Person centered care in neurorehabilitation: a secondary analysis

"Wasting time": a qualitative study of stroke survivors' experiences of boredom in non-therapy time during inpatient rehabilitation

PURPOSE

Stroke survivors regularly report experiencing boredom during inpatient rehabilitation which may detrimentally affect mood, learning and engagement in activities important for functional recovery. This study explores how stroke survivors meaningfully occupy their non-therapy time and their experiences of boredom, to further our understanding of this complex phenomenon.

METHODS

Secondary analysis of transcripts from semi-structured interviews with stroke survivors exploring activity during non-therapy time. Transcripts were coded and analysed using a hybrid approach of inductive and deductive thematic analysis, guided by a published boredom framework.

RESULTS

Analysis of 58 interviews of 36 males and 22 females, median age 70 years, revealed four main themes: (i) Resting during non-therapy time is valued, (ii) Managing "wasted" time, (iii) Meaningful environments support autonomy and restore a sense of normality, and (iv) Wired to be social. Whilst limited therapy, social opportunities and having "nothing to do" were common experiences, those individuals who felt in control and responsible for driving their own stroke recovery tended to report less boredom during their rehabilitation stay.

CONCLUSION

Creating rehabilitation environments that support autonomy, socialisation and opportunities to participate in activity are clear targets to reduce boredom during non-therapy time, increase meaningful engagement and possibly improve rehabilitation outcomes post-stroke.

Psychometric properties of the client-centred rehabilitation questionnaire-is derived from a large and varied group of rehabilitation users

PURPOSE

The purpose of this study was to inspect and establish the factor structure of the Icelandic Client-Centred Rehabilitation Questionnaire [CCRQ-is] and investigate the service experiences of a large and varied sample of rehabilitation users.

MATERIALS AND METHODS

Altogether 499 rehabilitation users completed the questionnaire. Confirmatory and exploratory factor analysis was conducted for analysis of items. Mann-Whitney's U and Kruskal-Wallis test was used to compare subscale responses based on participants' characteristics.

RESULTS

Four factors explained 53,2% of the variance: Respect and attentiveness, Interaction with significant others, Responsiveness to needs and preferences and Education and enablement. Subscales showed internal consistency from 0.72-0.91 and 0.92 for the whole instrument. The subscale Respect and attentiveness represented user centred rehabilitation the most and Interaction with significant others the least. Significant differences in relation to health conditions and age were obtained on all four subscales and differences by gender on one subscale.

CONCLUSIONS

Our results suggest the CCRQ-is is a reliable tool that can be used with rehabilitation users with a broad range of characteristics within the Icelandic context. The extent to which the intersection of age, gender and health issues influence users' perception of services needs to be further scrutinized.

A Brain Computer Interface Neuromodulatory Device for Stroke Rehabilitation: Iterative User-Centered Design Approach

BACKGROUND

Rehabilitation technologies for people with stroke are rapidly evolving. These technologies have the potential to support higher volumes of rehabilitation to improve outcomes for people with stroke. Despite growing evidence of their efficacy, there is a lack of uptake and sustained use in stroke rehabilitation and a call for user-centered design approaches during technology design and development. This study focuses on a novel rehabilitation technology called exciteBCI, a complex neuromodulatory wearable technology in the prototype stage that augments locomotor rehabilitation for people with stroke. The exciteBCI consists of a brain computer interface, a muscle electrical stimulator, and a mobile app.

OBJECTIVE

This study presents the evaluation phase of an iterative user-centered design approach supported by a qualitative descriptive methodology that sought to (1) explore users' perspectives and experiences of exciteBCI and how well it fits with rehabilitation, and (2) facilitate modifications to exciteBCI design features.

