Shifting mindsets: a realist synthesis of evidence from self-management support training

Exploring access to community neurorehabilitation for people with progressive neurological conditions: a qualitative study

PURPOSE

Community neurorehabilitation enables people with progressive neurological conditions (PNCs) to manage their symptoms to live an active, fulfilling life; however, it is not accessible to all. This study explored the factors influencing access to community neurorehabilitation in Northern Ireland from the perspective of people with PNCs and their carers.

METHODS

Eleven people living with a PNC and three carers took part in virtual focus groups. Data was thematically analysed using the framework method.

RESULTS

Access to neurorehabilitation was described as a staged journey, driven by people with PNCs, and impacted by interactions with others. Four themes were identified: the person in the driving seat, describing the value of person-centred care and the need for proactivity; the traffic lights, depicting the role and influence of health care professionals (HCPs); the need for direction; and roadworks and roadblocks, identifying additional barriers to access. In addition, six fundamentals of good access were identified.

CONCLUSIONS

This study adds depth to our understanding of the complexity, and the roles and needs of people with PNCs and HCPs, in accessing community neurorehabilitation. Further research is needed to determine how best to empower people to access rehabilitation.

Exercise as a Therapeutic Intervention in Multiple Sclerosis

The role of exercise as a therapeutic intervention in multiple sclerosis (MS) has shifted over time. Early views surrounding exercise in MS advocated for caution against participation. With increasing evidence, perspectives shifted to promote exercise as a therapeutic approach for symptom management. Recent efforts have focused on understanding the potential disease-modifying effects of exercise in MS, although this work is still in its infancy. While efforts continue to optimize exercise prescriptions and unravel underlying mechanisms of exercise effects, current knowledge and implementation gaps limit the accessibility of exercise as therapy for all people living with MS. This topical review is based on an invited presentation on 'Exercise as a Therapeutic Intervention in MS' delivered at the ACTRIMS Forum 2024. The review summarizes current evidence for the role of exercise as a therapeutic intervention in MS from symptomatic to disease-modifying potential. We highlight directions for future research efforts to advance our understanding of potential exercise benefits and translate findings into real-world contexts for people living with MS.

Realist analysis of qualitative data in health professions education research

BACKGROUND

Qualitative realist analysis is gaining in popularity in health professions education research (HPER) as part of theory-driven program evaluation. Although realist approaches such as syntheses and evaluations typically advocate mixed methods, qualitative data dominate currently. Various forms of qualitative analysis have been articulated in HPER, yet realist analysis has not. Although realist analysis is interpretive, it moves beyond description to explain generative causation employing retroductive theorising. Ultimately, it attempts to build and/or 'test' (confirm, refute or refine) theory about how, why, for whom, when and to what extent programs work using the context-mechanism-outcome configuration (CMOC) heuristic. This paper aims to help readers better critique, conduct and report qualitative realist analysis.

REALIST ANALYSIS METHODS

We describe four fundamentals of qualitative realist analysis: (1) simultaneous data collection/analysis; (2) retroductive theorising; (3) configurational analysis (involving iterative phases of identifying CMOCs, synthesising CMOCs into demi-regularities and translating demi-regularities into program theory); and (4) realist analysis quality (relevance, rigour, richness). Next, we provide a critical analysis of realist analyses employed in 15 HPER outputs-three evaluations and 12 syntheses. Finally, drawing on our understandings of realist literature and our experiences of conducting qualitative realist analysis (both evaluations and syntheses), we articulate three common analysis challenges (coding, consolidation and mapping) and strategies to mitigate these challenges (teamwork, reflexivity and consultation, use of data analysis software and graphical representations of program theory).

CONCLUSIONS

Based on our critical analysis of the literature and realist analysis experiences, we encourage researchers, peer reviewers and readers to better understand qualitative realist analysis fundamentals. Realist analysts should draw on relevant realist reporting standards and literature on realist analysis to improve the quality and reporting of realist analysis. Through better understanding the common challenges and mitigation strategies for realist analysis, we can collectively improve the quality of realist analysis in HPER.

