Client-centred practice: Perspectives of persons with a traumatic brain injury

Engaging children and adolescents with acquired brain injury and their families in goal setting: The family perspective

This study explored the experiences of goal setting in paediatric rehabilitation from the perspectives of children and adolescents with acquired brain injury (ABI) and their parents in paediatric rehabilitation. Using a qualitative research design, 15 semi-structured interviews were conducted with 13 parents and 8 young people with ABI aged between 9 and 18 years who were engaged in outpatient rehabilitation. Interview transcripts were analysed using constructivist grounded theory methods. Two main themes and several sub-themes emerged: Experiences of goal setting: The role of professionals; The role of the young person; and The role of the parents. Working as a team: Understanding each other and building trust; Communicating, sharing knowledge and different perspectives; and Being flexible. These themes reflect parent's and young people's experience of goal setting during paediatric rehabilitation for ABI and suggest clinicians play an important role in educating young people and their families about goal setting in the outpatient rehabilitation context. Young people and their parents also perceive the focus of outpatient rehabilitation as working collaboratively with clinicians to gain knowledge to manage the consequences of ABI. Our findings emphasize the importance of the therapeutic consumer-clinician relationship and the need to actively engage young people in goal setting.

Perceiving Therapeutic Communication: Client-Therapist Discrepancies

IMPORTANCE

Few studies have examined differences in clients' and therapists' perspectives on therapeutic communication; this article contributes to the knowledge base.

OBJECTIVE

To examine clients' and therapists' real-time perceptions of therapeutic communication.

DESIGN

Observational, quantitative, cross-sectional study.

SETTING

Inpatient and outpatient units of a large urban teaching hospital.

PARTICIPANTS

Clients (n = 110) and rehabilitation therapists (n = 38; occupational, physical, and speech).

OUTCOMES AND MEASURES

Demographic characteristics, Clinical Assessment of Modes (CAM).

RESULTS

Clients perceived that therapists communicated by instructing more, and therapists reported empathizing more.

CONCLUSIONS AND RELEVANCE

The findings suggest that clients and therapists may perceive therapeutic communication differently. What This Article Adds: This article supports therapists' use of the CAM to examine multiple perspectives on their communication mode use, as described in the Intentional Relationship Model.

Team-based rehabilitation after traumatic brain injury: a qualitative synthesis of evidence of experiences of the rehabilitation process

OBJECTIVE

To synthesize and explore experiences of the rehabilitation process for adults with traumatic brain injury receiving team-based rehabilitation.

DATA SOURCES

A qualitative evidence synthesis was conducted according to the "Enhancing transparency in reporting the synthesis of qualitative research" (ENTREQ) Guidelines, of qualitative studies published in 5 databases in 2000-21.

STUDY SELECTION AND DATA EXTRACTION

Screening, selection of relevant studies, assessment of methodological limitations, systematic qualitative content analysis and assessment of confidence with Grading of Recommendations Assessment, Development, and Evaluation- Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) were carried out by independent researchers.

DATA SYNTHESIS

The 10 included studies revealed how people with traumatic brain injury perceived that they struggled on their own for a long time to adapt their daily life. They experienced that access to team-based rehabilitation was scarce and that the interventions offered were neither individually tailored nor coordinated. A respectful attitude from professionals and individually adapted information facilitated their rehabilitation process.

CONCLUSION

This qualitative evidence synthesis indicates areas for improvement and a need to develop person-centred team-based rehabilitation for adults with traumatic brain injury, in terms of accessibility, coordination, continuity, content and participation. Given the limited opportunities for team-based rehabilitation after hospital discharge, further research is needed to understand how rehabilitation can support the adaptation of everyday life.