METHODS

The iterative usability evaluation of exciteBCI was conducted in 2 phases. Phase 1 consisted of 3 sprint cycles consisting of single usability sessions with people with stroke (n=4) and physiotherapists (n=4). During their interactions with exciteBCI, participants used a "think-aloud" approach, followed by a semistructured interview. At the end of each sprint cycle, device requirements were gathered and the device was modified in preparation for the next cycle. Phase 2 focused on a "near-live" approach in which 2 people with stroke and 1 physiotherapist participated in a 3-week program of rehabilitation augmented by exciteBCI (n=3). Participants completed a semistructured interview at the end of the program. Data were analyzed from both phases using conventional content analysis.

RESULTS

Overall, participants perceived and experienced exciteBCI positively, while providing guidance for iterative changes. Five interrelated themes were identified from the data: (1) "This is rehab" illustrated that participants viewed exciteBCI as having a good fit with rehabilitation practice; (2) "Getting the most out of rehab" highlighted that exciteBCI was perceived as a means to enhance rehabilitation through increased engagement and challenge; (3) "It is a tool not a therapist," revealed views that the technology could either enhance or disrupt the therapeutic relationship; and (4) "Weighing up the benefits versus the burden" and (5) "Don't make me look different" emphasized important design considerations related to device set-up, use, and social acceptability.

CONCLUSIONS

This study offers several important findings that can inform the design and implementation of rehabilitation technologies. These include (1) the design of rehabilitation technology should support the therapeutic relationship between the patient and therapist, (2) social acceptability is a design priority in rehabilitation technology but its importance varies depending on the use context, and (3) there is value in using design research methods that support understanding usability in the context of sustained use.

Learning from clinical placement experience: how do undergraduate physiotherapy students approach person-centered practice?

INTRODUCTION

It is now widely accepted in physiotherapy and in other health professions, that involving patients in the design, planning and implementation of services is best practice. Little is, however, known about how physiotherapy students perceive their professional development in applying person-centered practice.

OBJECTIVE

To analyze how undergraduate physiotherapy students experience the process of learning to work in a person-centered way in clinical practice.

METHOD

Five focus-group interviews of final-year physiotherapy students.

RESULTS

It is important that students communicate in ways that accommodate the sociocultural characteristics of their patients. Students, where they experience that mutual understanding is not possible to achieve, tend to resort to the biomedical model and take on an expert instructor role that is met with acceptance from the patients. Some practice contexts were also found to strongly promote person-centered practice, others tightly restricting it.

CONCLUSION

In the educational setting, attention should be paid to the practice learning context, to the improvement of the ability of students to grasp the lived world of patients, and to activate their own identities and experiences as a relational tool in practicing person-centered care.

Communication between rehabilitation staff and people with traumatic brain injury: A systematic review

This systematic review aimed to synthesize barriers and facilitators in communicative interactions between staff and people with traumatic brain injury (TBI) in the rehabilitation context. Searches captured published evidence up to November 2022 in MEDLINE, Embase, SCOPUS, Web of Science, CINAHL, AMED, and PsycINFO. Eligible studies reported on the communicative interaction between rehabilitation staff and adults with TBI. In total, 31 studies were included in the review; including quantitative, qualitative, and mixed-methods designs. Quality assessment was carried out using standard checklists. Quantitative studies and quantitative components of mixed-method studies were synthesized descriptively according to reported communication barriers and facilitators. Qualitative studies and qualitative components of mixed-method studies were analysed through an inductive thematic meta-synthesis; generating six main themes with four subthemes. Themes were categorized as barriers or facilitators to communicative interaction. Findings demonstrated that cognitive-communication disorders of people with TBI challenge the communicative interaction between rehabilitation staff and people with TBI. However, the extent to which these disorders create a communicative barrier is closely related to staff's communicative approach. While staff holding a collaborative and acknowledging approach and using supportive strategies may facilitate successful communicative interactions, staff using the opposite approach may exacerbate communication barriers.

An ethnographic study exploring person-centred nutrition care in rehabilitation units

PURPOSE

Person-centred care (PCC) is an essential component of high-quality healthcare across professions and care settings. While research is emerging in subacute nutrition services more broadly, there is limited literature exploring the person-centredness of nutrition care in rehabilitation. This study aimed to explore person-centred nutrition care (PCNC) in rehabilitation units, as described and actioned by patients, support persons and staff. Key factors influencing PCNC were also explored.