Communication partner training for student health and social care professionals engaging with people with stroke acquired communication difficulties: A protocol for a realist review

Background

Stroke acquired communication impairments impede effective communication. Consequently, in stroke care, communicative interactions can be challenging for both patients and staff and can predispose patients to increased risk of preventable adverse events. Communication partner training (CPT) can mitigate such negative outcomes by optimising communicative interactions. Providing CPT to student health and social care professionals (SH&SCPs) has the potential to enhance their clinical expertise and experiences and enhance the future clinical care of patients with stroke acquired communication impairments. This research aims to expand our understanding of how CPT is operationalised for SH&SCPs in higher education institutions and determine: what works; for whom; in what contexts; how and why?

Methods

This review is Phase 1 of a research project employing a realist approach with public and patient involvement (PPI). It incorporates five iterative steps: 1.) Clarifying the scope; 2.) Searching for evidence; 3.) Selecting and appraising evidence; 4.) Data extraction; 5.) Synthesising data and developing a middle range theory explaining how CPT is expected to work for SH&SCPs. An advisory panel, including PPI advisors, content advisors, student advisors, realist advisors and educationalist advisor has been set up to consult throughout the review and collaboratively agree the middle range theory.

Discussion

While there is an evolving evidence base for CPT, including stroke specific CPT for SH&SCPs, it is acknowledged that there are challenges to its implementation in complex real-world settings. In combining empirical evidence with theoretical understanding, realist review permits synthesis of data from diverse sources and goes beyond determining efficacy to explore generative causation and solutions for real world practice. A middle range realist programme theory that coherently explains how CPT is expected to work when teaching SH&SCPs to communicate with people with stroke acquired communication impairments will provide educators with new insights into CPT development and implementation in their higher education institutions.

Participants' perspectives of "NeuroSask: Active and Connect"-a virtual chronic disease management program for individuals with a neurological condition

Introduction

Neurological conditions account from more than half of Canadians requiring chronic care. Both physical activity and the development of a self-management skillset are critical components supporting individuals with chronic health conditions. "NeuroSask: Active and Connected" is a virtual chronic disease management program offering twice weekly neuro-physiotherapist directed "active" exercise sessions, followed by weekly knowledge-exchange "connect" sessions with invited guest experts. NeuroSask was launched April 2020 in response to the restricted services and supports for people with neurological conditions. The program aimed to provide seated physical activity, social interaction, and access to expertise in neurological conditions and neurorehabilitation. A program evaluation of NeuroSask was conducted to gain participants' perspectives.

Methods

All participants registered for the NeuroSask program were invited to complete optional online surveys (SurveyMonkey) circulated by email at 3 occasions post-program launch: 10 weeks, 1 year, and 2 years. Participants could complete any one or all of the surveys, at their discretion. The number of potential respondents changed dependent on the total number of participants registered for NeuroSask at the time the survey was circulated. Questions were co-designed by multi-stakeholder team members. Descriptive statistics were used for closed-ended questions and a reflexive thematic analysis was completed with coding conducted in NVivo 12 Plus for open-ended text.

Results

Response rates (participants/registrants) were as follows: 10-week survey 260/793, one year survey 326/1224, and 2-year survey 434/1989. 90% of participants reported being in either the age categories of 40-59 years or above 60 years. 75% of both survey respondents and program registrants were female. 70% of both survey respondents and program registrants reported a diagnosis of multiple sclerosis and 30% reported other neurological conditions. Survey respondents were from all ten Canadian provinces, with 45% reporting living outside of large cities. Respondents reported preferring online vs. in person format for this type of programming. Three main themes, and eight corresponding subthemes were identified highlighting the perceived impact and key components of the NeuroSask program: Theme 1 "together in a positive and encouraging environment" (subthemes 1a: connection, 1b: empowerment); Theme 2 "access to enthusiastic qualified leaders from home" (subthemes 2a: leader characteristics, 2b: accessibility, 2c: program logistics); Theme 3 "being able to enjoy everyday life" (subthemes 3a: symptom benefits and beyond, 3b: carry-over, 3c: keep going, please do not cancel).

