Facilitators and barriers to patient-centred goal-setting in rehabilitation: A scoping review

Family expectations and demand for home-based videogaming therapy in children with cerebral palsy in Costa Rica: a mixed methods study

PURPOSE

To understand the expectations and demand for a movement-tracking videogame (Bootle Blast) for home-based, upper limb (UL) rehabilitation among Costa Rican children with cerebral palsy (CP).

METHODS

Data were collected via telephone screening (demand) and child-parent dyads Zoom interviews (expectations). Descriptive statistics and data transformation were used to report on demand success criteria (i.e., recruitment rate, having an appropriate screen and space to play, setting a weekly play time goal (PTG) ≥45 min, identifying one UL therapy goal). The DEPICT model for collaborative qualitative analysis was used in the thematic analysis of interview data.

RESULTS

Fifteen dyads participated (1.6 ± 1 recruited/month). All had a flat-screen TV in a suitable location to play, were able to set a UL therapy goal, and established PTGs ranging from 45-120 min per week. Identified themes were: 1) Socio-cultural factors heighten demand, 2) Feelings of hope prevail for the intervention, and 3) Collaborative goal setting supports realistic expectations for Bootle Blast.

CONCLUSIONS

Dyads had positive and realistic expectations about implementing the proposed videogaming intervention. This study provides insights on tailoring a family-centered, therapy gaming intervention to improve access to motor rehabilitation for children with CP in rural/remote settings and low-middle income countries.

Outcome measures in muscular dystrophy rehabilitation: an ICF content comparison approach to the most commonly used MD scales

INTRODUCTION

Functioning is the reason to be of rehabilitation as it is essential to the lives of people who suffer from a disease. The International Classification of Functioning, Disability and Health (ICF) can help in designing a functioning profile of a patient, identifying needs for rehabilitation plans and measuring the results of an intervention.

OBJECTIVE

To identify the outcome measurement instruments reported in clinical studies in muscular dystrophies (MDs) and provide an ICF content analysis.

METHOD

A systematic literature review was conducted until October 2022, using Medline, PubMed, and Scopus databases. Papers assessing outcomes related to functioning in patients with MDs were included.

RESULTS

A total of 116 papers were included and all identified outcome measures were linked to the ICF. Inter-researcher agreement for the linking process was 0.82. The analysed instruments focused mainly on aspects of body functions, followed by activities and participation. General scales were more comprehensive than specific.

CONCLUSIONS

The application of ICF in this research enhances the understanding of functioning of patients with MDs and the need to develop more specific but comprehensive scales tailored to the needs of MD patients, and can guide clinicians in a assessing patients through a biopsychosocial perspective.

Participatory Action Research to Enhance Patient-Centred Goal Setting in Geriatric Rehabilitation: A Nursing Team's Quest

AIM

The aim of this study was to provide insights into how, through exploring goal-setting interventions, a nursing team in geriatric rehabilitation might refine their patient-centred strategies.

DESIGN

The study design was participatory action research (PAR).

METHOD

Team members and nursing students, under the guidance of a facilitator, performed two PAR cycles. In the first cycle, the action phase consisted of preparing a multidisciplinary team meeting (MTM) with a patient. In the second cycle, based on the evaluation of the first, the participants worked with goals on a whiteboard in the patient's room. The data were collected in The Netherlands between February 2020 and June 2022. The data collection methods included the facilitator's logbook, observations, (group) interviews, charting activities and short surveys. Data analysis was conducted in weekly team sessions. The Guidelines for Best Practices in the Reporting of Participatory Action Research were followed.

RESULTS

In the first PAR cycle, the team learned that preparing an MTM with a patient did not enhance the patient's engagement in achieving their rehabilitation goals, but it was beneficial for the nurses' intermediate role between the patient and the multidisciplinary team. Clarity about responsibilities in the multidisciplinary team was a prerequisite for nurses to take on this role adequately. In the second PAR cycle, it became clear that working with a whiteboard in the patient's room had a positive effect on the patient's engagement in the rehabilitation process, and the nurses gained knowledge about a broader variety of professional rehabilitation domains.

CONCLUSION

Through PAR, the nursing team learned two lessons: cooperating with patients through MTM preparation and working with whiteboards enhanced their patient-centredness, but patients needed tangible goals to become engaged in their rehabilitation planning.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Prepare the multidisciplinary team meeting with the patient, as discussing rehabilitation goals can indirectly boost motivation by making older patients feel seen and heard, even if they seem unable to fully participate in the conversation. Clarify responsibilities in the multidisciplinary geriatric rehabilitation team. This is a prerequisite for nurses to take on an advocacy role for patients in multidisciplinary team meetings. To enhance patient-centred care, consider working with tangible goals on a whiteboard in the patient's room.