MATERIALS AND METHODS

An ethnographic study was undertaken across three rehabilitation units. Fifty-eight hours of field work were completed with 165 unique participants to explore PCNC. Field work consisted of observations and interviews with patients, support persons and staff. Data were analysed through the approach of reflexive thematic analysis, informed by PCC theory.

RESULTS

Themes generated were: (1) tensions between patient and staff goals; (2) disconnected moments of PCNC; (3) the necessity of interprofessional communication for PCNC; and (4) the opportunity for PCNC to enable the achievement of rehabilitation goals.

CONCLUSIONS

PCNC was deemed important to different stakeholders but was at times hindered by a focus on profession-specific objectives. Opportunities exist to enhance interprofessional practice to support PCNC in rehabilitation. Future research should consider the system-level factors influencing PCNC in rehabilitation settings.

Effective Teams in Vocational Rehabilitation: An Exploration of Complexities and Practice in Aotearoa-New Zealand

PURPOSE

Vocational rehabilitation (VR) involves complex skills, and often inter-disciplinary teams need to work effectively to meet the needs of stakeholders. Research highlights important influences on effective teamwork, including funding systems, team structure, policies and procedures, and effects of professional hierarchies. This qualitative study aimed to explore these issues in-depth including how factors interact to produce problems and solutions. We focused on identifying challenges and opportunities for VR teams working in the Aotearoa-New Zealand context which may also be transferrable to other settings.

METHODS

Qualitative descriptive instrumental case study involving focus groups and interviews with two VR teams (n = 14). Teams worked in musculoskeletal injury and were geographically diverse. Reflexive thematic analysis was used to analyse the data.

RESULTS

Analysis constructed three overarching themes: Having the Power, Being Human, and VR is Not for Everyone. Achieving trusting relationships within the team was paramount. This was achieved through seeing everyone as equal, and as human. Equality within the team was particularly important for professionals that occupied different positions of power in a wider professional hierarchy. VR specialist skills (experience and postgraduate qualifications) were often under-recognised, leading them to have little power in VR decision making processes. VR professionals also experienced competing demands between client needs and business drivers.

CONCLUSION

Findings offer detail of processes teams engage in to create effective team relationships and manage systemic factors to facilitate positive outcomes. Additionally, findings highlight opportunities in decision-making processes for VR medical certification that may increase job satisfaction and better utilize skills and expertise.

An educational intervention to promote a culture of gender equity among persons with traumatic brain injury and caregivers: A pilot study

Background

Traumatic brain injury (TBI) outcomes are dependent on patients' biological sex (e.g., hormone levels) and sociocultural gender (e.g., norms, responsibilities). Informal caregivers additionally experience disruptions to identity and roles post-TBI. However, information on this topic remains largely unavailable to patients and caregivers.

Purpose

This study aimed to determine the effectiveness of a one-time educational intervention on sex and gender influences in TBI for patients and informal caregivers.

Materials and methods

We conducted a pilot pre-test/post-test randomized control-group design study. Groups (i.e., passive, active and control) consisted a total of 16 persons with TBI and caregivers (75% persons with TBI, 63% women). Individual and group learning gains, and group-average normalized gain, were computed for three learning domains: knowledge, attitude, and skill. An intervention with an average normalized gain of ≥30% was considered effective. Educational intervention evaluation and qualitative comments post-participation were summarized.

Results

The passive group demonstrated the highest average normalized gain across the three learning domains, including 100% for knowledge, 40% and 61% for attitude, and 37% for skill. The remaining groups did not reach an average normalized gain of ≥30%, except for the attitude domain of the control group (33% and 32%). Two key categories were identified qualitatively: (1) gendered self-expectations post-injury and (2) implications of gender stereotypes in rehabilitation, including the need for rehabilitation treatment to look beyond sex and gender. The post-participation educational session evaluation conveyed high appraisal of content, organization, and usability of the intervention.

