Critical issues in interviewing people with traumatic brain injury

Interventions facilitating the involvement of relatives of patients with acquired brain injury or malignant brain tumour: A scoping review

AIM

To identify and map the evidence on interventions facilitating the involvement of relatives of patients with an acquired brain injury (ABI) or a malignant brain tumour (MBT).

BACKGROUND

An ABI or a MBT are severe diseases that have profound impact on the lives of patients and their relatives. The well-being of the patient may be deteriorated, and relatives may experience a new role and changing caregiving tasks. Involvement of relatives seems essential, and there is a need for identifying interventions facilitating the involvement.

DESIGN

Scoping review.

METHODS

The Joanna Briggs Institute methodology was used in this review and the review was reported in accordance with the PRISMA extension for scoping reviews.

DATA SOURCES

The literature search was conducted in MEDLINE, Embase, CINAHL and Cochrane Library. Reference lists of included studies, Google Scholar and Web of Science were also searched.

RESULTS

In total, 46 studies were included of which 36 (78%) involved patients with stroke. Median duration of study interventions were 8 weeks, and nurses were involved as providers of the intervention in 23 (50%) studies. Thirty (65%) studies used a multicomponent intervention. Thirty-five unique outcomes were identified using 60 unique outcome measurements.

CONCLUSION

Interventions facilitating the involvement of relatives differed importantly in key characteristics of study interventions, and in relation to the context in which they were used. There was no consensus regarding choice of outcomes and outcome measurements. Our results highlight the complexity of interventions in this field.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

To our knowledge this is the first scoping review examining interventions facilitating the involvement of relatives of patients with an acquired brain injury or a malignant brain tumour. This review suggests a clear definition of 'involvement' in future research and there is a need of development of a core outcome set for use in interventions facilitating the involvement.

REPORTING METHOD

The scoping review was reported in accordance with the PRISMA extension for scoping reviews.

NO PATIENT OR PUBLIC CONTRIBUTION

The authors decided to undertake this scoping review without patient and public contribution. However, the protocol was published prior to review conduct and available to the public but we did not receive any comments on it.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Reclaiming Agency in Care Decisions and Barriers From the Perspectives of Individuals With Acquired Brain Injury and Their Family Members

BACKGROUND

The ability to self-advocate or have a say in one's care is integral to personalised care after acquired brain injury (ABI). This study aimed to understand what constitutes self-advocacy and associated barriers and facilitators throughout hospital transitions and into the community.

METHOD

Qualitative methodology was employed with semistructured interviews conducted with 12 people with ABI and 13 family members. Interviews were conducted at predischarge (in-person or via telephone) and 4 months postdischarge (via telephone) from the brain injury rehabilitation unit of a tertiary hospital. Data were thematically analysed using a hybrid deductive-inductive approach.

RESULTS

Self-advocacy reflects the process of reclaiming agency or people's efforts to exert influence over care decisions after ABI. Agency varies along a continuum, often beginning with impaired processing of the self or environment (loss of agency) before individuals start to understand and question their care (emerging agency) and ultimately plan and direct their ongoing and future care (striving for agency). This process may vary across individuals and contexts. Barriers to self-advocacy for individuals with ABI include neurocognitive deficits that limit capacity and desire for control over decisions, unfamiliar and highly structured environments and lack of family support. Facilitators include neurocognitive recovery, growing desire to self-advocate and scaffolded support from family and clinicians.

CONCLUSION

Self-advocacy after ABI entails a process of reclaiming agency whereby individuals seek to understand, question and direct their ongoing care. This is facilitated by neurocognitive recovery, growing capacity and desire and scaffolded supports. Research evaluating approaches for embedding self-advocacy skills early in brain injury rehabilitation is recommended.

PATIENT OR PUBLIC CONTRIBUTION

Two caregivers with lived experience of supporting a family member with ABI were involved in the design and conduct of this study and contributed to and provided feedback on the manuscript.

Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study

Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.

Efficacy of BETTER transitional care intervention for diverse patients with traumatic brain injury and their families: Study protocol of a randomized controlled trial

OBJECTIVE

The purpose of this study is to examine the efficacy of BETTER (Brain Injury, Education, Training, and Therapy to Enhance Recovery) vs. usual transitional care management among diverse adults with traumatic brain injury (TBI) discharged home from acute hospital care and families.

METHODS

This will be a single-site, two-arm, randomized controlled trial (N = 436 people, 218 patient/family dyads, 109 dyads per arm) of BETTER, a culturally- and linguistically-tailored, patient- and family-centered, TBI transitional care intervention for adult patients with TBI and families. Skilled clinical interventionists will follow a manualized protocol to address patient/family needs. The interventionists will co-establish goals with participants; coordinate post-hospital care, services, and resources; and provide patient/family education and training on self- and family-management and coping skills for 16 weeks following hospital discharge. English- and Spanish-speaking adult patients with mild-to-severe TBI who are discharged directly home from the hospital without inpatient rehabilitation or transfer to other settings (community discharge) and associated family caregivers are eligible and will be randomized to treatment or usual transitional care management. We will use intention-to-treat analysis to determine if patients receiving BETTER have a higher quality of life (primary outcome, SF-36) at 16-weeks post-hospital discharge than those receiving usual transitional care management. We will conduct a descriptive, qualitative study with 45 dyads randomized to BETTER, using semi-structured interviews, to capture perspectives on barriers and facilitators to participation. Data will be analyzed using conventional content analysis. Finally, we will conduct a cost/budget impact analysis, evaluating differences in intervention costs and healthcare costs by arm.