PATIENT AND PUBLIC CONTRIBUTION

No public and patient involvement.

A joint venture: patients' experiences with goal setting in rheumatology rehabilitation - a qualitative study

PURPOSE

To explore how patients with rheumatic musculoskeletal diseases (RMDs) perceive participation in the goal setting process prior to interdisciplinary rehabilitation.

METHODS

We conducted semi-structured interviews with 22 participants admitted to an interdisciplinary rehabilitation stay for patients with RMDs at two Danish rehabilitation centres. Qualitative content analysis was applied.

RESULTS

The participants perceived goal setting as a joint venture between two parties: the health professionals and the participant. Three categories were formed, which described both facilitators and barriers in the process. Responsibility for goal setting described the importance of shared responsibility, or health professionals as experts, taking full responsibility for goal setting. Equipped for goal setting included perceptions of being well prepared for the process, or considerations that goal setting was difficult because of a lack of information. An equal member of the team entailed both the feeling of being recognised as one in the team, or feeling like an outsider.

CONCLUSION

Goal setting is perceived as a challenge by some patients. Participation in goal setting depends on both the capacity and the opportunity to participate which are factors linked to patients' level of health literacy.

Child-led goal setting and evaluation tools for children with a disability: A scoping review

AIM

To examine child-led goal setting and evaluation tools and approaches for children with a disability or developmental delay.

METHOD

Six databases were searched for studies that included population (children aged less than 18 years with disability or developmental delay); construct (child-led goal setting tool or approach); and context (developmental therapy or rehabilitation). The utility of tools and approaches across the goal setting and evaluation process was investigated using abductive content analysis.

RESULTS

Fifty articles met the inclusion criteria. Three approaches and four tools for child-led goal setting and evaluation were identified. No studies reported the clinimetric properties of tools specifically for child self-respondents. Qualitative analysis revealed six distinct goal phases in which tools and approaches were used, which were synthesized into a new framework for child-led goal setting and evaluation titled DECIDE: Direct children to goal setting; Elicit goal topics and priorities; Construct a goal statement; Indicate baseline goal performance; Develop an action plan to address the goal; and Evaluate goal progress after the intervention.

INTERPRETATION

Children actively participated in goal setting and evaluation across six DECIDE goal phases. Further clinimetric information is required to support use of goal setting and evaluation tools with child self-respondents. Future research should emphasize the development of multi-phase goal setting tools and approaches for diverse populations of children.

Optimal child-led goal setting practices for school-aged children with a disability or delay: an international Delphi consensus study

AIM

To achieve expert consensus on optimal child-led goal setting and evaluation practices for school-aged children (5 ≤ 17 years) who have a disability or delay.

METHOD

A three-round, eDelphi consensus design was used. In Round 1, expert allied health professionals identified factors important during child-led goal setting for: (i) planning, (ii) process steps and tools, and (iii) support strategies. Factors were collated into items for Rounds 2 and 3. Participants rated item agreement on a 7-point Likert scale. Consensus was determined as ≥75% of participants in agreement or disagreement.

RESULTS

Sixty professionals from nine countries and six disciplines participated. Of 323 unique items generated, 159 (50%) reached consensus. Strong agreement was reached for goal setting and evaluation "process steps" and "support strategies" to engage children. It was strongly recommended that allied health professionals should tailor their processes to each child's individual needs, provide ability-specific strategies and resources, and empower children to share their perspectives. Fewer items reached consensus for "planning" and "tools" to guide child-led goal setting.

INTERPRETATION

Professional experts agree that children can be actively involved in goal setting and evaluation. Future research should focus on tools and technologies to support child-led goal setting for children with diverse abilities.

An intensive eye-tracking intervention in children with dyskinetic cerebral palsy: a multiple case study

This study aimed to explore the effects of a four-week intensive eye-tracking intervention on children with dyskinetic cerebral palsy (DCP), focusing on goal attainment, communication competencies, stress levels, subjective workload, and caregivers' perception of psychosocial impact. A multiple case study design with non-concurrent, staggered multiple baselines was employed, involving three children aged 7, 12, and 13 years. The study included a randomized baseline period of two or three weeks, an intensive eye-tracking intervention, and a six-month follow-up. Two individual eye-tracking goals were identified and assessed using the Goal Attainment Scale, while communication competencies were evaluated with the Augmentative and Alternative Communication Profile: A Continuum of Learning. Stress levels were monitored through Heart Rate Variability measured by the Bittium Faros 360° ECG Holter during eye-tracking tasks. Subjective workload and psychosocial impact were assessed using pictograms and the Psychosocial Impact of Assistive Devices Scale, respectively. Descriptive statistics were applied for analysis. All participants attained and retained their eye-tracking goals, regardless of their initial functional profiles or prior experience with eye-tracking technology. Post-intervention improvements in communication competencies were maintained at the six-month follow-up. Variations in stress levels, subjective workload, and psychosocial impact were observed among participants across different phases of the study, aiding the interpretation of the results. The study concludes that a structured, tailored, four-week intensive eye-tracking intervention can yield successful results in children with DCP, irrespective of their baseline communication abilities or functional profile. Recommendations for future research, including more robust methodologies and reliable computerized tests, are provided.