Conclusion

A one-time passive educational intervention on sex and gender in TBI may improve knowledge, attitude, and skill on the topic of sex and gender among adults with TBI and caregivers. Obtaining knowledge and skill on sex and gender effects in TBI can potentially help persons with TBI and caregivers adapt to changes in roles and behaviours post-injury.

Reflecting on challenges and opportunities for the practice of person-centred rehabilitation

OBJECTIVES

To (1) reflect on challenges to the practice of person-centred rehabilitation; and (2) propose opportunities for the development of person-centred rehabilitation.

CHALLENGES

Person-centred practice has received widespread endorsement across healthcare settings and is understood to be an important, positive approach in rehabilitation. However, the rhetoric of this approach does not always translate meaningfully into practice. Emphasis on patient choice, patient involvement in decision making, and increasing patient capacity for self-management have become a proxy for person-centred rehabilitation in lieu of a more fundamental shift in practice and healthcare structures. System (e.g. biomedical orientation), organisational (e.g. key performance indicators) and professional (e.g. identity as expert) factors compete with person-centred rehabilitation.

OPPORTUNITIES

Four key recommendations for the development of person-centred rehabilitation are proposed including to: (1) develop a principles-based approach to person-centred rehabilitation; (2) move away from the dichotomy of person-centred (or not) rehabilitation; (3) build person-centred cultures of care in rehabilitation; and (4) learn from diverse perspectives of person-centred rehabilitation.

CONCLUSION

Fixed assumptions about what constitutes person-centred rehabilitation may limit our ability to respond to the needs of persons and families. Embedding person-centred ways of working is challenging due to the competing drivers and interests of healthcare systems and organisations. A principles-based approach, enabled by person-centred cultures of care, may achieve the aspirations of person-centred rehabilitation.

Exemplary post-discharge stroke rehabilitation programs: A multiple case study

Objective

The objective of this study was to identify essential aspects of exemplary post-discharge stroke rehabilitation as perceived by patients, care partners, rehabilitation providers, and administrators.

Design

We carried out an exploratory qualitative, multiple case study. Stroke network representatives from four regions of the province of Ontario, Canada each nominated one post-discharge rehabilitation program they felt was exemplary.

Setting

The programs included: a mixed home- and clinic-based service; a home-based service; a clinic-based service with a stroke community navigator and; an out-patient clinic-based service.

Participants

Participants included 32 patients, 16 of their care partners, 23 providers, and 5 administrators.

Methods

We carried out semi-structured qualitative interviews with patients and care partners, focus groups with providers, and semi-structured interviews with administrators. Health records of patient participants were reviewed. Using an interpretivist-informed inductive content analysis, we developed overarching categories and subcategories first for each program and then across programs.

Results

Across four regions with differing types of programs, exemplary care was characterized by three essential components: stroke and stroke rehabilitation knowledge, relationship built through personalized respectful care, and a commitment to high quality, person-centered care.

Conclusion

Exemplary post-discharge care included knowledge regarding identification and treatment of stroke-related impairment, that is, information found in best practice guidelines. However, expertise related to building relationship through providing personalized respectful care, within a mutually supportive, improvement-oriented team was also essential. Additionally, administrators played a crucial role in ensuring continued ability to deliver exemplary care.

Person-centred care in individuals with stroke: a qualitative study using in-depth interviews

BACKGROUND

Person-centred care (PCC) has considerable effects on the clinical practice of health professionals. The purpose of this study was to describe the perspectives and perceived barriers and enablers of individuals with stroke regarding the PCC model in stroke rehabilitation.