DISCUSSION

Findings will guide our team in designing a future, multi-site trial to disseminate and implement BETTER into clinical practice to enhance the standard of care for adults with TBI and families. The new knowledge generated will drive advancements in health equity among diverse adults with TBI and families.

TRIAL REGISTRATION

NCT05929833.

Experiences of adults with stroke attending a peer-led peer-support group

PURPOSE

Peer-support groups for stroke survivors are often organized and facilitated by health authorities and disability related organizations within rehabilitation programs. However, the benefits of peer-led, peer-support groups have not yet been evaluated. The purpose of this study was to explore participants' experiences in a community-based, peer-led, peer-support group for stroke survivors.

MATERIALS AND METHODS

Semi-structured interviews were conducted and analyzed following constructivist grounded theory with 11 participants who attended a peer-led, peer-support group for people with stroke. The data were also complemented with one quantitative rating question regarding their experience attending the group.

RESULTS

Three themes were identified. Meeting unmet needs after stroke captured how the group was created by stroke survivors to address life in the community post-stroke. Buddies helping buddies highlighted that stroke recovery is a shared process at the group, where members help and encourage each other to contribute what they can. Creating authentic friendships revealed how people experienced social connection and developed relationships in the peer-led, peer-support group.

CONCLUSIONS

Peer-led, peer-support groups may provide opportunities for stroke survivors to connect with like-minded people in their community to have fun while exploring their abilities.

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.

"It gave her that soft landing": Consumer perspectives on a transitional rehabilitation service for adults with acquired brain injury

Transitional rehabilitation service models for people with acquired brain injury (ABI) may address sub-optimal support for individuals returning home after hospitalization for ABI. This study investigated perspectives of people with ABI and close others who received transitional rehabilitation. A qualitative study involving semi-structured interviews with 10 individuals with ABI and 12 associated close others was conducted as part of a mixed-method evaluation of an Australian transitional rehabilitation service (TRS) pilot project. Thematic analysis based on the Framework method was conducted independently by two researchers. Three broad themes illustrated participants' experience of the TRS: (1) structure after hospital discharge; (2) a "soft landing"; and (3) equipped for community living. Findings suggest that home-based, interdisciplinary transitional rehabilitation after hospital discharge was perceived as an important stage of rehabilitation by participants. Valued features relate to post-hospital rehabilitation structure: a single point of contact to facilitate organization and information exchange, a known discharge destination, and consistent communication; support and therapy within a familiar home environment; and being equipped with relevant knowledge and strategies to manage ongoing challenges. Further research exploring the experiences of individuals with ABI without close family or social support, and research capturing longitudinal outcomes from transitional rehabilitation is recommended.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"The bucket of gold at the end of the rainbow": personal experiences of hope after acquired brain injury

PURPOSE

To investigate personal experiences of, and factors influencing hope following Acquired Brain Injury (ABI).

METHODS

A qualitative phenomenological approach was adopted consisting of semi-structured interviews with 15 adults with ABI. Interviews were transcribed and analysed using thematic analysis, and the Social Ecological Model (SEM) applied as a guiding framework to discuss findings and implications for policy and practice.

RESULTS

Five themes emerged: the importance of hope, changes in hope over time, the connection between hope and positivity, factors influencing hope and the importance of fostering hope. Participants reported varying experiences, with increased levels of hope influenced by: faith; supportive networks and professionals; goals; experiencing progress; having something to look forward to; and seeing others achieve. Professional attitudes were reported to either foster or negatively impact hope after brain injury.

CONCLUSIONS

These findings suggest that hope can play an important and often essential role in the lives of people with ABI. Factors influencing experiences of hope are organised against a SEM framework, identifying intrapersonal, interpersonal, institutional, community, and state and national implications for policy, professional practice and research.Implications for rehabilitationHope plays a critical role in the lives of people following acquired brain injury.Factors which positively influence hope include faith, supportive networks, goals, experiencing progress, and having something to look forward to.Professionals can impact an individual's experience of hope through person-centred and supportive therapeutic relationships.

A qualitative exploration of fatherhood after acquired brain injury (ABI)

Acquired Brain Injury (ABI) significantly affects individuals across multiple areas of intimate, familial, and parental domains. Gender and identity are pivotal research areas in navigating life after ABI. To date, scant research has explored gendered experiences, particularly those related to the masculine lifeworld. This study aimed to explore how men who were fathers before their injuries experience fatherhood after ABI. An Interpretative phenomenological analysis (IPA) methodology was used, and seven fathers participated in the semi-structured interviews (time since injury 1-18 years, age range 27-66 years) which explored their meaning-making. Four superordinate themes were drawn from all interviews through engaging with the qualitative research process: (1) what being a father means, (2) altered relationships with others, (3) becoming lost and finding their way through, and (4) renewed fatherhood. The findings show intersectionality between pre-and post-injury comparisons of self and social identities, alongside the contextual and societal identities in the subjective fathering experiences. Through increased understanding, we may enable fathers to find new ways to resolve, reformulate, and connect to move into their future possible fatherhood. The importance of this research is in giving voice to these less represented men so that we may shape our understanding to aid future fathers post-ABI.

