Client-centred practices and work in inpatient rehabilitation teams: results from four case studies

A New Process Model for Relationship-Centred Shared Decision-Making in Physical Medicine and Rehabilitation Settings

INTRODUCTION

We present a relationship-centred shared-decision-making (RCSDM) process model to explicate factors that shape decision-making processes during physical medicine and rehabilitation (PMR) encounters among patients, their care partners and practitioners. Existing shared decision-making (SDM) models fall short in addressing the everyday decisions routinely made regarding persons with chronic disabilities who require high levels of support, their care partners and rehabilitation practitioners. In PMR, these everyday decisions are small scale, immediate and in service to a larger therapeutic goal. They can be thought of as micro-decisions and involve multiple practitioners, care partners and patients. How micro-decisions are made in this context is contingent on multiple roles and relationships among these relevant parties. Our model centres on micro-decisions among patients, their care partners and practitioners based on our disorders of consciousness (DoC) research.

METHODS

To develop our model, we examined peer-reviewed literature in SDM in PMR, chronic disability and person-centeredness; formed collaborations and co-created our constructs with rehabilitation practitioners and with care partners who have lived experience of caring for persons with DoC; analysed emerging empirical data and vetted early versions with expert scientific and clinical audiences. Our model builds from the core tenets of relational autonomy, and scholarship and activism of disability advocates.

FINDINGS

Our model conceptualizes four non-hierarchical levels of analysis to understand the process of micro-decision-making in chronic disability and medical rehabilitation: social forces (historical and sociological); roles and relationships (multiple and intersecting); relational dimensions (interactional and contextual) and micro-decision moments (initiation, response and closure).

DISCUSSION

Relationships among patients, their care partners and practitioners are the intersubjective milieu within which decisions are made. Our conceptual model explicates the process of micro-decision-making in PMR.

PATIENT OR PUBLIC CONTRIBUTION

Care partners (or caregivers) and rehabilitation practitioners are active members of our team. We work together to develop research projects, collect, analyse and disseminate data. The conceptual model we present in this manuscript was co-created-input from care partners and practitioners on previously collected data became the impetus to develop the RCSDM process model and share co-authorship in this manuscript.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

'It's been an extraordinary journey': Experience of engagement from the perspectives of people with post-stroke aphasia

BACKGROUND

Engagement is recognized as an important factor in aphasia treatment response and outcomes, yet gaps remain in our understanding of engagement and practices that promote engagement from the client perspective.

AIMS

The purpose of this phenomenological study was to explore how clients with aphasia experience engagement during their inpatient aphasia rehabilitation.

METHODS & PROCEDURES

An interpretative phenomenological analysis approach guided the study design and analysis. Data were collected through in-depth interviews with nine clients with aphasia, recruited through purposive sampling, during their inpatient rehabilitation admission. Analysis was completed using a variety of analytic techniques including coding, memoing, triangulation between coders and team discussion.

OUTCOMES & RESULTS

The analysis revealed that for clients with aphasia in the acute phrase of recovery, the rehabilitation process resembles travelling on a journey through a foreign land. Successful engagement in the journey was accomplished when one had a therapist who served as a trusted guide and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable.

CONCLUSIONS & IMPLICATIONS

Engagement is a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. Findings from this work have implications for measuring engagement, training student clinicians to be skilled facilitators in engaging their clients and implementing person-centred practices that promote engagement within clinical settings.