METHODS

A qualitative exploratory study was conducted based on an interpretive framework. Participants were recruited using non-probabilistic purposeful sampling and a snowball-technique strategy. The inclusion criteria consisted of: (a) individuals > 18 years, (b) diagnosed with moderate or severe stroke according to the National Institutes of Health Stroke Scale and (c) in the post-acute or chronic stage of the disease. In total, 31 individuals with stroke were included. In-depth interviews and researchers' field notes were used to collect the data. A thematic analysis was performed. Also, credibility, transferability, dependability and confirmability techniques were followed to establish trustworthiness of the data.

RESULTS

Thirty-one individuals with stroke (11 women) were included. Three main themes were identified: (a) The person behind the "patient" label, recognizing the person beyond their illness and valuing their identity and individual characteristics, (b) The person at the centre of care, considering themselves as an active agent in their own care and respecting their preferences and expectations for their care process and (c) Training for PCC, providing health professionals with tools to achieve professional skills for the implementation and development of the PCC model.

CONCLUSIONS AND SIGNIFICANCE

This paper describes relevant aspects that health professionals should consider when providing PCC in the context of the rehabilitation of individuals with stroke. Key messagesThe individuals' perspective regarding person-centred care (PCC) has considerable effects on the clinical practice of health professionals.Individuals with stroke describe how there is a person behind the "patient" label, with identity, needs and desire to participate in decision making.Training in the PCC model helps healthcare professionals identify the needs of individuals with stroke during rehabilitation.

Organization of rehabilitation services in randomized controlled trials - which factors influence functional outcome? A systematic review

Objective

To identify factors related to the organization of rehabilitation services that may influence patients’ functional outcome and make recommendations for categories to be used in the reporting of rehabilitation interventions.

Data Sources

A systematic review based on a search in MEDLINE indexed journals (MEDLINE [OVID], Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials) until June 2019.

Study Selection

In total 8587 candidate randomized controlled trials reporting on organizational factors of multidisciplinary rehabilitation interventions and their associations with functional outcome. An additional 1534 trials were identified from June 2019 to March 2021. Data Extraction: Quality evaluation was conducted by 2 independent researchers. The organizational factors were classified according to the International Classification for Service Organization in Health-related Rehabilitation 2.0.

Data Synthesis

In total 80 articles fulfilled the inclusion criteria. There was a great heterogeneity in the terminology and reporting of service organization across all studies. Aspects of Settings including the Mode of Service Delivery was the most explicitly analyzed organizational category (44 studies). The importance of the integration of rehabilitation in the inpatient services was supported. Furthermore, several studies documented a lack of difference in outcome between outpatient vs inpatient service delivery. Patient Centeredness, Integration of Care, and Time and Intensity factors were also analyzed, but heterogeneity of interventions in these studies prohibited aggregation of results.

Conclusions

Settings and in particular the way the services were delivered to the users influenced functional outcome. Hence, it should be compulsory to include a standardized reporting of aspects of service delivery in clinical trials. We would also advise further standardization in the description of organizational factors in rehabilitation interventions to build knowledge of effective service organization.

‘The wairua first brings you together’: Māori experiences of meaningful connection in neurorehabilitation

Background and Aims:

Therapeutic connections enhance patient experience and outcomes after neurological injury or illness. While we have some understanding of the components necessary to optimise therapeutic connections, these have developed from western-centric ideals. This study sought to explore the perspectives of Māori brain injury survivors, and their whānau (wider family and community), to develop more culturally informed understandings of what matters most for Māori in the development and experience of therapeutic connection.

Design and Methods:

A bicultural approach underpinned by principles of Kaupapa Māori Research was used. Whānau views and experiences were gathered through wānanga (focus groups). These perspectives were analysed drawing on Māori methods of noho puku (self-reflection), whanaungatanga (relational linkage) and kaitiakitanga (guardianship).

Findings:

Three wānanga were held with 16 people – 5 brain injury survivors and 11 whānau members. The phrase ‘therapeutic connection’ did not resonate; instead, people spoke of meaningful connections. For rehabilitation encounters to be meaningful, three layers of connection were acknowledged. The elemental layer features wairua (spirit) and hononga (connection) which both underpinned and surrounded interactions. The relational layer reflects the importance of whānau identity and collectivism, of being valued, known, and interactively spoken with. Finally, the experiential layer consists of relational aspects important within the experience: relationships of reciprocity that are mana-enhancing and grounded in trust. These layers are interwoven, and together serve as a framework for meaningful connections.