"I'm aging faster": social participation as experienced by individuals aging with a traumatic brain injury

OBJECTIVES

1) To get an insight into the experience of aging with traumatic brain injury (TBI), and 2) explore intervention avenues perceived as promising for the social participation of this population.

METHOD

Through an exploratory descriptive study, in-depth semi-structured interviews were conducted with aging TBI survivors recruited in a nonprofit community organization whose mission is to support the social participation of people living with TBI. Thematic analysis was done on qualitative data, using a hybrid approach of deductive and inductive analysis.

RESULTS

Ten aging TBI survivors with an average age of 64.9 years were interviewed. Participants expressed the perception of declining faster and with greater limitations than their fellow seniors unchallenged by TBI but also of having social participation opportunities due to their condition. A list of ten facilitators (e.g., doing activities in synch with life story) and five barriers (e.g., unequal levels of disability) to their social participation emerged.

CONCLUSION

Social participation is crucial to TBI-affected individuals' healthy aging. Nonprofit community organizations should offer opportunities for participation, mobilize environmental resources, foster self-confidence, and support the achievement of meaningful personal projects to enable the social participation of people aging with TBI.

Who are relatives? Young adults, relatives and professionals' perceptions of relatives during the rehabilitation of young adults with a severe acquired brain injury

PURPOSE

This paper explores the perception of "relatives" during the rehabilitation of young adults with severe acquired brain injury (SABI).

METHODS

This longitudinal qualitative study followed eight young adults with a SABI from hospital discharge to a year and a half after discharge. The design encompassed professional records, interviews, and surveys, including a name generator list completed by the young adults and focus group interviews with both their families and professionals. We apply a sociological theoretical framework concerning friendship, and we employ social network analysis (SNA) methodology to capture, visualise, and analyse the young adults' significant social relations.

RESULTS

Social relations engaged as relatives during rehabilitation are to a large extent determined by the perceptions of professionals and the parents of the young adult. These perceptions contain a limited number of social relations, with priority given to biological and juridical ties. This might reflect the reduced social support available for the young adult, who initially had a much larger social network.

CONCLUSION

The authors suggest a professional rethinking of who "relatives" are as well as considering these social ties as dynamic. Implications for rehabilitationRehabilitation professionals must be aware of and pay attention to differing perceptions that exist as to who qualifies as significant social relations in order to reconsider the practical implementation of relative involvement.The perception of who relatives are during the rehabilitation process should be reconsidered and extended to include who the young adult perceive as significant social relations.Relatives are not a fixed entity and should be considered dynamically throughout the rehabilitation process.Social relations of the young adult must to a larger extent be considered during rehabilitation to prevent social isolation in the long run.

Exploring the experiences and challenges for patients undergoing cranioplasty: a mixed-methods study protocol

INTRODUCTION

Cranioplasty is a widely practised neurosurgical procedure aimed at reconstructing a skull defect, but its impact on a patient's rehabilitation following a traumatic brain injury (TBI) or stroke could be better understood. In addition, there are many issues that a TBI patient or the patient who had a stroke and their families may have to adapt to. Insight into some of the potential social barriers, including issues related to social engagement and cosmetic considerations, would be beneficial. Currently, little is known about how this procedure impacts a patient's recovery, the patient's perceptions of rehabilitation precranioplasty and postcranioplasty and the broader issues of cosmesis and social reintegration. This study hopes to understand some of these issues and therefore help inform clinicians of some of the difficulties and perceptions that patients and their relatives may have.

METHODS AND ANALYSIS

A mixed-methods study. Data will be collected through focus groups with healthcare professionals (HCPs) and semi-structured interviews with patients and their relatives, field notes, a researcher diary and a patient questionnaire. Different perspectives will be brought together through method triangulation. Patient and relative data will be analysed using interpretive phenomenological analysis, and HCPs data will be analysed thematically using deductive and inductive coding.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Wales REC 7 ethics committee (Rec ref: 19/WA/0315). There is limited literature regarding a patient's perception of the cranioplasty process, the potential impact on rehabilitation and how this may impact their reintegration into the community. The results of this study will be presented at national brain injury conferences and published in peer-reviewed, national and international journals.

Strategies for Empowering activities in Everyday life (SEE 1.0): study protocol for a feasibility study of an Internet-based occupational therapy intervention for people with stroke

Background

Rehabilitation after stroke seldom focuses on needs related to an active everyday life and the process of change that people must undergo to adapt to an altered capacity and life situation. In particular, occupational therapy in the late phase needs to support clients in adopting sustainable self-initiated management strategies to regain daily activities and an active everyday life. To improve access to rehabilitation, the use of digital solutions has been suggested. This study aims to evaluate the feasibility of the Internet-based occupational therapy intervention “Strategies for Empowering activities in Everyday life” (SEE, version 1.0). We will investigate the feasibility of the intervention process in terms of acceptability and adherence as well as the most suitable outcome measures to evaluate SEE and improve the knowledge about the potential changes and outcomes of SEE for clients with stroke.

Methods

This feasibility study is based on a pretest posttest design without a control group. Quantitative and qualitative data will be collected from clients and staff concurrently embedded in a mixed-method design during the entire study.

Discussion

The project is a first test of a novel Internet-based occupational therapy intervention, and the research will contribute to the continued development and evaluation of the SEE programme. SEE can provide people with strategies in daily activities that can support them to live an active everyday life despite changed capacity and to improve access to rehabilitation interventions.

