Client-centred ADL intervention after stroke: Significant others’ experiences

In search of self after stroke: a longitudinal qualitative study in the context of client-centred rehabilitation

PURPOSE

The aim was to illuminate the experiences of stroke survivors returning to everyday life in the year following stroke, in the context of client-centred rehabilitation.

METHODS

Four men who participated in a client-centred rehabilitation program were followed during the first year after stroke. Semi-structured interviews were conducted, allbut the first in the participants' home. The data were analysed using a grounded theory approach.

RESULTS

The results revealed a process with the overarching core category; The "new" self becomes reality through challenging everyday experiences, and five main categories driving the process: 1) Striving for structure in a "new" chaotic world, 2) Homecoming an ambiguous experience, 3) Reaching the "new" self through reflections of self-understanding, 4) Socialising in new circumstances, and 5) Realising a new reality.

CONCLUSIONS

While in hospital, stroke survivors can have unrealistic expectations. When at home they can begin to realise their actual capacity . To find a "new" self after a stroke can involve time-consuming and taxing processes of reflections of self-understanding. Engagement in self-selected meaningful and valued activities can support stroke survivors' reconstruction of the "new" self but not all stroke survivors may succeed in finding their "new" self during the first year after stroke.

Activities in Daily Living: The development of a new client-centred ADL intervention for persons with stroke

BACKGROUND

An intervention that contains several interacting components can be defined as a complex intervention. This intervention was developed in accordance with the Medical Research Council (MRC) guidance for complex interventions.

AIM

To describe the development, theoretical framework, and content of a client-centred activities in daily living intervention (CADL) for people with stroke.

MATERIAL AND METHODS

Different steps were used; identifying the evidence base, identifying/developing theory and the modelling process and outcomes in the development of the CADL. The remodelling of the process and content of the intervention that emerged are defined.

RESULTS

Findings from a series of qualitative studies of people with stroke demonstrated the need to develop an ADL intervention based on the clients' lived experiences. The theoretical framework is based on empirical research, theories about human occupation and client-centredness. The CADL is applying an occupational and phenomenological perspective in order to enable agency in daily activities and participation in everyday life among persons with stroke.

CONCLUSIONS AND SIGNIFICANCE

The article can be used as an example of how to present the development and theoretical framework of a new complex intervention in occupational therapy.

Analysis of the occupational therapist's professional identity when working in acquired brain injury rehabilitation within a municipal service

Background

Changes in rehabilitation pathways are reducing the amount of time patients spend in hospital, resulting in an earlier return to municipal care. Studies show that occupational therapists find working with patients with acquired brain injury to be complex and that, in some situations, they fail to believe in their own professional expertise. This qualitative study aimed to explore how the professional expertise of occupational therapists working in acquired brain injury rehabilitation within a municipal service is understood.

Methods

One monoprofessional focus group interview with occupational therapists and five focus group interviews with professionals from municipal interprofessional rehabilitation coordinating units formed the basis for the study. Data were analysed using systematic text condensation.

Results

A holistic view and strategically selected areas of expertise were found to characterise the work of occupational therapists in the municipal setting. A composed base of knowledge enables occupational therapists to be rehabilitators while working in collaboration with multiple professional partners.

Conclusions

Expertise in the areas of adaptation, assistive devices and cognition are considered to be valuable in acquired brain injury rehabilitation in a municipal setting. A practical synthesis of knowledge, transprofessional collaboration and role release enable the occupational therapist to act as a multifarious rehabilitator.

Five-year follow-up of a cluster-randomized controlled trial of a client-centred activities of daily living intervention for people with stroke

Objective:

To compare five-year outcomes and changes over time of a client-centred activities of daily living (ADL) intervention versus usual ADL interventions for people with stroke and their significant others.

Design:

Five-year follow-up of a cluster-randomized controlled trial where a client-centred ADL intervention (n = 129) or usual ADL interventions (n = 151) were delivered to people with stroke.

Setting:

Multicentre study including 16 inpatient or home-based rehabilitation units.

Participants:

People with stroke and significant others.

Intervention:

The client-centred ADL intervention aimed at enabling agency in daily activities and participation in everyday life and at reducing caregiver burden.