Designing an occupation-based group intervention for adult inpatient rehabilitation: Partnering with clinicians and patients using a nominal group technique design

INTRODUCTION

Occupation-based interventions use engagement in a person's daily activities to achieve change. There is growing research into the use of occupation-based group interventions in the inpatient rehabilitation setting. It remains unclear whether occupation-based groups offer comparable outcomes to occupation-based interventions delivered individually; this research will precede a clinical trial aimed at comparing these two approaches for improving occupational performance outcomes. This study details the process of co-designing the intervention. Partnering with clinicians and patients in the design of healthcare interventions can promote patient-centred care, enhance uptake, and improve applicability and sustainability of the intervention to that setting.

METHODS

A modified nominal group technique (NGT) design was applied to facilitate two meetings and an electronic survey with an expert panel of clinicians and patients. Twelve participants (n = 4 occupational therapists, n = 1 registered nurse, n = 1 physiotherapist, n = 1 occupational therapy assistant, n = 1 occupational therapy manager, and n = 4 patients) were purposively recruited. A modified approach to the technique's four stages was used: silent generation, round robin, clarification, and voting. Consensus was set at >50%. Qualitative data from group discussions were analysed thematically.

FINDINGS

All participants agreed the intervention should include patient-centred, goal-directed, practice of daily activities, including breakfast and lunch preparation, domestic tasks, and laundry. Other components that were agreed included where the groups could run, group size, eligibility criteria, and frequency. Key themes from clinicians included needing a goal-directed intervention, focused on progressing towards hospital discharge; time and resource requirements were also discussed. Patients emphasised the importance of building social connections, opportunity to engage in meaningful activity, and the importance of linking participation to patient goals.

CONCLUSION

Through collaboration with clinicians and patients, an occupation-based group intervention considering the available evidence, alongside clinical, experiential, and contextual sources of knowledge was developed; this resulted in an evidence-based, patient-centred, and contextually relevant intervention.

Exploring Consumer Experiences of Barriers and Enablers to Accessing Rehabilitation That Meets Their Needs: The Rehabilitation Choices Study, Part 2-Consumer Perspectives

INTRODUCTION

Improved access to rehabilitation is highlighted as a key pathway to achieving the World Health Organisation's (WHO) goal of ensuring healthy lives and promoting well-being for all (Sustainable Development Goal 3). This article is the second in a two-part series outlining the findings from the Rehabilitation Choices study, which aimed to identify how health professionals and consumers in Australia are informed to make decisions about rehabilitation, and their experience with barriers and enablers to accessing that rehabilitation. In this study, we present the perspectives of consumers with different health conditions and a range of experiences with rehabilitation services.

METHODS

This was a qualitative study using focus groups and semi-structured interviews. People with self-reported lived experience of rehabilitation and carers were recruited using maximum variation sampling. Thematic analysis of data was conducted using an inductive approach.

RESULTS

Fifty-six consumers with diverse lived experiences of rehabilitation (19-80 years, 49 patients, 7 carers) participated in focus groups and interviews to discuss how they sourced information about rehabilitation and their experiences of what made it hard or easy to access rehabilitative care to meet their needs. Four themes were produced from the data: (1) service-centricity of options limits access, (2) access is the patient's responsibility, (3) enabling decision-making about rehabilitation with appropriate information and (4) provision of a psychologically safe environment.

CONCLUSIONS

Any planned (re)design of services to improve consumer access to rehabilitation should consider the themes identified in this study. This will ensure that consumers are provided with rehabilitation options that suit their holistic and unique needs beyond consideration of their medical diagnoses, and are actively supported to navigate this access, provided with information to help them make informed choices and provided a psychologically safe environment to engage effectively with rehabilitation.

PATIENT OR PUBLIC CONTRIBUTION

Three consumer research partners with lived experience of rehabilitation as patients or carers were core team members. They were involved in the design and implementation of the recruitment and communications strategies, design of the interview approach and discussion guide, contributed to the interpretation and contextualisation of findings and writing of this manuscript and are included as co-authors (A. O., T. W. and S. W.).