Trial registration

NCT04588116. Name of the registry: Strategies Empowering Activities in Everyday Life (SEE 1.0). A Web-based Occupational Therapy Intervention. URL of trial registry record. Date of registry: Trial first posted: October 19, 2020; first submitted: October 2, 2020

Client experiences with holistic neuropsychological rehabilitation: "It is an ongoing process"

The effectiveness of holistic neuropsychological rehabilitation for people with acquired brain injury has previously been demonstrated by means of standardized and routinely administered outcome measures. However, the most important outcomes from the perspective of former clients are largely unknown. This study explored the experience of participating in a holistic neuropsychological rehabilitation programme by conducting three focus groups with twelve former clients who had sustained a brain injury. Data were transcribed verbatim and analysed using thematic analysis. "It is an ongoing process" emerged as the overarching theme for the experience of recovery from brain injury. Four subthemes, or phases, were identified. Participants went through (1) a phase of confrontation, after which they (2) trained their skills and strategies, and (3) experimented with these in daily life. In the end, clients reached a phase of (4) coming to terms with their injury. Participants described increased levels of self-esteem, sense of competence, and adaptation as the most important outcomes of the programme, as these factors helped them regain a sense of identity. The results indicate that including these factors in outcome evaluations of complex interventions after brain injury may be important as they appear essential for capturing the client's perspective on change.

Conducting focus groups in neurodegenerative disease populations: ethical and methodological considerations

BACKGROUND

Involvement of vulnerable populations in research is critical to inform the generalisability of evidence-based medicine to all groups of the population.

OBJECTIVE

In this communication, we reflect on our previous research, and that of other authors, to identify and explore key ethical and methodological considerations.

DISCUSSION

Focus groups are a widely implemented qualitative methodology, but their use, particularly in vulnerable neurodegenerative disease populations, is not straightforward. Although the risk of harm is generally low in focus group research, neurodegenerative disease populations are particularly vulnerable to issues relating to comprehension and their capacity to consent. Physical and cognitive impairments may also affect social interactions among participants and therefore impact data collection and analyses.

CONCLUSION

We offer a number of ethical and methodological recommendations to facilitate the processes of recruitment and data collection when conducting focus groups with neurodegenerative disease populations.

Developing a model of long-term social rehabilitation after traumatic brain injury: the case of the head forward centre

Background: Social isolation and inactivity are highly problematic long-term consequences of Traumatic Brain Injury. They are rarely addressed by rehabilitation programmes, which focus on early phases of recovery. Day centres, or "drop-in" peer support groups, have emerged as an informal solution to social rehabilitation needs. However, there is a lack of knowledge regarding the therapeutic ingredients of these services.Methods: Twelve survivors of Traumatic Brain Injury that attended a social rehabilitation service (Head Forward Centre, UK; HFC), were interviewed to explore the meanings attached to the service and its activities. Thematic analysis was used to describe emerging themes and build a model of social rehabilitation.Results: Four therapeutic functions were attached to HFC: (a) HFC as a safe and predictable milieu; (b) HFC as a space where identity can be reconstructed; (c) HFC as a place where survivors can remain cognitive and socially active; (d) HFC as a network of continuous support.Conclusion: A model of long-term social rehabilitation should consider both psychological and practical/functional ingredients. Such a model can help informal rehabilitation services reflect upon their goals and activities, as well as articulate therapeutic actions along the rehabilitation path. The conceptualization of these four therapeutic ingredients in holistic rehabilitation models is described, and contrasted with its use in long-term social rehabilitation.IMPLICATIONS FOR REHABILITATIONSocial isolation and inactivity are important problems in the long-term rehabilitation of people with TBI. Both problems can be addressed by social rehabilitation services (day centres and peer support groups).Participation in social rehabilitation can promote a sense of normality and belongingness, which contribute to the long-term process of identity reconstruction.Social rehabilitation can help maintaining people with TBI cognitive and socially active, as well as developing a network of continuous support.

Difficulties and Problem-Solving Strategies in Wayfinding Among Adults With Cognitive Disabilities: A Look at the Bigger Picture

Many people with cognitive disabilities avoid outside activities, apparently for fear of getting lost. However, little is known about the nature of the difficulties encountered and the ways in which these individuals deal with them. None of the few studies on wayfinding by people with cognitive disabilities have explored the various specific difficulties they meet in everyday life. Using both a qualitative and quantitative methodology, this study aimed at profiling the types of difficulties encountered in urban mobility and the associated problem-solving strategies. In order to provide more direct evidence from the field, we conducted semi-structured interviews using the critical incident technique (Flanagan, 1954). Among the 66 participants interviewed, 44 had cognitive disabilities and 22 were matched controls. The analysis of the transcripts showed in particular an overall reduced autonomy in problem-solving strategies for people with a cognitive disability. The multiple correspondence analysis highlighted three main types of complex situations, covering a comprehensive range of complex situations that are met in everyday life by these individuals. Results also indicated that people with cognitive disabilities request assistance from another person more frequently when a complex event occurs. These situations are discussed as potential cues for improvements in navigational aids. Conclusions and perspectives are provided to improve wayfinding among people with cognitive disabilities.