Finding Goal Focus With People With Severe Traumatic Brain Injury in a Person-Centered Multi-Component Community Connection Program (M-ComConnect)

Background and Objectives: Loss of social connections in the community is a common consequence of severe traumatic brain injury (TBI), resulting in reduced well-being and quality of life. M-ComConnect is an individualized multi-component community connection intervention with the key objectives of increasing social activity, developing social relationships, and supporting community participation following severe TBI. As part of the M-ComConnect approach, semi-structured initial interviews were conducted to develop a holistic understanding of each participant and their goal focus for the project. In this paper we describe how clinicians worked with participants to identify a desired community-based social activity in which to participate. Method: Transcripts of initial interviews between participant and clinician were analyzed using the phases of reflexive thematic analysis developed by Braun and Clarke. Participants were ten individuals aged between 24 and 75 with severe TBI. All were living in the community and reported reduced social connections since their TBI. The aim of the analysis was to evaluate the skills and strategies used by clinicians in their interactions with participants to derive goal focus for the program. Results: Thematic analysis of initial interview data revealed three main categories and fourteen sub-categories of clinical strategies. These were: (1) Humanizing (curiosity; demonstrating respect and empathy; providing compliments and affirmations; simple reflections; revealing aspects of self; and humor and laughter), (2) Empowering (emphasizing choice and control; highlighting strengths; identifying roadblocks and reframing to reveal opportunities; and collaborative problem solving), and (3) Focusing (making suggestions; identifying preferences; working with ideas; and negotiating). These strategies aligned with the program's relational approach and supported the core processes of the goal-focussing framework, namely understanding and connecting with you, building a relationship, and working together with you to find focus. Conclusion: The goal-focusing framework and clinical strategies outlined provide guidance for clinicians working with people with TBI in the community and is a promising way to engage clients when focusing on individualized social activity-based goals.

It takes two to tango: The therapeutic alliance in community brain injury rehabilitation

Objective:

A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.

Method:

This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.

Results:

A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.

Conclusion:

These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

Humanising brain injury rehabilitation: a qualitative study examining humanising approaches to engagement in the context of a storytelling advocacy programme

Objectives:

Building upon the findings of an earlier study that explored the experience and impact of narrative storytelling following acquired brain injury (ABI), this study sought to examine the engagement of storytelling facilitators with storytellers.

Methods:

Transcripts of in-depth interviews conducted with six storytelling facilitators were analysed drawing upon content analysis. The analysis included a process of mapping previously analysed data (D’Cruz et al., 2020b) to a humanising values framework (Galvin & Todres, 2013; Todres et al., 2009).

Results:

The findings of this study provide insights into how facilitators engaged in humanising practice within the context of a storytelling advocacy programme. The facilitator participants ranged in years of facilitation experience from 1 to 11 years, with a mix of professional backgrounds, including health care (3), journalism (1) and community development (2). Analysed facilitator data mapped to each of the eight dimensions of the framework (insiderness, agency, uniqueness, togetherness, sense-making, personal journey, sense of place and embodiment), with a breadth of codes represented in each dimension, revealing the depth of humanisation.

Conclusions:

This study extends our understanding of approaches to engagement with adults living with ABI, demonstrating the humanising potential of storytelling. Furthermore, the findings help us to think about what it means to be human, guiding us to find ways to better partner with and support adults living with brain injury.

Beneficial and limiting factors in return to work after primary total knee replacement: Patients' perspective

BACKGROUND:

Return to work (RTW) is an important outcome in Total Knee Arthroplasty (TKA). At present, 70–80%of TKA patients return to work within three to six months.

OBJECTIVE:

What are patients’ perspectives regarding beneficial and limiting factors in RTW after TKA?

METHODS:

Focus groups were formed in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Three major topics were explored: 1. What was beneficial for RTW after TKA; 2. What was limiting for RTW after TKA; and 3. What additional care would benefit RTW after TKA?

RESULTS:

Data saturation was reached after four focus groups, comprising 17 participants—nine men and eight women (median age 58, range 52–65). The focus group study identified four main themes that contributed to a successful RTW namely rehabilitation (medical) like post-operative physical therapy, patient characteristics (personal), like motivation to RTW, occupational characteristics (work-related) like build-up in work tasks and medical support (medical) like availability of a walker or crutches.

CONCLUSION:

According to participants, factors within the following four themes can contribute to a successful return to work: occupational, patient, rehabilitation and medical care. Incorporating these factors into the integrated care pathway for the “young” TKA patients may increase the chances of a successful RTW.