Conclusion

NeuroSask is an example of an accessible and meaningful virtual approach to providing ongoing support for some individuals with neurological conditions. It was perceived as beneficial for fostering community and connection in a positive environment with perceived benefits extending beyond symptom management to participant reported improvements in function, daily life, and disease experience.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

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.

Implementing a Health Care Professional-Supported Digital Intervention for Survivors of Cancer in Primary Care: Qualitative Process Evaluation of the Renewed Intervention

Background

Primary care plays an important role in supporting survivors of cancer; however, support is limited because of practitioners’ perceived lack of expertise and time. A digital intervention for survivors of cancer could provide an efficient way for primary care staff to support survivors of cancer without the need to accumulate expertise and skills to help patients make behavior changes; providing very brief support alongside this could maximize adherence to digital interventions. Renewed is a digital intervention that combines web-based behavior change advice with brief health care practitioner support from a nurse or health care assistant. Knowledge about the views and experiences of primary care staff providing support alongside a digital intervention for survivors of cancer is sparse, limiting the understanding of the acceptability and feasibility of this type of intervention.

Objective

This study aims to explore supporters’ experiences of providing support to survivors of cancer using Renewed, understand potential barriers to and facilitators of the implementation of Renewed in practice, and investigate the strengths and weaknesses of the intervention from the perspective of health care professionals.

Methods

This was a qualitative process evaluation nested within a large trial evaluating Renewed. A total of 28 semistructured telephone interviews were conducted with nurses and health care assistants. Data were analyzed using inductive thematic analysis.

Results

Four themes were developed during the analysis, which reflected the factors that supporters identified as hindering or enabling them to provide support alongside Renewed Online: Renewed Online as an acceptable digital tool with some improvements, confidence in enacting the supporter role, practicalities of delivering support alongside a digital intervention, and managing a patient-led approach. The analysis suggests that supporters perceived that a digital intervention such as Renewed would be beneficial in supporting survivors of cancer in primary care and fit within current practices. However, barriers to providing support alongside the intervention were also identified, including concerns about how to facilitate rapport building and, in a minority, concerns about using a nondirective approach, in which most advice and support is provided through digital interventions, with brief additional support provided by primary care staff.

Conclusions

These findings add to the literature on how best to provide support alongside digital interventions, suggesting that although most practitioners cope well with a nondirective approach, a minority requires more training to feel confident in implementing this. This study suggests that the barriers to providing formal support to survivors of cancer in primary care could be successfully overcome with an approach such as Renewed, where a digital intervention provides most of the support and expertise, and health care practitioners provide additional brief human support to maximize engagement. Strategies to maximize the chances of successful implementation for this type of intervention are also discussed.

Development and validation of INTENSS, a need-supportive training for nurses to support patients' self-management

BACKGROUND

The growing prevalence of chronic illnesses requires nurses to support self-management and help patients integrate the chronic illness into their life. To our knowledge there are currently no training programs that combine the necessary components to adequately enhance nurses' competencies in self-management support.

OBJECTIVE

The systematic development and validation of a need-supportive training in self-management support for nurses.

DESIGN

A three-phased study, according to van Meijel et al. (2004), with collection of building blocks, design, and validation of the need-supportive character of the training.

SETTING AND PARTICIPANTS

Eight training groups with 30 nurses, 34 nursing students and nine social healthcare workers from different nursing colleges in Flanders, Belgium.