"A non-person to the rest of the world": experiences of social isolation amongst severely impaired people with multiple sclerosis

Purpose: To gain insight into the experiences of, and potential solutions to, social isolation amongst severely impaired people with multiple sclerosis.Methods: A phenomenological research approach using face-to-face, in-depth semi-structured, audio-recorded interviews. Data were transcribed and analyzed thematically.Results: Sixteen severely impaired people with multiple sclerosis were interviewed (Expanded Disability Status Scale >6.5); aged 38-72 years, nine female, time since diagnosis ranged 3-30 years). Four key themes were generated in line with the study objectives, each with further sub-themes. The themes were (1) Definitions of isolation (2) Causes of isolation (3) Impact of isolation, and (4) Potential eases of isolation.Conclusions: Data portrayed social isolation as complex and multi-factorial in its definitions, its causes, and its impact. Isolation is not just about being lonely or left on one's own, but represents a spiral of impacts. Physical deterioration can lead to reduced choice and control regarding access to, and interaction with others and society, affecting personal identity. Sometimes this leads to further self-isolation. Personalised psychosocial support, with improved ease of access, focused on helping people with severe multiple sclerosis regain a sense of self and their place in the world may ease social isolation.Implications for rehabilitationPeople with severe multiple sclerosis can experience a sense of powerlessness, a lack of choice and control over daily life, leading to changes in self-identity and social isolation.Peoples' experiences are very personal, and any approach to help deal with social isolation needs to be based in considering how to think positively about how life can be lived and how to make that work.Multiple sclerosis support groups should not be assumed to alleviate feelings of social isolation.Interventions should focus on personalized psychosocial input aimed at helping the person with multiple sclerosis regain a sense of self and their place in the world.

Patient perceptions of participation in group-based rehabilitation in an inpatient brain injury rehabilitation setting

OBJECTIVES

The use of groups is common in healthcare. There is a paucity of research which captures patient experiences of group participation. The aims of this study were to explore the perceptions and experiences of people with traumatic brain injury (TBI) about their participation in inpatient occupational therapy rehabilitation groups.

METHOD

A phenomenological approach guided the study. Patients with a TBI who were participating in an inpatient occupational therapy group program were recruited. Data were collected through semi-structured interviews and analysed using content analysis.

RESULTS

Fifteen participants consented to the study. Three themes emerged from the data; 1) feeling normal, comfortable and connected; 2) learning by doing, seeing and sharing and; 3) practicalities of groups. Participants highlighted that groups facilitated opportunities to practice skills and prepared them for the real world. Opportunities for interaction and support were also emphasised as positive by participants.

CONCLUSION

Perceptions of patients about participation in groups were generally positive, and as such a consumer-focused approach to healthcare would support the use of occupational therapy groups in TBI rehabilitation.

PRACTICE IMPLICATIONS

Recommendations from the perspectives of patients include consideration of the selection of group participants, and meeting individual needs and goals within a group setting.

Extreme Control and Instability: Insight Into Head Injury From Intimate Partner Violence

AIM

The aim of this study was to understand the social context of the lives of women who experienced a head injury from intimate partner violence.

BACKGROUND

Sixty percent to 92% of survivors of intimate partner violence receive head trauma during the abuse. Little research exists regarding the episodes of abuse when women receive a head injury, or the reasons women might not seek medical care for the head injury or the abuse.

METHOD

Twenty-one interviews from nine women who self-reported passing out from being hit in the head were analyzed using thematic analysis.

FINDINGS

Themes of extreme control and manipulation from abusers emerged, and women described living with instability from cycles of incarceration, drug and alcohol use, and fear of losing their children. Women did not receive medical care for head injury because the abusers often used forced sex immediately after the head injury to instill fear and authority.

IMPLICATIONS FOR FORENSIC NURSING

Hitting women in the head is not only about physical abuse, but also about exerting dominance and creating an environment of extreme control. Forensic nurses are uniquely positioned to screen for head injuries during initial assessments and follow-up visits and connect women with appropriate resources.

Adding insult to brain injury: young adults' experiences of residing in nursing homes following acquired brain injury

PURPOSE

There is general consensus that adults under age 65 with acquired brain injury residing in nursing homes is inappropriate, however there is a limited evidence base on the issue. Previous research has relied heavily on third-party informants and qualitative studies have been of questionable methodological quality, with no known study adopting a phenomenological approach. This study explored the lived experiences of young adults with brain injury residing in aged care facilities.

METHODS

Interpretative phenomenological analysis was employed to collect and analyze data from six semi-structured interviews with participants regarding their experiences of living in nursing homes.

RESULTS

Two themes were identified, including "Corporeal prison of acquired brain injury: broken selves" and "Existential prison of the nursing home: stagnated lives". Results illustrated that young adults with acquired brain injury can experience aged care as an existential prison in which their lives feel at a standstill. This experience was characterized by feelings of not belonging in a terminal environment, confinement, disempowerment, emptiness and hope for greater autonomy through rehabilitation.

CONCLUSION

It is hoped that this study will provide relevant professionals, services and policy-makers with insight into the challenges and needs of young adults with brain injury facing these circumstances. Implications for rehabilitation This study supports the contention that more home-like and age-appropriate residential rehabilitation services for young adults with acquired brain injury are needed. As development of alternative accommodation is a lengthy process, the study findings suggest that the interim implementation of rehabilitative care in nursing homes should be considered. Taken together with existing research, it is proposed that nursing home staff may require training to deliver evidence-based rehabilitative interventions to those with brain injury. The present findings add support to the call for systemic change in Ireland, to clarify the acquired brain injury care pathway and establish integrated rehabilitation services.

