, sense of control and accomplishment), and hope for the future.

CONCLUSIONS

The positive life experiences reflect both processes and outcomes (indicators of success) and highlight the need for a multidimensional approach when seeking to understand resiliency following TBI. The transactional framework of life experiences can be applied in future TBI resiliency research to understand how individuals negotiate adversity through experiences promoting understanding of oneself and the world, social relationships, engagement in activity and hope. Implications for rehabilitationRehabilitation services should consider how to afford opportunities for engagement in activity, social interaction, meaning making (i.e., coming to new understandings), and hope.With respect to engaging in activity and social relationships, having social interaction, being understood, being active and productive, having autonomy, and having accomplishments, reflect important experiences to enable within rehabilitation services.Rehabilitation professionals should consider how providing opportunities for their clients to have positive life experiences may contribute toward an adaptive and empowered mindset.

Embedding the living well toolkit into service delivery - A complex process

Objective

To embed the Living Well Toolkit package and to understand how it was implemented at each site and to explore the experiences of users.

Methods

The toolkit package was introduced in four rehabilitation settings using a tailored implementation process negotiated with each site. The varied data sources were analysed drawing on directed content analysis.

Results

Clients with neurological conditions and clinicians initially weighed the merits of the toolkit package. A positive weighing up was prerequisite for deciding to use. Clinicians described considerable thought and planning to make the toolkit package fit and flow in clinical practice. Users of the toolkit package described ways in which it shaped their thinking.

Conclusion

Implementation of the toolkit package was a complex process for clinicians and services, involving ongoing work to optimise its impact relative to the client and context. Clinicians and clients who used the toolkit package described positive changes, congruent with person-centred communication.

Innovation

The Living Well Toolkit is freely available for all to use. Clinicians who used reflective and responsive thinking to make the toolkit package work found it provided them with a broader perspective of the client.

"It's been a long hard road": challenges faced in the first three years following traumatic brain injury

PURPOSE

There is limited qualitative research exploring challenges experienced following severe traumatic brain injury (TBI). We investigated challenges to recovery identified by individuals who sustained severe TBI three years earlier or their close others (COs), as well as suggestions for managing these challenges.

MATERIALS AND METHODS

Nine participants with TBI and 16 COs completed semi-structured interviews. Using reflexive thematic analysis, challenges were identified across several timeframes (i.e., at the injury, acute care, inpatient rehabilitation, outpatient rehabilitation, and at home/other location).

RESULTS

Challenges experienced across all timeframes included: lack of information and poor communication, pre-existing conditions, missed injuries, and issues with medical staff, and continuity of care. From acute care onwards, there were TBI-related consequences, issues with coping and emotional adjustment, negative outlook, insufficient treatment, lack of support for COs, and issues with compensation and funding for rehabilitation needs. Some challenges were unique to a specific timeframe (e.g., over-stimulating ward setting during acute care, and limited or unsupportive families once injured individuals went home). Suggestions for managing some of the challenges were provided (e.g., information provision, having peer supports).

CONCLUSION

Suggestions should be considered to promote successful outcomes following severe TBI.IMPLICATIONS FOR REHABILITATIONRecovery following a severe traumatic brain injury can be hindered by challenges, such as poor communication, limited information provision, injury-related consequences, limited services and emotional support for the injured individual and their Close Others, and a need for education of the broader community about traumatic brain injury.Suggestions for managing these challenges (e.g., peer supports; services closer to home) could be used to inform clinical guidelines that could be used in a rehabilitation context.These suggestions ultimately aim to improve the post-injury experience and outcomes of individuals with traumatic brain injury and their Close Others.

Wearable OPM-MEG: A changing landscape for epilepsy

Magnetoencephalography with optically pumped magnometers (OPM-MEG) is an emerging and novel, cost-effective wearable system that can simultaneously record neuronal activity with high temporal resolution ("when" neuronal activity occurs) and spatial resolution ("where" neuronal activity occurs). This paper will first outline recent methodological advances in OPM-MEG compared to conventional superconducting quantum interference device (SQUID)-MEG before discussing how OPM-MEG can become a valuable and noninvasive clinical support tool in epilepsy surgery evaluation. Although OPM-MEG and SQUID-MEG share similar data features, OPM-MEG is a wearable design that fits children and adults, and it is also robust to head motion within a magnetically shielded room. This means that OPM-MEG can potentially extend the application of MEG into the neurobiology of severe childhood epilepsies with intellectual disabilities (e.g., epileptic encephalopathies) without sedation. It is worth noting that most OPM-MEG sensors are heated, which may become an issue with large OPM sensor arrays (OPM-MEG currently has fewer sensors than SQUID-MEG). Future implementation of triaxial sensors may alleviate the need for large OPM sensor arrays. OPM-MEG designs allowing both awake and sleep recording are essential for potential long-term epilepsy monitoring.