Conclusions:

Meaningful connections in neurorehabilitation are underpinned by wairua and hononga; are multi-layered; are enabled through interactions with people, practice, process and place; are inclusive of whānau and resonate with Māori worldviews. The primacy of wairua and whānau within an interconnected view of health, challenges individualistic notions inherent in western health models and deepens existing understandings of meaningful connections in neurorehabilitation which can guide future rehabilitation research, teaching and practice.

It takes two to tango: The therapeutic alliance in community brain injury rehabilitation

Objective:

A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.

Method:

This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.

Results:

A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.

Conclusion:

These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

Humanising brain injury rehabilitation: a qualitative study examining humanising approaches to engagement in the context of a storytelling advocacy programme

Objectives:

Building upon the findings of an earlier study that explored the experience and impact of narrative storytelling following acquired brain injury (ABI), this study sought to examine the engagement of storytelling facilitators with storytellers.

Methods:

Transcripts of in-depth interviews conducted with six storytelling facilitators were analysed drawing upon content analysis. The analysis included a process of mapping previously analysed data (D’Cruz et al., 2020b) to a humanising values framework (Galvin & Todres, 2013; Todres et al., 2009).

Results:

The findings of this study provide insights into how facilitators engaged in humanising practice within the context of a storytelling advocacy programme. The facilitator participants ranged in years of facilitation experience from 1 to 11 years, with a mix of professional backgrounds, including health care (3), journalism (1) and community development (2). Analysed facilitator data mapped to each of the eight dimensions of the framework (insiderness, agency, uniqueness, togetherness, sense-making, personal journey, sense of place and embodiment), with a breadth of codes represented in each dimension, revealing the depth of humanisation.

Conclusions:

This study extends our understanding of approaches to engagement with adults living with ABI, demonstrating the humanising potential of storytelling. Furthermore, the findings help us to think about what it means to be human, guiding us to find ways to better partner with and support adults living with brain injury.

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.

Patient-centeredness in Physiotherapy - A literature mapping review

Background and purpose: Research on patient-centeredness within physiotherapy points to a need for clarification about what the concept entails in science and practice and how research positions itself within health care. Thus, the aim is to systematically map the characteristics of research on patient-centeredness in physiotherapy and critically discuss the dominant understandings within. Methods: A systematic research mapping was carried out, based on searches in leading bibliographic databases. Four categories were selected in order to characterize the research field: focus, design, theoretical approach and inherent logic. Findings: Of 5,324 studies, 101 were included in the final mapping, pointing to a limited amount of research. The papers included were published in 47 different journals. Two major research foci emerges: one testing or developing technologies (tools) to promote patient-centeredness and one exploring patients' or professionals' experiences related to physiotherapy practice. Most papers reported on empirical research and there seems to be a dearth of conceptual papers. The theoretical approaches applied were mainly psychological, pedagogical and biomedical. The papers included were divided into equal amounts of studies carried out within inherent logics of causality and complexity. Conclusion: The mapping suggests an incipient awareness of patient-centeredness within the research field of physiotherapy. Empirical studies dominate the field, whereas conceptual and critical papers seem in need of wider acknowledgment. The research field is divided into two mutually disconnected trends: one concerned with understanding the complexity of clinical practice and patients' experiences of treatment and illness, and another trend concerned with solving "the problem" of patient involvement.