Brain Injury and Severe Eating Difficulties at Admission-Patient Perspective Nine to Fifteen Months after Discharge: A Pilot Study

The purpose of this pilot study was to explore and interpret the way that individuals with acquired brain injury, admitted to inpatient neurorehabilitation with severe eating difficulties, experienced eating nine to fifteen months after discharge. Four individuals with acquired brain injury were interviewed via qualitative semi-structured interviews. An explorative study was conducted to study eating difficulties. Qualitative content analysis was used. Four main themes emerged from the analysis: personal values related to eating, swallowing difficulties, eating and drinking, meals and social life. Three predominating experiences were: fed by tube, “relearning” to eat, and eating meals together. The preliminary results regarding the four participants suggest that the meaning of food and being able to eat and take part in meals may be nearly the same as before the injury; however, having the ability to eat reduced or lost completely, even temporarily, was unexpected and difficult, and caused strong emotional reactions, even 18 months after injury. Time spent using a feeding tube had a negative, but not persistent, impact on quality-of-life. The preliminary findings provide knowledge regarding the patient perspective of adapting to and developing new strategies for activities related to eating, however, further prospective, longitudinal research in a larger scale and with repeated interviews is needed.

Occupations outside the home: Experiences of people with acquired brain injury

Introduction

Understanding those occupations outside the home that people with acquired brain injury find difficult, including the influencing factors, may help to develop appropriate support. The aim of this paper was to explore and describe how people with acquired brain injury experience engagement in occupations outside the home.

Method

This qualitative study included repeated semi-structured interviews with eight working-age persons with acquired brain injury, which were analysed by a constant comparison analysis.

Findings

The findings indicated that there were three influencing factors that had a critical effect on the participants’ changes in their engagement in occupations, the strategies they adopted, and the consequences for their lives. The categories reflected how the different changes in occupations outside the home were influenced by their struggles with sensory processing and fatigue, difficulties with completing preparations, and occupational risks.

Conclusion

The findings indicate that to improve engagement in occupations outside the home for people with acquired brain injury, professionals need to identify the different factors that are critical for each person’s engagement. The findings also indicate the importance of considering not only occupations outside the home but also preparations required at home and recovery afterward, and how engagement outside the home is influenced by the entire occupational repertoire.

The lived experience of behaviours of concern: A qualitative study of men with traumatic brain injury

BACKGROUND AND AIMS

Behaviours of Concern (BoC) are a debilitating consequence of Traumatic Brain Injury (TBI). Whilst perspectives of clinicians, carers and family members on BoC have been previously explored, few qualitative studies have included individuals with TBI. The aim of this study was to explore the lived experience of BoC in individuals with TBI, their close others and clinicians.

METHOD

Eleven males with TBI and BoC were recruited and 25 semi-structured qualitative interviews were conducted (9 individuals with TBI, 9 close others, 7 clinicians). A six-phase thematic analysis approach was utilised.

RESULTS

Frequent and persistent BoC were reported and the key themes identified included the brain injury, control, environment, mood, identity, social relationships, and meaningful participation. Whilst the brain injury contributed to BoC in all cases, the way the other themes manifested and interacted was variable.

CONCLUSIONS

This study enriches our understanding of factors associated with BoC. Themes emerging from this study will inform interventions designed to reduce BoC and ultimately maximise quality of life for individuals with TBI and their families.

The experience of patients with ABI and their families during the hospital stay: A systematic review of qualitative literature

BACKGROUND

Patients with acquired brain injury (ABI) and their families have unique experiences and needs during the hospital stay; yet, limited literature exists on this topic. The purpose of this systematic review was to compile and synthesize literature on the experience of patients with ABI and their families during the hospital stay.

METHODS

A systematic review of qualitative studies was conducted by searching for studies from seven databases. Content analysis was used to analyse and synthesize studies' findings separately for the patient and family experience.

RESULTS

The initial search provided 2871 records. Ultimately, 11 studies relevant to the research question were included in this review. No studies were excluded based on critical quality appraisal. Findings on the patient experience showed patients had negative perceptions of the rehabilitation environment and a perceived need for information. Findings on the family experience included difficulty adjusting after the patient's injury, a desire to be involved in the patient's care, mixed feelings about staff support and a high perceived need for information.

CONCLUSIONS

Findings provide awareness for healthcare providers on the multifaceted experiences of patients with ABI and their families during the hospital stay, strategies to make care more patient- and family-centred and directions for future research.

First steps in designing an all-in-one ICT-based device for persons with cognitive impairment: evaluation of the first mock-up

Background

This project Smart Assisted Living involving Informal careGivers++ (SALIG) intends to develop an ICT-based device for persons with cognitive impairment combined with remote support possibilities for significant others and formal caregivers. This paper presents the identification of the target groups’ needs and requirements of such device and the evaluation of the first mock-up, demonstrated in a tablet.

Methods

The inclusive design method that includes end-users in the design process was chosen. First, a scoping review was conducted in order to examine the target group’s need of an ICT-based device, and to gather recommendations regarding its design and functionalities. In order to capture the users’ requirements of the design and functionalities of the device three targeted focus groups were conducted. Based on the findings from the publications and the focus groups a user requirement specification was developed. After that a design concept and a first mock-up was developed in an iterative process. The mock-up was evaluated through interviews with persons with cognitive impairment, health care professionals and significant others. Data were analysed using content analysis.