Implementing falls prevention patient education in hospitals - older people's views on barriers and enablers

BACKGROUND

World falls guidelines recommend that hospitalised older patients receive individualised falls prevention education, yet no studies have sought older people's feedback on how best to deliver falls prevention education in hospitals. The objective of the study was to explore the perspectives of older people and their caregivers about barriers and enablers to implementation of a tailored hospital falls education program.

METHODS

A qualitative descriptive design was used. Three focus groups and 16 semi-structured interviews were conducted. A purposive sample of older people who had previous hospital admissions and caregivers of older people were selected to review a co-designed patient falls education program (the revised Safe Recovery program). They provided feedback on how to implement the program in hospital settings. Data were thematically analysed taking an deductive-inductive approach.

RESULTS

Participants were 37 older people [female n = 24 (64.9%), age range 64 to 89 years] and nine caregivers (female n = 8). The first theme was that the Safe Recovery Program resources were of high quality, enabling strong patient engagement and increased knowledge and awareness about falls prevention in hospitals. The second theme identified practical strategies to enable program delivery in hospital wards. The key enablers identified were: timing of delivery around wellness and the patient's mobility; tailoring messages for each older patient; key staff members being assigned to lead program delivery. Participants recommended that staff assist older patients to set appropriate behavioural goals in relation to preventing falls in hospitals. They also recommended that staff raise older patients' confidence and motivation to take action to reduce the risk of falls. Providing resources in other languages and alternative shorter versions was recommended to enable broad dissemination.

CONCLUSIONS

Older people and their caregivers advised that implementing falls education in hospitals can be enabled by using high quality resources, delivering falls education in a timely manner and personalising the education and support to individual needs.

Empowering sickle cell disease care: the rise of TechnoRehabLab in Sub-Saharan Africa for enhanced patient's perspectives

Sickle-cell Disease (SCD) is a major public health problem in Africa, and there are significant obstacles to its comprehensive management, particularly in terms of access to appropriate healthcare. This calls for inventive approaches to improve patients' prospects. Among the major challenges to be met are the primary and secondary prevention of certain serious complications associated with the disease, such as neurocognitive, motor and respiratory functional disorders. This perspective argues for the rapid creation of specific, cost-effective, technology-supported rehabilitation centres to advance SCD care, identify patients at high risk of stroke and implement tailored rehabilitation strategies. The TechnoRehabLab in Lubumbashi illustrates this shift in thinking by using cutting-edge technologies such as virtual reality (VR), serious games and mobile health to create a comprehensive and easily accessible rehabilitation framework. Diagnostic tools used to perform functional assessment can be used to identify cognitive, balance and walking deficits respectively. Transcranial Doppler enables early detection of sickle cell cerebral vasculopathy, making it possible to provide early and appropriate treatment. VR technology and serious games enable effective rehabilitation and cognitive stimulation, which is particularly advantageous for remote or community-based rehabilitation. In the context of African countries where there is a glaring disparity in access to digital resources, the TechnoRehabLab serves as a tangible example, demonstrating the flexibility and accessibility of technology-assisted rehabilitation. This perspective is an urgent call to governments, non-governmental organisations and the international community to allocate resources to the replication and expansion of similar facilities across Africa.

Why did this happen to me? Causal attributions of illness and cultural health capital

This study examines how conversations between patients and clinicians about the causes of their health conditions relate to patient engagement in care. Leveraging cultural health capital (CHC) theory, we find that patient-physician discussions of health attributions are one mechanism to build patient understanding and activate engagement. We present a qualitative interpretive analysis of data collected in three phases with adult home health care patients: phone interviews (n = 28), field observations (n = 61), and semi-structured field interviews (n = 38). We find that engaging in discussions of causal health attributions with clinicians enables patients to overcome uncertainty, envision preventive actions, and engage in setting future goals. Such discussions must be supported by acknowledgement of the co-responsibility of individual factors and structural factors such as social determinants of health. These discussions are not easy to navigate but they can potentially help patients transition from a mindset of treating the disease (pathogenic approach) to an awareness of their available capabilities to improve health (salutogenic approach). This study contributes to research on attribution theory and cultural health capital theory by demonstrating how discussing causes for poor health can enable patients resolve doubts and accrue instrumental and symbolic resources that facilitate healing.