Living in a reshaped reality: Exploring social participation and self-identity after TBI

Individuals with a moderate to severe traumatic brain injury (TBI) experience substantial changes in their life. This constructivist grounded theory study aimed to develop an explanatory model that explores the impact of changes in social participation and self-identity after sustaining a TBI. Sixteen participants with moderate to severe TBI (mean age = 49.8, 69% male) were recruited, and were on average 16.4 years post-injury (SD = 10.4). Data from semi-structured interviews were analysed thematically. An overarching theme of "living in a reshaped reality" was identified, which depicted how changes in social participation and self-identity influenced ongoing experiences with TBI. Three main themes were generated: (1) "there's nothing that's the same" highlighted the daily challenges individuals faced post-injury, (2) "rebuilding and restarting" described how individuals with TBI navigated through their unfamiliar reality, and (3) "embrace it and run with it" explored participants' reactions towards life with a TBI. An explanatory model was developed, consisting of the overarching theme ("living in a reshaped reality") with the three integrated themes. Future research and clinical practices can build on this understanding to develop programmes to help individuals address their needs in post-injury life.

Psychological, functional and social outcomes in adolescent and young adult cancer survivors over time: A systematic review of longitudinal studies

Objective

Most adolescents and young adults (AYA) can expect to survive a cancer diagnosis and treatment, but all will be left with the potential of long‐term negative effects that can impact their ability to reach their full potential in life. Understanding aspects of psychological, functional, and social health and well‐being outcomes, is pivotal for optimising long‐term well‐being.

Methods

We completed a systematic review of longitudinal studies reporting outcomes after anti‐cancer treatment for Adolescents and Young Adults diagnosed between the age of 12–29 years according to established systematic review processes. The protocol was registered with PROSPERO (ID: CRD 42020203116).

Results

Thirteen reports from 10 studies met eligibility criteria representing 17,645 individuals (50.3% female, mean age at diagnosis 22 years, and 26 years at last, follow up). Eleven reports were from eight quantitative studies that relied on self‐report surveys and two were qualitative studies. Psychological outcomes were reported to improve over time, as were functional health outcomes, although reported health behaviours were inconsistent between studies. Neurocognitive deficits were reported to affect the ability to return to work and impacts on fertility and sexuality were sustained over time.

Conclusions

While some outcomes for AYA are reported to improve over time, particularly for physical functioning, and anxiety and depression, the long‐term impact of cancer on many important domains remains largely unknown. Specifically, the evidence to understand what changes occur over time, and when, remains underdeveloped.

Adolescents and young adults have a long time to live as survivors of cancer, and the negative effects of disease and treatment can compromise long‐term well‐being

Longitudinal research is important for understanding changes in outcomes over time

While a wide range of outcomes have been studied, the evidence to understand what changes occur and when remains underdeveloped

Team-based rehabilitation after traumatic brain injury: a qualitative synthesis of evidence of experiences of the rehabilitation process

OBJECTIVE

To synthesize and explore experiences of the rehabilitation process for adults with traumatic brain injury receiving team-based rehabilitation.

DATA SOURCES

A qualitative evidence synthesis was conducted according to the "Enhancing transparency in reporting the synthesis of qualitative research" (ENTREQ) Guidelines, of qualitative studies published in 5 databases in 2000-21.

STUDY SELECTION AND DATA EXTRACTION

Screening, selection of relevant studies, assessment of methodological limitations, systematic qualitative content analysis and assessment of confidence with Grading of Recommendations Assessment, Development, and Evaluation- Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) were carried out by independent researchers.

DATA SYNTHESIS

The 10 included studies revealed how people with traumatic brain injury perceived that they struggled on their own for a long time to adapt their daily life. They experienced that access to team-based rehabilitation was scarce and that the interventions offered were neither individually tailored nor coordinated. A respectful attitude from professionals and individually adapted information facilitated their rehabilitation process.

CONCLUSION

This qualitative evidence synthesis indicates areas for improvement and a need to develop person-centred team-based rehabilitation for adults with traumatic brain injury, in terms of accessibility, coordination, continuity, content and participation. Given the limited opportunities for team-based rehabilitation after hospital discharge, further research is needed to understand how rehabilitation can support the adaptation of everyday life.