WHAT THIS PAPER ADDS

What is already known on the subject Engagement is recognized as an important factor in rehabilitation treatment response and outcomes. Prior literature suggests that the therapist plays a critical role in facilitating engagement within the client-provider relationship. Communication impairments associated with aphasia may negatively impact a client's ability to develop interpersonal connections and participate in the rehabilitation process. There is a dearth of research directly exploring the topic of engagement in aphasia rehabilitation, particularly from the perspective of clients with aphasia. Capturing the client perspective can provide novel insights regarding practices to foster and maintain engagement in aphasia rehabilitation. What this paper adds to existing knowledge This interpretative phenomenological study revealed that for individuals with aphasia in the acute phase of recovery, the rehabilitation process resembles travelling on a sudden and foreign journey. Successful engagement in the journey was accomplished when one had a therapist who served as a 'trusted guide' and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable. Through the client experience, engagement is seen as a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. What are the potential or actual clinical implications of this work? The current study highlights the complexity and nuance of engagement within the rehabilitation context, which has implications for measuring engagement, training student clinicians to be skilled in engaging their clients and implementing person-centred practices that promote engagement within clinical settings. It is necessary to recognize that client and provider interactions (and thus engagement) are embedded in and influenced by the broader healthcare system. With this in mind, a patient-centred approach to engagement in aphasia care delivery cannot be achieved through individual efforts only and may require prioritization and action at the systems level. Future work is needed to explore barriers and facilitators to enacting engagement practices, in order to develop and test strategies to support practice change.

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

OBJECTIVES

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

CHALLENGES

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

OPPORTUNITIES

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

CONCLUSION

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

Assuring patient participation and care continuity in intermediate care: Getting the most out of family meetings using the four habits model

Introduction

As a transitional care intervention, intermediate care (IC) bridges the pathway for older patients from hospital to home. Within family meetings in IC, the older patient, his or her relatives, the interdisciplinary team and the municipal case manager come together to discuss goals and interventions during the IC stay, including follow‐up services after discharge. Although family meetings are a common aspect of teamwork in IC, it is unclear how the voices of older people and their relatives are coming across. The aim of this study is to explore how patient participation is framed and negotiated within family meetings in IC.

Methods

This study is based on qualitative data from the observation of 14 interdisciplinary family meetings in Norwegian IC services. As a theoretical framework, the authors have used the four habits model developed by Frankel and Stein as a lens to understand the interrelated sequence of events that typically takes place during a family meeting and the importance of communication skills to promote patient participation.

Results

The thematic analysis resulted in 16 categories and 4 main themes related to the 4 habits model: (i) grounding the family meetings, (ii) what matters to you?, (iii) being empathically present and (iv) the power of a final closure.

Conclusion

There was considerable variation in the way current family meetings were conducted. It seemed crucial to start the meeting with a proper introduction and explanation of the purpose of the meeting to establish trust and to be able to successfully move to the next stage of eliciting the patients' preferences, views and goals via the ‘what matters to you?’ question. There were examples of empathetic communication among meeting participants perceived to facilitate patient participation. Finally, to successfully end the meeting and agree on a shared plan, it seemed crucial for case managers who held the decision‐making power to attend the meetings. Framing family meetings in line with the four habits sequential approach may have the potential to assure patient participation and care continuity in IC services.

Patient or Public Contribution

This article is part of a larger project based on a James Lind Alliance process that brings patients, relatives, health care professionals and researchers together in priority setting partnerships to identify and prioritize evidence uncertainties that they agree are the most important. Accordingly, the design and content of this article have been initiated and discussed in the project's stakeholder group consisting of one patient representative, one relative representative, two health care professionals from IC settings, two representatives from the Norwegian Health Association and two representatives from the Agency of Health in Norway.

Dynamic and distributed exchanges: an interview study of interprofessional communication in rehabilitation

PURPOSE

Interprofessional communication (IPC) in rehabilitation is important for patient care yet it has been shown to be variable and challenging. Existing research does not address the complexity of IPC in this setting. Understanding the influence of contextual factors on IPC may guide improvements to increase the effectiveness of communication within interprofessional teams.

METHODS

From July 2020 to February 2021 semi-structured interviews were conducted with 24 healthcare professionals across Australia and New Zealand. Cultural Historical Activity Theory provided a guiding theoretical and analytical framework for this qualitative study.

RESULTS

Participants described engaging in IPC through evolving interactions, piecing together information that underpinned patient care. Meetings occurred frequently, however communication extended well beyond formalised interactions, often requiring individuals to balance clinical workload with communication tasks. IPC reportedly relied on communication tools, however navigating information from multiple sources was demanding.