Living with embodied vibrations: Sensory experiences following a traumatic brain injury

Based on autoethnography, this article adopts a (neuro)phenomenological lens to explore sensory experiences following a traumatic brain injury (TBI). Although focussing particularly on pain, vision, hearing, and somatic experiences connected with sleep, we also touch on how these are interwoven with other symptoms associated with TBIs. We use these experiences to enliven, and thereby enrich, clinical constructions and understandings of 'sensitivity' to light and to noise, as well as 'sleep disturbance'. We conclude with a discussion of how these sensory experiences can be understood in relation to embodied dynamics of vibration, oscillation, and (stochastic) resonance. The article closes with the suggestion that an embodied, sensorial, and phenomenologically informed analysis of the experiences of people with TBIs, particularly in relation, for example, to embodied sensations and perceptions of vibration, might provide novel insights for research and clinical practice.

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.

Experiences of inpatient rehabilitation from the perspective of persons with acquired brain injury

BACKGROUND

Perspectives of individuals with acquired brain injury (ABI) regarding inpatient rehabilitation experiences can inform patient-centered care; however, these voices are under-represented in the literature.

PURPOSE

To explore the experiences, needs, and preferences of patients from an ABI inpatient rehabilitation program in Ontario.

METHODS

Using an interpretive description approach, we interviewed 12 participants and analyzed the transcripts inductively to generate themes.

FINDINGS

We identified three major themes: (1) Life Rerouted - participants felt their lives diverted due to ABI, with rehabilitation seen as a way to return to pre-injury life, (2) Autonomy within Rehab highlighted the perceived importance of personal autonomy in decision-making within rehabilitation, and (3) Life (and Recovery) Go On reflected an ongoing recovery process after discharge - leading to mixed emotions. An overall message, "re-establishing personal identity is important to the recovery process," reflected theories of biographical disruption and relational autonomy.

IMPLICATIONS

Our findings provide a patient perspective for clinicians and administrators to consider. We found that ABI was significantly disruptive to personal identity - resulting in tensions in autonomy while attempting to reclaim a sense of identity. We suggest counseling services and strategies supporting post-injury adjustment, along with ways for rehabilitation professionals to enhance patient autonomy where possible.Implications for rehabilitationSustaining an ABI can significantly disrupt personal identity and sense of autonomy - especially as persons occupy the role of "patient" while in inpatient rehabilitation.Psychological support is recommended to address the impacts of ABI on patients' sense of identity, as well as on family members.Strategies of support might include, providing formal psychotherapy, as well as creating opportunities for patients and family members to discuss the changes they are experiencing, and to establish their personal narratives (e.g., through writing or art) or peer mentorship programs between discharged and current patients.Clinicians can enhance patient autonomy by increasing opportunities for communication with patients about choice; educating patients and family members on the rehabilitation team's decision-making process, and other methods that increase communication and provide consistent up-to-date information to patients and their family members.

The student journey: Living and learning following traumatic brain injury

Primary objective: In this research we set out to gain further understanding of the experiences of students participating in secondary and tertiary education following TBI: exploring academic and non-academic factors, as well as changes in experiences over time.Methods and procedures: A longitudinal, qualitative investigation was completed. 12 students (17-32 years) completed up to three in-depth interviews over a period of 4-15 months, capturing atotal of 30 time points. Data were analyzed using grounded theory methods.Main outcomes and results: Students' participation experiences were unique and varied with different timelines and outcomes, however they shared many similar critical points. We interpreted their experiences as a student journey traveling through four significant landscapes, "Choosing to study", "Studying", "Deciding what to do", "Making the next step." Journeys involved complex processes of living and learning. Moving along the pathway was not always smooth or straightforward.Conclusions: Students' experiences of returning to study following TBI can be interpreted as a complex journey of living and learning. Four important stages of the journey provide clinicians and educators with landscape features that can provide a structure for exploring supports to address both academic and non-academic factors to assist students in their study journey.

Client-centred practice in occupational therapy after stroke: A systematic review

Background: Client-centred practice aims to involve the person in making decisions during the therapeutic intervention process, giving him or her a central and active role.Objectives: To analyze the effects of client-centred practice in occupational therapy on issues related to occupational performance and participation among people with stroke and traumatic brain injury.Material and methods: A systematic review of randomized clinical trials examining the effects of a client-centred practice carried out by occupational therapists in patients with stroke or traumatic brain injury aged over 18 years was conducted. PubMed, Web of Science, Scopus, OT Seeker, PsycINFO and EBSCO were used to retrieve potentially eligible publications.Results: Eight studies, from 294 identified, were included. The extracted data showed that the application of client-centred practice in occupational therapy improved satisfaction with occupational performance compared to conventional interventions. However, client-centred practice and conventional intervention had similar effects on functionality (Activities of Daily Living), life satisfaction and burden on caregivers.Conclusions and significance: Client-centred practice has the effect of achieving greater satisfaction with occupational performance. This suggests that client-centred practice in occupational therapy helps patients to accept the new limitations on their occupational performance. Further studies are needed to determine the effects of client-centred practice on other aspects.