Improving physical mobility is critical for wellbeing in people with severe impairment after an acquired brain injury: a qualitative study

OBJECTIVES

1) Understand the experience, and personal significance, of mobility skills for people with severe mobility impairment after brain injury 2) Determine how these evolve over time.

DESIGN

Longitudinal qualitative study.

PARTICIPANTS

Ten adults, unable to walk at 8 weeks post-injury.

METHODS

Participants were interviewed up to three times, at three-month intervals. Semi-structured interviews were transcribed and coded independently by two researchers, then themes developed. Codes were then reviewed longitudinally.

RESULTS

Initial analysis derived six themes: I lost everything overnight; It feels frustrating; Walking is absolutely the most important; I need help; I'm making progress; I can start doing things that I used to be able to do. Participants described overwhelming losses, with loss of mobility affecting many aspects of life. All participants described progress other than walking that was critical for their wellbeing, including assisted standing and transfers without a lifter. Themes from longitudinal analyses: My losses softened by progress; Walking means freedom; Control helps adjustment happen; Challenges keep coming. Over time, participants valued greater control within their lives and progress with mobility was key.

CONCLUSION

Participants saw mobility as crucial to recovering control of life. Mobility achievements other than independent walking matter to individuals after brain injury.

The psychological adjustment needs of individuals following an acquired brain injury: A systematic review

This systematic review explored the psychological adjustment needs of individuals following an acquired brain injury (ABI). Whilst the landscape of rehabilitation in ABI has changed rapidly over the last decade, there is still a lack of emphasis on psychological processes in this area. An electronic search of PsycArticles, PsycINFO, PubMed, JSTOR, and Cochrane Library databases was conducted for records between January 2009 and December 2019 detailing the psychological adjustment needs of individuals in a general ABI population. A total of 17 studies with varying methodologies were initially extracted. Methodological quality was then independently assessed by the three authors, with 14 articles meeting the quality threshold. Across methodologies, key themes emerged in relation to: difficulties adjusting to a new sense of self, the critical nature of social support, and the multifaceted nature of the adjustment process which incorporates many internal and external factors. These results illustrate the importance of psychological factors in ABI rehabilitation and as such highlight that the emphasis on functional outcomes in ABI may be an obstacle to the facilitation of the process of psychological adjustment. This provides justification for a more psychologically informed, holistic approach and inspires further debate as to the fundamental importance of psychological adjustment for individual's post-ABI.

The unexpected other: Challenges and strategies after acquired impairment

People experiencing traumatic brain injury or multitrauma will often live with problems in functioning for a profound period in life. A situation of great complexity emerges involving both the experience of an impaired body and the experience of a changed social position. This article addresses the intricate relations between the altered body, personal ambitions, and social surroundings in the first 2-3 years after an injury. The conceptual framework centers around the process of change, applying concepts such as the unexpected other and biographical reconstruction. Twenty-one people of working age were interviewed two times. All interviewees had experienced traumatic brain injury or multitrauma. A thematic narrative analysis was applied. Consequences of the injury took place at a carnal level where fatigue is something completely different from becoming exhausted and where elimination of body waste takes place through practices novel to the injured person. Living with impairment also took place at the level of social interaction. Here, family relations, shame, and establishing a new identity seemed profoundly important. This article makes two novel contributions. First, it emphasizes more than previous studies do that the daily management of altered body functions is more important for independence and wellbeing. Second, the article identifies the narrative about the accident as an important issue for injured people to settle.

Returning to work or working on one's rehabilitation: Social identities invoked by impaired workers and professionals in health care and employment services

For persons with a long-term illness or impairment, return-to-work decisions involve considerations about work capacity, opportunities in the labour market, the impact of injuries, further treatment requirements, physical and cognitive rehabilitation, and mental health recovery. These considerations are undertaken by the affected individuals as well as by professionals in health care and employment services. Drawing upon institutional theories of organisations, especially the understanding that institutional logics provide different social identities to injured individuals, we study rehabilitation processes following multi-trauma or traumatic brain injury (TBI) within the Scandinavian welfare model. We identify which social identities are activated in professionals' considerations and in the stories of the injured individuals. The aim is to understand how professionals' reasoning about the clients' problems influences return-to-work processes. Our primary finding is that the wageworker identity, invoked by the injured individuals themselves, is subordinated by the professionals to the logic of profession and the associated patient identity. Consequently, not only is impaired people's anti-discrimination right to reasonably adjusted work ignored, ignored is also a possible resource in the rehabilitation process. Additionally, individuals who view themselves as wageworkers tend to be left unserved.