CONCLUSIONS

Our results indicate that IPC contributes significantly to the workload of healthcare professionals in rehabilitation. IPC was integral in the provision of cohesive patient care, however it proved time consuming, effortful and at times frustrating and potentially erroneous. Our findings promote the need for rigorous examination of communication practices to ensure they are meeting the needs of an increasingly interprofessional workforce. IMPLICATIONS FOR REHABILITATIONHealthcare professionals should recognise that time spent communicating within their team is a legitimate and important part of patient care.Rehabilitation teams should consider how they allocate resources for communication tasks.Teams should reconsider how they can use communication more effectively to save time by reducing repetition and errors.

Effect of Communication and Education within the Rehabilitation Team: Therapists' and Nurses' Views

Objective

To improve the rehabilitation team's awareness of patient mobility and participation by improving communication between therapists and nurses and conducting patient education.

Design

This study used a non-equivalent control group with a nonsynchronized design. To facilitate communication between therapists and nurses, we used a manual for mobility management to improve the sharing of information on the functional status of patients. We also implemented patient education to improve their awareness of mobility and participation. Finally, we conducted newly devised surveys related to patient functional status and awareness that were applied by therapists and nurses.

Results

The nurses reported significantly lower functional levels of patients compared to those assessed by therapists. After the intervention, the kappa values representing the concordance between therapists and nurses improved to almost perfect agreement for transfer ability (κ=0.836), mobility (κ=0.664), and toileting (κ=1.000). We also observed a statistically significant increase in questionnaire scores with respect to nurses' awareness (p < 0.05).

Conclusion

Improving communication among the rehabilitation team, including nurses through the use of a continuous education program, was effective in promoting the mobility and functional level of patients in the inpatient ward.

The Person-Centered Rehabilitation Model: Framing the concept and practice of person-centered adult physical rehabilitation based on a scoping review and thematic analysis of the literature

OBJECTIVE

To develop a cross-professional model framing the concept and practice of Person-Centered Rehabilitation (PCR) in adult populations, based on a scoping review and thematic analysis of the literature.

DATA SOURCES

Key databases (PubMed, Scopus, CINAHL), snowballing searches, and experts' consultation were the data sources for English-language empirical or conceptual papers, published from January 2007 to February 2020.

STUDY SELECTION

Two independent reviewers selected adult-based papers addressing at least one of the six categories of PCR-related content, a priori specified in the published review protocol. From 6527 unique references, 147 were finally included in the analysis. Of those, 26 were exclusively conceptual papers.

DATA EXTRACTION

Two independent reviewers extracted textual data on what PCR entails conceptually or as a practice. No quality appraisals were performed as is typical in scoping reviews.

DATA SYNTHESIS

A thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by five external experts. PCR was framed as a way of thinking about and providing rehabilitation services "with" the person. PCR is embedded in rehabilitation structures and practice across three levels: 1) the person-professional dyad, 2) the micro-system level (typically an interprofessional team, involving significant others) and 3) a macro-system level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR.

CONCLUSION

The PCR model can inform both clinical and service organization practices. The PCR Model may benefit from further developments including obtaining wider stakeholders' input, determining relevance in different cultural and linguistic groups, and further operationalization and testing in implementation projects.

Understanding interprofessional team delivery of patient-centered care: a qualitative secondary analysis

Primary Care providers are expected to deliver patient-centered care (PCC) within teams; however, PCC tends to be studied within the provider-patient dyad, often to the exclusion of interprofessional team relationships. The purpose of this study was to explore how PCC is understood in the context of inter-provider relationships within Collaborative Mental Health Care teams. Previously collected data formed the basis of a qualitative secondary analysis using constructivist grounded theory. Focus group transcripts from six teams were analyzed using constant comparison. Coding, memoing, and diagramming were used to construct categories and themes. Having worked together over time, these teams developed a shared identity termed the Collective in this analysis. We define this social entity including antecedent conditions, the cultural milieu of the Collective, and provider-perceived outcomes. We further detail how these providers understood PCC as a team-delivered practice including the processes of coming together for a more complete picture, delivering the same message, and managing complexity together. We argue that practice settings supporting relationship development between providers, in addition to with the patient, may be essential to team delivery of PCC.