Knowledge of sex and gender and related information needs in patients with traumatic brain injury: in-depth interview study

AIM

This research aimed to gain an understanding of biological sex and social gender phenomena experienced by patients with traumatic brain injury in recovery, and to understand the educational needs of this group.

METHODS

We conducted semi-structured interviews of 40 adult patients (22 men, 18 women) of different ages, education levels, and ethnicities, with diagnoses of mild and moderate-severe traumatic brain injury at the acute and chronic stages post-injury.

RESULTS

Applying classic content analysis with inductive coding, three overarching themes that limited patients' knowledge and subsequent efforts to obtain information on the topic emerged: (1) the complexity of sex and gender subject matters, (2) patients' dependence on others, and (3) uncertainty about the course of recovery. The first diminished the patient's desire to seek further information. Dependence on others and trust that others were in a better position to use the information, compelled patients to redirect the need for education to clinicians, significant others, and the public on the unique post-injury experiences of men and women. Uncertainty about what to expect in the acute phases, and a feeling of identity loss in the chronic phases, established patients' desire to seek out only the information they believed to be necessary for them to carry on with life.

CONCLUSIONS

In developing recommendations for patient education, variations in patients' knowledge and desire for information, and the reasons behind these variations, should be considered. Improving injury prognosis requires taking into account the gendered context of injury and recovery from it.IMPLICATIONS FOR REHABILITATIONSex/gender issues in traumatic brain injury are complex; the challenge is identifying which information is most relevant for patients; this research assessed patients' knowledge of and interest in sex/gender-related topics in traumatic brain injury.Evidence shows most patients unable to differentiate between sex and gender, but when asked about living as a man or woman with traumatic brain injury, disturbed gender roles and identities became evident.Gender shapes the health status trajectory and outcomes of patients with traumatic brain injury which becomes evident when attention is paid to patients' personal life stories.To improve traumatic brain injury prognosis, clinicians should tailor management plans taking into account gender, an amalgamation of biological, behavioural, cultural, and social characteristics of their patients.In research, explicit and consistent consideration of the interrelated constructs of sex and gender would produce a better understanding of the different mechanisms that shape the course of traumatic brain injury.

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.

Conceptualizing movement by expert Bobath instructors in neurological rehabilitation

RATIONALE, AIMS, AND OBJECTIVES

Movement, a core aspect of physiotherapy practice, and integral to the clinical reasoning process has undergone limited theoretical development. Instead, research has focused on intervention effectiveness embedded within the positivist paradigm. The purpose of this study was to explore how expert neurorehabilitation therapists conceptualize movement as part of their clinical reasoning.

METHOD

A qualitative interpretive descriptive approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews was used. Theoretical sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA) who are recognized experts in neurorehabilitation. Interview transcripts were transcribed verbatim. Data analysis was progressive, iterative, and inductive.

RESULTS

Twenty-two IBITA instructors from 7 different countries volunteered to participate. They ranged in clinical experience from 12 to 40 years and instructor experience from 1 to 35 years. The conceptualization of movement by the IBITA instructors involves the following elements: (1) movement comprises the whole person and the whole body, not just individual body segments; (2) active alignment of body segments is integral to movement performance; and (3) efficient movement requires the relative integration of postural control/stability and selective movement/mobility.

CONCLUSIONS

The IBITA instructors conceptualize movement from a person-centred perspective. The integration of postural control and selective movement, with alignment and variability as key components, forms the foundation of their understanding of movement. Further investigation into the role of postural control in movement recovery post central nervous system lesion is required. Likewise, the dimensions of movement critical to the conceptualization of movement are not well understood from the perspective of the physiotherapist or persons with neurological impairments.

Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors

RATIONALE, AIMS, AND OBJECTIVES

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept.

METHODS

A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive.

RESULTS

Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group.

CONCLUSIONS

This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas.

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.