Surviving the "silent epidemic": A qualitative exploration of the long-term journey after traumatic brain injury

Previous studies examining life after traumatic brain injury (TBI) have taken a predominantly short-term and quantitative perspective, with generally narrow focus, and have not specifically investigated changes in experience over time post-injury to gain a uniquely long-term perspective. This study therefore aimed to qualitatively explore the broad long-term experience of living for 10 years or more with TBI. Thirty participants completed semi-structured interviews investigating the impact of TBI on various life domains, the rehabilitation experience and support received, and overall perspectives of the long-term journey after TBI. Results demonstrated that: (a) although some participants reported full recovery, several experienced persistent physical, cognitive and emotional problems that impacted their independence, employment and interpersonal relationships; (b) early rehabilitation was very helpful, but some participants experienced difficulties accessing ongoing services; (c) family and social support were important to recovery; (d) most participants drew upon inner strength to find positives in their experience. These findings have identified factors that facilitate and impede long-term recovery from TBI, which may inform better support and care for injured individuals over the years after injury to improve their quality of life.

A qualitative study of persons with persistent postconcussion symptoms and clinicians with concussion expertise to inform the development of a concussion-specific questionnaire

PURPOSE

To explore the experiences of adults with persistent postconcussion symptoms and clinicians to inform the development of a concussion-specific questionnaire.

METHODS

Using a qualitative descriptive design, we conducted 10 focus groups with persons with persistent post-concussion symptoms (n = 35; female 66%; age range 19.0-65.1 years) and semi-structured interviews with clinicians with concussion expertise (n = 16; female 81%). Thematic analysis was used to identify themes within their narratives. The International Classification of Functioning, Disability and Health (ICF) provided a standardized language for coding.

RESULTS

Three overarching themes emerged from the data: Functioning, Environmental and Personal Factors, and Capacity. Functioning mapped closely onto Activities and Participation within the ICF. Contextual factors, both Environmental and Personal, had a significant influence on functioning following concussion. Capacity was a unique finding that described how long a person is able to engage in a task before the onset or worsening of symptoms.

CONCLUSIONS

Capacity is fundamental to measuring limitations in functioning based on symptom threshold and time to recovery. The impact of contextual factors on functioning needs to be considered on a continuum from barrier to facilitator. These findings provide the basis for the development of a concussion-specific questionnaire.Implications for RehabilitationClinicians should explore with their patients limitations across all areas of functioning.Clinicians should explore and address support and relationships, attitudes of others, access to affordable and high-quality healthcare, coping strategies, and a patient's own knowledge of concussion as these influence functioning.Current guidelines recommend a symptom-based approach to concussion management, whereas persons with concussion emphasize the importance of measuring functional capacity.Capacity is defined as the length of time one can perform a task before symptom onset, primarily fatigue.Currently, no concussion-specific measure of functioning exists.

Pilot trial of The Living Well Toolkit: qualitative analysis and implications for refinement and future implementation

Background

Following a neurological event, people’s long-term health and well-being is hampered by a system that struggles to deliver person-centred communication and coordinated care and fails to harness individual and family capability to live well with the condition. We aimed to implement and evaluate a toolkit package to support these processes for people with long-term neurological conditions.

Methods

This is a multi-phased study drawing on the principles of participatory research. In this pilot phase, the toolkit package was introduced to clinicians, who introduced it to clients in four neurorehabilitation settings (inpatient and community-based). Individual and focus group interviews were carried out with clients (n = 10) and clinicians (n = 9). Data were categorised by the four components of Normalisation Process Theory (NPT), and data within each component was then coded inductively. This analysis was used to inform revisions to the toolkit package and wider implementation processes.

Results

There was widespread support for the principles underpinning the toolkit package from clients and clinicians. However, it was less clear how the client toolkit could support these principles in clinical practice which impacted buy-in. The flexibility of use of the client toolkit, which we encouraged, made it difficult for clinicians and clients to be clear about its purpose and for clinicians to operationalise in practice. Clinicians and clients identified a number of barriers that limited the time, energy and work users were able or prepared to invest, to the extent that uptake of the toolkit package was modest. Use of the toolkit package appeared more likely when clinicians perceived it to augment existing processes (e.g. goal setting) rather than detract from ‘doing’ therapy. This analysis was used to inform revisions to the toolkit package, including simplification of the client toolkit, development of videos with examples of use and a modular and reflective training package for clinical services. The refinements were intended to improve sense-making and minimise the cognitive barriers associated with implementation of a new intervention.