Results

Several useful recommendations of the design and functionalities of the SALIG device for persons with cognitive impairment were identified. The main benefit of the mock-up was that it was a single device with a set of functionalities installed on a tablet and designed for persons with cognitive impairment. An additional benefit was that it could be used remotely by significant others and formal caregivers.

Conclusion

The SALIG device has the potentials to facilitate everyday life for persons with cognitive impairment, their significant others and the work situation for formal caregivers. The results may provide guidance in the development of different types of technologies for the target population and for people with diverse disabilities. Further work will focus on developing a prototype to be empirically tested by persons with cognitive impairment, their significant others and formal caregivers.

Cognitive rehabilitation groups: A thematic analysis of feasibility and perceived benefits for clients with moderate to severe traumatic brain injury living in the Western Cape

Background

Traumatic brain injury (TBI) has a significant impact on the burden of care within the South African setting, impacting on the individual, the family, and the community as a whole. Often the consequences of TBI are permanent, resulting in numerous financial and emotional stressors.

Objective

This research focusses on the experience of outpatient cognitive rehabilitation groups for individuals who have suffered moderate to severe brain injuries within the South African setting.

Method

Participants with moderate to severe brain injury were required to attend five cognitive rehabilitation groups and engage in a semistructured interview. Qualitative data were examined via thematic analysis, to determine participants’ subjective experiences of group participation.

Results

There is a need within the South African setting for cognitive rehabilitation and support groups for individuals who have experienced a TBI. The benefits were notable for both the individuals attending and their support systems. In spite of the benefits there were notable limitations to attendance, including financial restrictions and transport limitations.

Conclusion

According to participants and their families, there is a scarcity of resources within the Western Cape for clients who have sustained a TBI. Despite limitations in capacity to attend there appears to be a need for structured outpatient cognitive rehabilitation programmes integrating the complex cognitive and emotional challenges faced by individuals with TBI and their families.

Communication during goal-setting in brain injury rehabilitation: What helps and what hinders?

Introduction

Setting goals with individuals with acquired brain injury may be challenging due to impairments in cognition and communication. The purpose of this study was to explore how occupational therapists' communication behaviours during goal-setting with individuals with traumatic brain injury facilitated and hindered this process.

Method

This exploratory study used a conversation analysis inspired approach and frequency calculations to analyse and interpret videotaped goal-setting sessions. Sequences of dialogue leading to, and distracting from, problem identification, a key step in goal-setting, were identified and analysed. Specific therapist behaviours that facilitated or hindered problem identification were subsequently distinguished.

Results

Acknowledgements and affirmations, open-ended questions about specific tasks and reflective listening, were found to lead to problem identification by the client (facilitators). Instances of disconnections were characterized by a single theme, ‘lack of uptake.' Examples of these hindrances to goal-setting included, abrupt topic shifts, lack of acknowlegement and failure to explore what the client said.

Conclusion

Clinicians should consider their language use during goal-setting interviews and aim to utilize conversational behaviours that are facilitative whilst minimizing those that distract to optimize their client's engagement during the problem identification phase of goal-setting.

An exploration of compassion focused therapy following acquired brain injury

BACKGROUND

People with acquired brain injuries (ABI) frequently experience psychological difficulties such as anxiety and depression, which may be underpinned and maintained by high self-criticism and shame alongside an inability to self-soothe. Compassionate focused therapy (CFT) was developed to address shame and self-criticism and foster the ability to self-soothe.

OBJECTIVES

This is a naturalistic evaluation with the aim of assessing the feasibility, safety, and potential value of CFT for ABI patients with emotional difficulties receiving neuropsychological rehabilitation.

METHODS

This study employed a mixed methods design combining self-report measures and qualitative interviews. Twelve patients received a combination of CFT group and individual intervention. Self-report measures of self-criticism, self-reassurance, and symptoms of anxiety and depression were collected pre and post programme and analysed using Wilcoxon signed rank test (N=12; five female, seven males). Follow-up data were analysed in the same manner (N=9). Interviews were conducted with six patients and analysed using interpretative phenomenological analysis.

RESULTS

CFT was associated with significant reductions in measures of self-criticism, anxiety, and depression and an increase in the ability to reassure the self. No adverse effects were reported. Three superordinate themes emerged from the interviews: psychological difficulties; developing trust and finding safeness; and a new approach.

CONCLUSIONS

This study suggests that CFT is well accepted in ABI survivors within the context of neuropsychological rehabilitation. Furthermore, the results indicate that further research into CFT for psychological problems after ABI is needed and that there may be key aspects, which are specific to CFT intervention, which could reduce psychological difficulties after ABI.

PRACTITIONER POINTS

CFT appears to be a feasible intervention for psychological problems after ABI. CFT was associated with a reduction in symptoms of anxiety and depression and associated self-criticism, as well as enhanced self-reassurance for ABI survivors. These ABI survivors reported that CFT provided them with tools to manage continued psychological difficulties.

Exploring researchers' experiences of working with people with acquired brain injury

PURPOSE

This study aimed to investigate the challenges and positive experiences of researchers who work with people who have experienced an acquired brain injury and their families.

METHODS

People who were currently or had previously worked as a researcher in the field of acquired brain injury (using either quantitative or qualitative methods) were invited to participate in a focus group or individual interview about their experiences. An expert reference group meeting was held to discuss strategies that could be implemented to enhance the researcher experience based on the interview data.