Theorising rehabilitation: Actors and parameters shaping normality, liminality and depersonalisation in a UK hospital

Sociological concern for rehabilitation remains limited. This paper aims to contribute to rehabilitation theory. It examines two units of a specialist rehabilitation hospital in the UK (amputee and neurological services) by focusing on the key actors involved - families, patients, staff - and the parameters shaping their relationships. The findings extend previous theoretical understandings of rehabilitation in three themes: normality, liminality and depersonalisation. We argue, first: normality is constantly negotiated amongst the different actors. This complicates existing works' critique of rehabilitation as reproducing the ideology of normality. Second, discourses produced during acute care shape the inpatient rehabilitation experience. This calls attention to the pre-rehabilitation phase and complicates existing works' emphasis on the transition from inpatient stay to the time of discharge. Finally, inpatient rehabilitation is notable in rendering the adverse effects of depersonalisation apparent. It combines the bureaucracy of a regular hospital ward, with institutionalising aspects of long-term care. These findings have a potential to enhance practice as well as knowledge. We call for a deeper sociological attention, combining theory-building with empirical data for a better understanding of inpatient rehabilitation.

Communication in interprofessional rehabilitation teams: a scoping review

PURPOSE

Effective communication in interprofessional rehabilitation teams is essential for optimal patient care. Despite the established importance, it remains unclear how interprofessional communication (IPC) within teams contributes to rehabilitation service delivery. The aim of this scoping review was to investigate how IPC has been described in rehabilitation literature.

METHODS

Databases (Medline, CINAHL, ERIC, Embase, PsychInfo, and Academic Search Complete) were searched for studies including rehabilitation interprofessional communication. Inclusion and exclusion criteria were identified and applied, data were charted, and thematic analysis conducted.

RESULTS

Twenty-nine papers were identified, and analysis revealed interrelated themes: communication processes, and inputs and effects. Formal communication processes were most prevalent, portraying variability in professional participation and a lack of patient involvement in dialogue and decision making. Inputs and effects were described at an organisational, team and individual level, highlighting the importance of communication throughout the healthcare hierarchy.

CONCLUSIONS

IPC in rehabilitation is central to effective team function and patient care. To further our understanding, empirical studies examining everyday informal IPC, as well as formal ritualised encounters are needed. Additionally, conceptualisations of IPC would benefit from including the patients' perspective and by using theoretical framing to attend to places, spaces, and artefacts identified in this review.

Healthcare teams and patient-related terminology: a review of concepts and uses

BACKGROUND

Discussions concerning health care teams and patient-related terminology remain an ongoing debate. Terms such as interdisciplinary, multidisciplinary and transdisciplinary, as well as interprofessional are ambiguously defined and frequently used, rightly or wrongly, interchangeably. Also, clarification on the terminology regarding patients is rarely explicitly addressed in the health care team's literature, potentially resulting in confusion among health professional students, novice researchers, and practitioners.

METHODS

A structured literature review was conducted. Electronic searches were performed from August 2018 to September 2019 on the following databases: CINHAL, Scopus, Science Direct, PubMed, Nursing and Allied Health and JSTOR. The following terms were used: 'terminology', 'team(s)', 'nursing', 'health', 'medical', 'education', 'interprofessional', 'interdisciplinary', 'multidisciplinary', 'transdisciplinary', 'collaboration', 'patient', 'client', 'customer', 'user' and 'person'.

RESULTS

Small but significant nuances in the use of language and its implications for patient care can be made visible for health professional education and clinical practice. Healthcare is necessarily interdisciplinary and therefore we are obligated, and privileged, to think more critically about the use of terminology to ensure we are supporting high-quality evidence and knowledge application.

CONCLUSION

To avoid confusion and lack of consistency in the peer-review literature, authors should be encouraged to offer brief definitions and the rationale for the use of a particular term or group of term. In addition, a deeper understanding of the values that each patient-related term represents for particular disciplines or health care professions is essential to achieve a more comprehensive conceptual rigour.