Barriers and Enablers for Accessing Rehabilitation Services: Findings From the Rehabilitation Choices Study, Part 1-Healthcare Professionals' Perspectives

INTRODUCTION

Globally, there is an increasing demand for quality medical rehabilitation services. This is the first article of a two-part series showing the findings from the Rehabilitation Choices study in which the main aim was to understand the current landscape of decision-making, enablers and barriers to access appropriate rehabilitation services in the Australian setting. In Part 1, these insights were sought from a healthcare professionals' perspective.

METHODS

This was an exploratory, qualitative study, using semi-structured interviews with a discussion guide that was codesigned together with rehabilitation clinicians and rehabilitation researchers. Themes and sub-themes were identified using an inductive approach.

RESULTS

We interviewed a heterogeneous group of 31 professionals who are involved in making referral decisions about rehabilitation or who design and deliver rehabilitation programs, including specialist rehabilitation physicians and other medical doctors across in-patient, outpatient, and primary care settings, allied health professionals, rehabilitation service managers, nurses, multicultural health liaison officers and rehabilitation research scientists. Three key themes relevant to barriers and enablers to service access were identified from the data: defining rehabilitation; a lack of timely access to patient and rehabilitation service data; and patient diversity not expected by the system.

CONCLUSIONS

Healthcare professionals who make decisions about rehabilitation referrals and services feel that it was necessary for them to keep up to date with information relating to rehabilitation services. There was some concern regarding what rehabilitation constituted and what services were available for different clinical indications. They also indicated that current systems did not consider diversity among patients' needs and goals. Their recommendations included the need for better communication pathways, improved referral systems and resources that could help provide best practice of rehabilitative care in the future.

PATIENT OR PUBLIC CONTRIBUTION

Three study team members had a lived experience of rehabilitation as a patient or carer, and previous experience participating in qualitative research. They worked with the study team to codesign the recruitment strategy, participant-facing communications, the interview discussion guide, and the approach to the conduct of activities with participants and in the interpretation and contextualization of findings and all were involved in writing this manuscript.

Inpatient trial of a tablet app for communicating brain injury rehabilitation goals

PURPOSE

We examine the use of a custom iPad application, the Rehab Portal, to provide clients in an inpatient brain injury rehabilitation service with access to short videos where clinicians-or the clients themselves-discuss their current rehabilitation goals.

MATERIALS AND METHODS

We developed an initial version of the Rehab Portal app based on our previous co-design with service users, their families, and clinicians. This was examined in a field trial with a series of six clients over the course of their stays in inpatient rehabilitation, collecting quantitative data on clinician and client engagement with the Rehab Portal, alongside a thematic analysis of qualitative interviews with clients and clinicians at the point of discharge.

RESULTS

Engagement with the platform was high for two clients while it was limited with four more. In our thematic analysis we discuss how introduction of the Rehab Portal disrupted practice, changing how things are done, causing deviation from usual routines, adding burden, and threatening professional integrity. At the same time, where it worked well it led to a repositioning of goal planning away from being clinician directed and towards an ongoing, dynamic collaboration between clinicians, clients and their families. Finally, in some cases we identified a reverting to the status quo, with client demotivation having an unexpected impact on clinician behaviour leading to the process being abandoned.

CONCLUSIONS

The current findings do not provide wholesale support for this approach, yet we continue to feel that approaches that support clinician-client communication using asynchronous video may offer considerable future value and are worthy of further investigation.

Development of a practical guideline for person centred goal setting in geriatric rehabilitation: a participatory action research

PURPOSE

To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting.

METHODS

Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline.

RESULTS

In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously.

CONCLUSION

In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

Using the capability, opportunity, and motivation model of behaviour to assess provider perception of implementing solution-focused goal-setting in paediatric rehabilitation

Adoption of family and child goal-setting in paediatric rehabilitation is important to positive long-term outcomes. Solution-focused coaching (SFC) has been identified as a promising approach to ensuring this type of goal-setting occurs, while the actual implementation of SFC by health care providers (HCPs) is low. This study utilized the capacity, opportunity, and motivation model of behaviour change (COM-B) to identify which strengths and difficulties health care providers (HCPs) perceived with respect to SFC goal-setting in paediatric rehabilitation. A self-report survey was developed and administered to HCPs at a paediatric rehabilitation hospital. Each survey question was based upon a COM-B sub-component. Demographic information was collected from HCPs, and descriptive statistics were used to rank perceived COM-B components from strongest to weakest. Results indicate HCPs view the provision of SFC goal-setting as an important practice, while they also perceive difficulties to actual delivery due to: lack of adequate individual skill, lack of experience with this type of goal-setting, and insufficient preparation for clients to engage in sharing their goals. HCPs also perceived lack of organizational processes to support the practice within their teams. Recommendations for intervention are provided.