RESULTS

A total of 19 researchers who worked across four different research teams took part in the study. Six inter-connected themes were identified: researcher motivation, meaning and fulfillment; human connection; knowing and understanding the role; complexity of brain injury in the research context; the research process; and state of the researcher. A number of recommendations for supporting researchers more effectively were identified.

DISCUSSION

Researchers described a number of positive aspects as well as tensions they encountered in their role. The findings highlight the need to ensure researchers are supported effectively to ensure the quality of research studies in the field of brain injury.

Living with a diagnosis of behavioural-variant frontotemporal dementia: The person's experience

Research investigating behavioural-variant frontotemporal dementia has concentrated on identifying and quantifying people's difficulties; yet few studies have considered how people with behavioural-variant frontotemporal dementia make sense of their difficulties. Five participants were interviewed and interpretive phenomenological analysis used to analyse the data. Two superordinate themes emerged: 'Bewilderment' and 'Relationships with others'. 'Bewilderment' reflected the feelings of the participants from the start of their dementia, and was divided into two main themes (1) 'Awareness of change: What's the problem? and (2) Threats to self: This is not me. The superordinate theme, 'Relationships with others', reflected difficulties with social relationships and comprised two main themes (1) 'Family and friends: Things haven't changed… but do I say anything wrong?' and (2) Coping with threats to self: Blame others or just avoid them. The themes were discussed in relation to literature evaluating the difficulties associated with behavioural-variant frontotemporal dementia together with implications for clinical practice.

Embodiment and self in reorientation to everyday life following severe traumatic brain injury

People with severe traumatic brain injury (sTBI) are often young and need long-term follow-up as many suffer complex motor, sensory, perceptual and cognitive impairments. This paper aims to introduce phenomenological notions of embodiment and self as a framework to help understand how people with sTBI experience reorientation to everyday life, and to inform clinical practice in neurological physiotherapy. The impairments caused by the sTBI may lead to a sense of alienation of one's own body and changes in operative intentionality and in turn disrupt the reorganization of self, identity, everyday life and integration/co-construction of meaning with others. Applying a first-person conception of the body may extend insights into the importance of an adapted and individualized approach to strengthen the sensory, perceptual and motor body functions, which underpin the pre-reflective and reflective aspects of the self. It seems important to integrate these aspects, while also paying attention to optimizing co-construction of meaning for the person with sTBI in the treatment context. This requires understanding the patient as an experiencing and expressive body, a lived body (body-as-subject) and not just the body-as-object as is favored in more traditional frameworks of physiotherapy.

The experience of being a parent with an acquired brain injury (ABI) as an inpatient at a neuro-rehabilitation centre, 0-2 years post-injury

PRIMARY OBJECTIVE

Little research has been conducted exploring the issues surrounding parenting with an acquired brain injury (ABI). This study aimed to explore the experiences and needs of parents who suffered an ABI in the last 2 years from their own perspectives. For individuals with an ABI who have dependent children their ABI has the potential to impact upon their parenting abilities, skills and relationships.

RESEARCH DESIGN

Interpretive phenomenological analysis (IPA) was used to analyse the data. Using IPA allowed the research questions and inquiry to be positioned epistemologically and directed towards 'meaning' rather than 'difference' or 'causality'.

METHODS

Five participants (two female, three male) were interviewed using a semi-structured interview schedule.

MAIN OUTCOMES

Four main themes were identified: (i) Multiple losses, (ii) A mix of resigned acceptance and uncertain future, (iii) Giving and receiving support is part of the healing process and (iv) Hopes and aspirations.

CONCLUSIONS

The results indicated that the participants experienced an oscillation between experiencing the multiple losses of their parental role and attempting to adapt and adjust to these changes. These findings are discussed in relation to clinical and theoretical implications for parents who are inpatients with an ABI up to 2 years post-injury.

Exploring participant experiences of research after traumatic brain injury

OBJECTIVE

To explore peoples' perceptions and experiences of taking part in research following a traumatic brain injury (TBI) and identify the factors that influence research participation.

METHODS

A total of 30 people (15 who had participated in research following a TBI and 15 who had previously declined or not been offered the opportunity to take part), were asked about their perceptions and experiences of research in a semi-structured qualitative interview. Audio recordings of the interviews were transcribed verbatim and analysed using the qualitative description approach.

RESULTS

Participants perceptions and experiences of research were strongly influenced by the researcher, the practicalities of taking part, including the timing and relevance of research, and perceived end results, such as access to a new treatment or reimbursement for their time.

CONCLUSION

People want to be empowered to make their own decisions about research participation following a TBI. The findings have implications for research procedures and researchers working in the field of brain injury and recommendations to enhance the research experience are proposed.

Between the lines: generating good qualitative data in studies involving persons with aphasia

High-quality data are essential for developing knowledge in qualitative inquiries. Language impairments affect the ability to meet the requirements that constitute good qualitative data. In this article, we focus on generating good qualitative data in persons with aphasia following stroke. We drew on experiences from a longitudinal nursing intervention to discuss how to maximize data generation in accordance with norms for data quality in this population. The longitudinal design, using a combination of research methods, and the iterative process of data generation and analysis over time constituted a continuity that enhanced communication, mutual understanding, and a trustful partnership.