Main measures:

For people with stroke, perceived participation (Stroke Impact Scale), independence in ADL, life satisfaction, and use of formal/informal care were measured. For significant others, caregiver burden, life satisfaction, and mood (Hospital Anxiety and Depression Scale) were assessed.

Results:

Five years post-intervention, data were collected from 145 people with stroke (intervention group: n = 71/control group: n = 74) and 75 significant others (intervention group: n = 36/control group: n = 39). For those with stroke, the Participation domain of the Stroke Impact Scale showed no group differences at year five (68.9 vs 75.4, P = 0.062) or in changes over time. At year five, the control group had better outcomes regarding Other help/supervision. Significant others in the control group were more likely to show signs of depression at year five (odds ratio = 22.3; P < 0.001).

Conclusion:

The client-centred ADL intervention appears to render similar long-term effects as usual ADL interventions for people with stroke, but for significant others signs of depression might be reduced.

A feasibility study of a mobile phone supported family-centred ADL intervention, F@ce™, after stroke in Uganda

Background

There is a lack of evidence-based health services to reduce the impact of stroke in low-income countries at a personal, family or community level.

The aim was to evaluate the feasibility of: i) a mobile phone supported family-centred intervention (F@ce™), and ii) the study design for evaluating the effects of the intervention on the perceived impact of stroke; perceived participation in everyday life; and self-efficacy in everyday activities amongst persons with stroke and their families in Uganda.

Methods

The study comprised a pre-post design with an intervention group (IG) receiving the F@ce™ and a control group (CG). The inclusion criteria’s were: a) confirmed stroke diagnosis, b) access to and ability to use a mobile phone, c) ability to communicate in English and/or Luganda, d) > 18 years, e) residents in Kampala, and f) a Modified Rankin Scale level 2 to 4.

The aim of the F@ce^TM was to increase functioning in daily activities for persons living with the consequences of stroke, and participation in everyday life for persons with stroke and their families. The F@ce™ was an eight-week family-centred intervention, which entailed goal setting and problem-solving strategies, daily reminders and self-rated follow-ups of performance by short message service (SMS).

Data were collected in the participants’ home environment at baseline and after eight weeks. Data on acceptability of the F@ce™ and study procedures were collected by log-books and the responses of the SMS follow ups on the server. The primary outcomes were performance and satisfaction of valued daily activities in everyday life using the Canadian Occupational Performance Measure (COPM), self-efficacy in performance of activities in daily life.

Results

The IG comprised n = 13 and the CG n = 15. There were differences between the IG and CG in changes between baseline and follow-up in the primary outcomes COPM (performance component) and self-efficacy in favour of F@ce™. Overall with minor modifications the intervention and the study design were feasible for all participants involved.

Conclusion

The results support the need for further research to rigorously evaluate the effects of F@ce™ since the intervention appears to be feasible for persons with stroke and their family members.

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0400-7) contains supplementary material, which is available to authorized users.

The case of value-based healthcare for people living with complex long-term conditions

BACKGROUND

There is a trend towards value-based health service, striving to cut costs while generating value for the patient. The overall objective comprises higher-quality health services and improved patient safety and cost efficiency. The approach could align with patient-centred care, as it entails a focus on the patient's experience of her or his entire cycle of care, including the use of well-defined outcome measurements. Challenges arise when the approach is applied to health services for people living with long-term complex conditions that require support from various healthcare services. The aim of this work is to critically discuss the value-based approach and its implications for patients with long-term complex conditions. Two cases from clinical practice and research form the foundation for our reasoning, illustrating several challenges regarding value-based health services for people living with long-term complex conditions.

DISCUSSION

Achieving value-based health services that provide the health outcomes that matter to patients and providing greater patient-centredness will place increased demands on the healthcare system. Patients and their informal caregivers must be included in the development and establishment of outcome measures. The outcome measures must be standardized to allow evaluation of specific conditions at an aggregated level, but they must also be sensitive enough to capture each patient's individual needs and goals. Healthcare systems that strive to establish value-based services must collaborate beyond the organizational boundaries to create clear patient trajectories in order to avoid fragmentation. The shift towards value-based health services has the potential to align healthcare-service delivery with patient-centred care if serious efforts to take the patient's perspective into account are made. This is especially challenging in fragmented healthcare systems and for patients with long-term- and multi-setting-care needs.