Health-care professionals' experiences of patient participation among older patients in intermediate care-At the intersection between profession, market and bureaucracy

Background

Patient participation is a key concern in health care. Nevertheless, older patients often do not feel involved in their rehabilitation process. Research states that when organizational conditions exert pressure on the work situation, care as a mere technical activity seems to be prioritized by the health‐care staff, at the expense of patient involvement.

Objective

The aim of this article is to explore how health‐care professionals experience patient participation in IC services, and explain how they perform their clinical work balancing between the patient's needs, available resources and regulatory constraints.

Design

Using a framework of professional work and institutional logics, underpinned by critical realism, we conducted semi‐structured interviews with 18 health‐care professionals from three IC institutions.

Results

IC appears as an important service in the patient pathway for older people with a great potential for patient participation. However, health care staff may experience constraints that prohibit them from using professional discretion, which is perceived as a threat to patient participation. Further, they may adopt routines that simplify their interactions with patients. Our results call for more emphasis on an individualized rehabilitation process and a recognition that psychological and social aspects are critical for patient participation in IC.

Conclusion

Patients interact in the face of conflicting institutional priorities or protocols. The study adds important knowledge about the practice of patient participation in IC from a front‐line provider perspective. Underlying mechanisms are identified to understand and recommend how to facilitate patient participation at different levels in narrowing the gap between policy and clinical work in IC.

What's in it for me? A process evaluation of the implementation of a mobile phone-supported intervention after stroke in Uganda

BACKGROUND

The prevalence of stroke in Uganda is increasing. In stroke rehabilitation, information and communication technology has been shown to have potential in improving service delivery in high-income countries but there is limited knowledge of its use and impact in low-income countries. The aim of the study was to evaluate the implementation process of a mobile phone-supported family-centred rehabilitation intervention and to gain knowledge on the mechanisms of impact as well as the contextual factors that might have affected the implementation process and its outcome.

METHOD

This was a single-case study design using the integrated Promoting Action on Research Implementation in Health Services framework and the Medical Research Council guidance as frameworks. Quantitative process data was derived from 14 log books used by occupational therapists during the implementation. Qualitative semi-structured interviews were conducted with 12 implementers in different professions, 12 months into the implementation, in order to obtain the primary data. Secondary data was derived from six semi-structured interviews conducted directly after pre-intervention workshops and 6 months later. The framework method was used in the data analysis.

RESULTS

In 11 out of 14 cases, the clients were compliant with the intervention. Yet, challenges such as technical problems were reported. The target of conducting 16 phone calls for each client was achieved to 74%. Eight categories emerged from the qualitative analysis of the interviews including: 1) perceptions on facilitation, 2) using scientific and experience-based knowledge, 3) tailoring the intervention, 4) supportive working culture, 5) barriers to the service delivery, 6) implementers' interaction with the intervention, 7) perceptions on motivations and values, and 8) improving the model and enabling sustainability. Mechanisms contributing to the implementation of the intervention included engaged facilitators and motivated participants. Challenges in the client recruitment and poor information dissemination were some of the mechanisms impeding the implementation.

CONCLUSIONS

The intervention was partially delivered in accordance with the logic model for the project, where the implementation process was influenced by several barriers in the context such as technical setbacks. However, there were also several mediators in the process driving the project forward, including strong facilitation and motivated participants.

A Concept Analysis of Patient Participation in Intermediate Care

OBJECTIVE

Although the concept of patient participation has been discussed for a number of years, there is still no clear definition of what constitutes the multidimensional concept, and the application of the concept in an intermediate care (IC) context lacks clarity. Therefore this paper seeks to identify and explore the attributes of the concept, to elaborate ways of understanding the concept of patient participation for geriatric patients in the context of IC.

METHODS

Walker and Avant's model of Concept analysis [1] based on a literature review.

RESULTS

Patient participation in the context of IC can be defined as a dynamic process emphasizing the person as a whole, focusing on the establishment of multiple alliances that facilitate individualized information and knowledge exchange, and ensuring a reciprocal engagement in activities within flexible and interactive/dynamic organizational structures.