Conclusion

Understanding how supporting the client toolkit could add value to the therapeutic encounter was necessary for clinicians to invest time and perceive the worth of the toolkit package.

Trial registration

ANZCTR: ACTRN12614000537651. Registered 21 May, 2014.

Electronic patient reported outcomes to support care of patients with traumatic brain injury: PRiORiTy study qualitative protocol

INTRODUCTION

Traumatic brain injury (TBI) represents a major health and socioeconomic problem internationally. The expansive nature of injuries results in a heterogeneous population. The degree and type of long-term impacts following TBI and improvement following injury are highly variable. The use of electronic Patient Reported Outcomes Measures (ePROMs) could help identify residual impacts of TBI and support patient management and care. The Patient Reported Outcomes Research in Trauma study is a qualitative study exploring the long-term symptoms and impacts that are experienced by those with TBI and the potential utility of an ePROM platform to collect real-time information on patient symptoms and quality of life to inform treatment and identify support needs.

METHODS AND ANALYSIS

Semi-structured telephone and face-to-face interviews will be conducted with approximately 30-40 individuals recruited from five groups: (1) people with TBI; (2) carers and relatives of individuals with TBI; (3) TBI healthcare professionals; (4) researchers and (5) third sector staff members and volunteers working with those with TBI. Data will be analysed using directed thematic analysis employing an iterative coding frame that will be modified as analysis progresses. Intercoder triangulation will be employed to enhance credibility.

ETHICS AND DISSEMINATION

This study was approved by the West Midlands-Black Country Research Ethics Committee (Ref: 18/WM/0033). Findings will be disseminated via conference presentations, peer-reviewed journals, social media (@CPROR_UoB; http://www.birmingham.ac.uk/cpror) and the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre.

Making sense of recovery after traumatic brain injury through a peer mentoring intervention: a qualitative exploration

OBJECTIVE

To explore the acceptability of peer mentoring for people with a traumatic brain injury (TBI) in New Zealand.

DESIGN

This is a qualitative descriptive study exploring the experiences reported by mentees and mentors taking part in a feasibility study of peer mentoring. Interviews with five mentees and six mentors were carried out. Data were analysed using conventional content analysis.

SETTING

The first mentoring session took place predischarge from the rehabilitation unit. The remaining five sessions took place in mentees' homes or community as preferred.

PARTICIPANTS

Twelve people with TBI took part: six mentees (with moderate to severe TBI; aged 18-46) paired with six mentors (moderate to severe TBI >12 months previously; aged 21-59). Pairing occurred before mentee discharge from postacute inpatient brain injury rehabilitation. Mentors had been discharged from rehabilitation following a TBI between 1 and 5 years previously.

INTERVENTION

The peer mentoring programme consisted of up to six face-to-face sessions between a mentee and a mentor over a 6-month period. The sessions focused on building rapport, exploring hopes for and supporting participation after discharge through further meetings and supported community activities.

RESULTS

Data were synthesised into one overarching theme: making sense of recovery. This occurred through the sharing of experiences and stories; was pivotal to the mentoring relationship; and appeared to benefit both mentees and mentors. Mentors were perceived as valued experts because of their personal experience of injury and recovery, and could provide support in ways that were different from that provided by clinicians or family members. Mentors required support to manage the uncertainties inherent in the role.

CONCLUSIONS

The insight mentors developed through their own lived experience established them as a trusted and credible source of hope and support for people re-engaging in the community post-TBI. These findings indicate the potential for mentoring to result in positive outcomes.

The process of adjustment over time following stroke: A longitudinal qualitative study

Understanding how people adjust following stroke is essential to optimise recovery and ensure services are responsive to people's needs. This study aimed to explore people's experiences over the first three years post-stroke and identify what helped or hindered recovery. As part of a longitudinal, qualitative descriptive study, 55 people and 27 significant others purposefully selected from a population-based stroke incidence study were interviewed 6, 12, 24 and 36 months post-stroke. Interviews were audio taped and transcribed verbatim. Participants described an ongoing process of shock, disruption, and fear, making sense of what happened, needing to fit in with what's offered, finding what works for them and evolving a new normal, whilst managing the ups and downs of life. This process needed to be re-negotiated over time, as people experienced changes in their recovery, comorbidities and/or wider circumstances. The adjustment process continued over the three years post-stroke, even for those who perceived that they were recovering well. Rehabilitation services need to support patients to make sense of their stroke, navigate the health system, address individual concerns and priorities and to know what, when and how much to challenge themselves. Rehabilitation plans need to be revised as circumstances change to facilitate adjustment following a stroke.