METHODS

In phase one a literature review, current practice analysis, and problem and needs analysis were performed. In phase two, the INTENSS training intervention was developed, framed within the Self-Determination Theory and the 5A's-Model. The training consisted of a basic training module and a video-interaction guidance module. The intervention was subsequently tested in eight training groups (N = 73). Participants provided feedback during focus group discussions. The intervention was cyclically adapted to trainees' experiences and suggestions. In phase three, we evaluated the need-supportive character of the training intervention.

RESULTS

Phase one indicated the need for training, since nurses' application of self-management support was limited and practiced from a narrow medical point of view. In phase two we developed a theory-driven and multifaceted training, building on attitude, knowledge, skills and reflection in the training. The training was framed within the Self-Determination Theory both at the didactical level as well as on content and format. Overall, participants appreciated the building blocks of the training as supporting their basic needs for autonomy, relatedness and competence.

CONCLUSIONS

INTENSS, a multifaceted need-supportive training in self-management support was developed, successfully taking into account participants' needs.

Continuity of Care and Self-Management among Patients with Stroke: A Cross-Sectional Study

(1) Background: Stroke is an important topic in the healthcare industry. The objective of the present study was to investigate patients' sociodemographic characteristics, health status, continuity of care, self-management, and other predictors that affect their self-management. (2) Methods: This cross-sectional correlational study was carried out from March to September 2020, and included a total of 150 patients aged 20 and above who were diagnosed within the past 6 months. The research participants were selected from the Division of Neurology, Department of Internal Medicine/Department of Surgery, at a medical center in Central Taiwan. (3) Results: The mean self-management score of patients with stroke was 110.50 points (30-150 points). As shown in the stepwise regression analysis, the overall regression model explained approximately 44.5% of the variance in self-management. Educational level (10.8%), frequency of exercise per week (2.1%), time that patients were affected by stroke (2.4%), and continuity of care (29.2%) were the main predictors affecting the self-management of stroke patients. (4) Conclusions: To improve stroke patients' self-management, medical teams should provide appropriate continuity of care to those with lower educational levels, those without exercise habits, and those who experienced a stroke within the past six months.

Training interventions for healthcare providers offering group-based patient education. A scoping review

OBJECTIVES

To provide overview of research on training interventions for healthcare providers aimed at promoting competencies in delivering group-based patient education.

METHODS

A systematic literature search identified relevant studies. Data was extracted on training details, study design, outcomes and experiences. Results were summarized and qualitative data analyzed using content analysis.

RESULTS

Twenty-seven studies exploring various training interventions were included. Ten studies used qualitative methods, eight quantitative and nine mixed methods. Use of a comparison group, validated instruments and follow-up measures was rare. Healthcare providers' reactions to training were mostly positive. Several studies indicated positive short-term effects on self-efficacy and knowledge. Results on observed skills and patient outcomes were inconclusive. Results on healthcare providers' experience of delivery of group-based patient education following training were categorized into 1) Benefits of training interventions, 2) Barriers to implementation and 3) Delivery support.

CONCLUSIONS

Further evaluation of training for healthcare providers delivering group-based patient education is needed before conclusions on training efficacy can be drawn. The results indicate an expanding research field still in maturation.

PRACTICE IMPLICATIONS

Efficacy studies evaluating theoretically grounded training with clear attention on group facilitation and follow-up support are needed. Inclusion of validated instruments and long-term outcomes is encouraged.

Exploring self-management within hospital-based stroke care: current and future opportunities

PURPOSE

This study explored stroke self-management within a tertiary hospital setting from the perspectives of health professionals working across the continuum of stroke care.

MATERIALS AND METHODS

A qualitative descriptive design guided five focus groups in the acute stroke service (n = 2), inpatient rehabilitation (n = 2), and outpatient day hospital service (n = 1). Focus groups were transcribed verbatim and analysed using thematic analysis.

RESULTS

Twenty-eight health professionals participated representing medical, nursing, and allied health services. Two themes emerged from the data: Pieces of the puzzle illustrates the inconsistent understanding about self-management with elements of the puzzle described but rarely within the full concept of self-management; Readiness for self-management highlighted that although self-management should commence in the acute setting, there were many factors influencing why this was not always happening.