CONCLUSION

Patient participation in IC means involving patients and their relatives in holistic interdisciplinary collaborative decision-making. The results highlight the complexity of patient participation and contribute to a greater understanding of the influence of organizational structure and management.

PRACTICAL IMPLICATIONS

The present study may provide a practical framework for researchers, policy makers and health professionals to facilitate patient participation in IC services.

Distributed decision making in action: diagnostic imaging investigations within the bigger picture

INTRODUCTION

Decision making in the health care system - specifically with regard to diagnostic imaging investigations - occurs at multiple levels. Professional role players from various backgrounds are involved in making these decisions, from the point of referral to the outcomes of the imaging investigation. The aim of this study was to map the decision-making processes and pathways involved when patients are referred for diagnostic imaging investigations and to explore distributed decision-making events at the points of contact with patients within a health care system.

METHOD

A two-phased qualitative study was conducted in an academic public health complex with the district hospital as entry point. The first phase included case studies of 24 conveniently selected patients, and the second phase involved 12 focus group interviews with health care providers. Data analysis was based on Rapley's interpretation of decision making as being distributed across time, situations and actions, and including different role players and technologies.

RESULTS

Clinical decisions incorporating imaging investigations are distributed across the three vital points of contact or decision-making events, namely the initial patient consultation, the diagnostic imaging investigation and the post-investigation consultation. Each of these decision-making events is made up of a sequence of discrete decision-making moments based on the transfer of retrospective, current and prospective information and its transformation into knowledge.

CONCLUSION

This paper contributes to the understanding of the microstructural processes (the 'when' and 'where') involved in the distribution of decisions related to imaging investigations. It also highlights the interdependency in decision-making events of medical and non-medical providers within a single medical encounter.

A framework for establishing connections in physiotherapy practice

The therapeutic relationship between practitioner and patient is embedded in the clinical interaction. Research using self-report tools has illustrated that positively evaluated therapeutic relationships can have favorable impacts on patient satisfaction with services and clinical outcomes. However, little is known about how physiotherapists develop the connections, or positive attachments, that help establish the therapeutic relationship. This study aimed to identify the various ways that physiotherapists establish meaningful connections with their patients. Interpretive description, a qualitative methodology, was used to structure the inductive and iterative design. Eleven physiotherapists and 7 patients from private practice clinics participated in semi-structured interviews to describe their experiences of the therapeutic relationship. Textual data were analyzed using qualitative content analysis and constant comparison. The iterative data generation and analysis process resulted in a framework composed of three "ways" (i.e. categories) of establishing connections: (1) acknowledging the individual, (2) giving-of-self, and (3) using the body as a pivot point. Findings were supported by various rigor strategies including peer debrief and external audit. This framework demonstrates that establishing connections is a multi-faceted endeavor with personal and professional characteristics. The findings provide practical knowledge that can be used to guide clinicians, educators, and researchers in addressing the therapeutic relationship.

A cluster-randomized controlled study to evaluate a team coaching concept for improving teamwork and patient-centeredness in rehabilitation teams

PURPOSE

Although the relevance of interprofessional teamwork in the delivery of patient-centered care is well known, there is a lack of interventions for improving team interaction in the context of rehabilitation in Germany. The aim of the present study is to evaluate whether a specially developed team coaching concept (TCC) could improve both teamwork and patient-centeredness.

METHOD

A multicenter, cluster-randomized controlled intervention study was conducted with both staff and patient questionnaires. Data was collected at ten German rehabilitation clinics (five clusters) of different indication fields before (t1) and after (t2) the intervention. Intervention clinics received the TCC, while control clinics did not receive any treatment. Staff questionnaires were used to measure internal participation and other aspects of teamwork, such as team organization, while patient questionnaires assessed patient-centeredness. A multivariate analysis of variance was applied for data analysis.

RESULTS

In order to analyze the effect of TCC on internal participation and teamwork, 305 questionnaires were included for t1 and 213 for t2 in the staff survey. In the patient survey, 523 questionnaires were included for t1 and 545 for t2. The TCC improved team organization, willingness to accept responsibility and knowledge integration according to staff, with small effect sizes (univariate: η2=.010-.017), whereas other parameters including internal participation, team leadership and cohesion did not improve due to the intervention. The patient survey did not show any improvements on the assessed dimensions.