Physiotherapists' views on their role in self-management approaches: A qualitative systematic review

Background: Self-management has been an increasingly important aspect of helping people manage their long-term conditions. The aim of this qualitative review was to synthesize the views of physiotherapists concerning their delivery of a self-management approach.Method: A systematic search was conducted on six electronic bibliographic databases to identify relevant primary studies. Studies were assessed for quality and data extracted. Qualitative data were analyzed using thematic synthesis. A total of 1189 studies were identified and screened. Eleven studies met the inclusion criteria.Results: Findings suggest that for self-management approaches to work, physio-therapists believe that patients need to actively participate. Boundaries on who is the expert were blurred at times with some physiotherapists struggling to relinquish control. High-quality patient-therapist relationships are required to build trust in order to support patients in the self-management of their long-term conditions. It is also important to consider the competing paradigms in which a service is delivered as this may facilitate or hinder self-management. Seeing patients as people is integral to supporting self-management approaches.Conclusion: Physiotherapists are well placed to support self-management but there is still a need for a cultural and paradigmatic shift in the physiotherapy profession and in some environments, this shift as yet is to be realized.

What matters most: a qualitative study of person-centered physiotherapy practice in community rehabilitation

BACKGROUND

Person-centered approaches to care require physiotherapists to engage in trying to understand the full range of biomedical, psychological, and social factors that people bring to the consultation, along with the client's individual responses to those factors. If, however, the main issues of importance to people are not openly declared and discussed they cannot be addressed. This is likely to result in people receiving interventions that clinicians think they need, rather than care based on their expressed needs and preferences.

OBJECTIVE

To understand people's abilities to express the issues of importance to them within a consultation and clinicians' abilities to acknowledge and address those issues.

DESIGN

A qualitative study using an interpretive phenomenological approach.

METHODS

Eight clients were interviewed before they met their physiotherapist, the initial consultation with their physiotherapist was recorded, and both were interviewed separately afterward.

ANALYSIS

The clients frequently do not raise their emotions or feelings as issues of importance, and physiotherapists generally struggle to elicit, or identify as important, such matters. How these were presented to the clinician and subsequently addressed varied. We formulated three themes: 1) managing complex situations; 2) establishing a person-centered agenda; and 3) addressing emotional issues.

CONCLUSIONS

Community physiotherapists may aim for a more person-centered approach; however, their habits, practices and behaviors remain within a culturally entrenched, clinician-centric, biomedical model.

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.

Factors Influencing the Delivery of Intensive Rehabilitation in Stroke: Patient Perceptions Versus Rehabilitation Therapist Perceptions

BACKGROUND

Despite increasing evidence regarding the benefit of intensive task-specific practice and aerobic exercise in stroke rehabilitation, implementation remains difficult. The factors influencing implementation have been explored from therapists' perspectives; however, despite an increased emphasis on patient involvement in research, patients' perceptions have not yet been investigated.

OBJECTIVE

The study aimed to investigate factors influencing implementation of higher intensity activity in people with stroke and to compare this with therapists' perspectives.

DESIGN

The design was a cross-sectional qualitative study.

METHODS

The study used semistructured interviews with people with stroke who were part of a randomized clinical trial, the Determining Optimal post-Stroke Exercise study, which delivered a higher intensity intervention. An interview guide was developed and data analyzed using implementation frameworks. Factors emerging from interviews with people with stroke were compared and contrasted with factors perceived by rehabilitation therapists.

RESULTS

Ten people with stroke were interviewed before data saturation was reached. Participants had a positive attitude regarding working hard and were satisfied with the graded exercise test, high intensity intervention, and the feedback-monitoring devices. Therapists and patients had contrasting perceptions about their beliefs regarding intensive exercise and the content of the intervention, with therapists more focused on the methods and patients more focused on the personal interactions stemming from the therapeutic relationship.

CONCLUSIONS

People with stroke perceived no barriers regarding the implementation of higher intensity rehabilitation in practice and were positive towards working at more intense levels. Contrastingly, from the therapists' perspective, therapists' beliefs about quality of movement and issues around staffing and resources were perceived to be barriers. In addition, therapists and people with stroke perceived the contents of the intervention differently, highlighting the importance of involving patients and clinicians in the development and evaluation of rehabilitation interventions.