CONCLUSIONS

A consistent conceptualisation and approach to stroke self-management in the hospital setting is required. Interprofessional education and shared intentional language can enhance understanding and practice.IMPLICATIONS FOR REHABILITATIONUnderstanding and application of stroke self-management varies among members of hospital-based stroke teams.Health professionals working in hospital-based stroke care should use the term self-management with their patients.Education of healthcare teams is necessary to develop knowledge about self-management and develop consistent practices across the continuum of care.

The student is key: A realist review of educational interventions to develop analytical and non-analytical clinical reasoning ability

OBJECTIVES

Clinical reasoning refers to the cognitive processes used by individuals as they formulate a diagnosis or treatment plan. Clinical reasoning is dependent on formal and experiential knowledge. Developing the ability to acquire and recall knowledge effectively for both analytical and non-analytical cognitive processing has patient safety implications. This realist review examines the way educational interventions develop analytical and non-analytical reasoning ability in undergraduate education. A realist review is theory-driven, seeking not only to identify if an intervention works, but also understand the reasons why, for whom, and in what circumstances. The aim of this study is to develop understanding about the way educational interventions develop effective analytical and non-analytical clinical reasoning ability, when they do, for whom and in what circumstances.

METHODS

Literature from a scoping search, combined with expert opinion and researcher experience was synthesised to generate an initial programme theory (IPT). Four databases were searched and articles relevant to the developing theory were selected as appropriate. Factors affecting educational outcomes at the individual student, teacher and wider organisational levels were investigated in order to further refine the IPT.

RESULTS

A total of 28 papers contributed to the overall programme theory. The review predominantly identified evidence of mechanisms for interventions at the individual student level. Key student level factors influencing the effectiveness of interventions included an individual's self-confidence, self-efficacy and pre-existing level of knowledge. These contexts influenced a variety of educational interventions, impacting both positively and negatively on educational outcomes.

CONCLUSIONS

Development of analytical and non-analytical clinical reasoning ability requires activities that enhance knowledge acquisition and recall alongside the accumulation of clinical experience and opportunities to practise reasoning in real or simulated clinical environments. However, factors such as pre-existing knowledge and self-confidence influence their effectiveness, especially amongst individuals with 'low knowledge.' Promoting non-analytical reasoning once novices acquire more clinical knowledge is important for the development of clinical reasoning in undergraduate education.

Training in health coaching skills for health professionals who work with people with progressive neurological conditions: A realist evaluation

Background

Supporting people to self‐manage their long‐term conditions is a UK policy priority. Health coaching is one approach health professionals can use to provide such support. There has been little research done on how to train clinicians in health coaching or how to target training to settings where it may be most effective.

Objective

To develop theories to describe how training health professionals in health coaching works, for whom and in what circumstances, with a focus on those working with people with progressive neurological conditions.

Design

Realist evaluation using mixed methods (participant observation, pre‐ and post‐training questionnaires, and telephone interviews with participants and trainers). Realist data analysis used to develop and refine theories.

Intervention

Two 1‐day face‐to‐face training sessions in health coaching with 11 weeks between first and second days.

Setting and participants

Twenty health‐care professionals who work with people with neurological conditions in the UK, two training facilitators.

Results

Four theories were developed using context‐mechanism‐outcome configurations to describe how training triggers critical reflection; builds knowledge, skills and confidence; how participants evaluate the relevance of the training; and their experiences of implementing the training. Some participants reported a major shift in practice, and others implemented the training in more limited ways.

Discussion

Fully embracing the role of coach is difficult for health professionals working in positions and settings where their clinical expertise appears most highly valued.

Conclusions

Training should address the practicality of using coaching approaches within existing roles, while organizations should consider their role in facilitating implementation.

Characteristics of Future Models of Integrated Outpatient Care

Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.