CONCLUSION

The TCC improved dimensions that were addressed directly by the approach and were linked to the clinics' needs, such as restructured team meetings and better exchange of information. The TCC can be used to improve team organization, willingness to accept responsibility, and knowledge integration in rehabilitation practice, but some further evaluation is needed to understand contextual factors and processes regarding the implementation of the intervention.

Rehabilitation in the real-life environment of a shopping mall

AIM

The aim of this study was to explore how shopping malls could be used during rehabilitation and to identify the facilitators and barriers to their use.

METHOD

Two focus groups, conducted with 15 rehabilitation professionals from various disciplines and working with people with disabilities of all ages were structured around two topics: (i) The usage of malls for rehabilitation and (ii) Factors that facilitate or limit rehabilitation professionals' use of the mall as an environment for clinical assessment and/or intervention.

RESULTS

The thematic analysis revealed that shopping malls were used to achieve several rehabilitation goals targeting physical and cognitive skills, psychological health and socialization. This real-life environment is motivating and helps foster independence and normalization. Factors affecting mall use during rehabilitation included personal factors (e.g. clients' personality and level of readiness) and environmental factors (e.g. clinical context, accessibility of the mall and social attitudes of store owners).

CONCLUSION

Shopping malls may be a relevant rehabilitation assessment and treatment environment that could contribute to optimizing community integration of people with disabilities. Implications for rehabilitation To ensure successful community reintegration, clients could be trained at some point during their rehabilitation, to perform activities in real-life settings, such as a shopping mall. Shopping malls appear to enable the attainment of rehabilitation goals targeting a variety of skills. This real-life environment appears to be motivating and helps foster independence and normalization. Factors felt to affect mall use during rehabilitation include personal factors (e.g. clients' personality and level of readiness) and environmental factors (e.g. clinical context, accessibility of the mall and social attitudes of store owners). The shopping mall may be an untapped resource as it appears to be a relevant rehabilitation assessment and treatment environment that could contribute to optimizing community integration of people with disabilities.

Person-centred rehabilitation: what exactly does it mean? Protocol for a scoping review with thematic analysis towards framing the concept and practice of person-centred rehabilitation

INTRODUCTION

Person-centredness is a philosophy for organising and delivering healthcare based on patients' needs, preferences and experiences. Although widely endorsed, the concept suffers from a lack of detail and clarification, in turn accounting for ambiguous implementation and outcomes. While a conceptual framework based on a systematic review defines person/patient-centred care components (Scholl et al, 2014), it applies across healthcare contexts and may not be sensitive to the nuances of the rehabilitation of adults with physical impairments. Accordingly, this study aims to build a conceptual framework, based on existing literature, of what person-centredness means in the rehabilitation of adults with physical impairments in the clinical encounter and broader health service delivery.

METHODS AND ANALYSIS

We will use a scoping review methodology. Searches on relevant databases will be conducted first, combining keywords for 'rehabilitation', 'person-centered' and associated terms (including patient preferences/experiences). Next, snowball searches (citation tracking, references lists) will be performed. Papers will be included if they fall within predefined selection categories (seen as most likely informative on elements pertaining to person-centred rehabilitation) and are written in English, regardless of design (conceptual, qualitative, quantitative). Two reviewers will independently screen titles and abstracts, followed by screening of the full text to determine inclusion. Experts will then be consulted to identify relevant missing papers. This can include elements other than the peer-reviewed literature (eg, book chapters, policy/legal papers). Finally, information that helps to build the concept and practice of person-centred rehabilitation will be abstracted independently by two reviewers and analysed by inductive thematic analysis to build the conceptual framework.

DISSEMINATION

The resulting framework will aid clarification regarding person-centred rehabilitation, which in turn is expected to conceptually ground and inform its operationalisation (eg, measurement, implementation, improvement). Findings will be disseminated through local, national and international stakeholders, both at the clinical and service organisation levels.