Development of a toolkit to enhance care processes for people with a long-term neurological condition: a qualitative descriptive study

Unpacking how trust, communication and flow interact to sustain quality relationships between disabled people, family and support workers: a realist qualitative study

PURPOSE

Many disabled people require support workers to complete personal care, daily tasks and participate in life roles. Due to the intimate nature of community disability support in domestic environments, understanding what facilitates positive relationships is paramount. We examined the intricate interplay of context and mechanisms that drive positive relationship outcomes for disabled people, their family members and support workers.

METHODS

A realist-informed, participatory methodology involving three participant groups: disabled people, family members, and disability support workers.

RESULTS

Sixteen participants participated in two workshops per group (5 disabled people, 5 family members, and 6 disability support workers). All three participant groups prioritised three key generative mechanism processes involved in positive relationship outcomes: (1) having clear communication, (2) building trust, and (3) developing a sense of flow. We describe how each mechanism manifested in a unique way for each group, and also how the activation of each mechanism was influenced by a dynamic resources/tensions balance specific to each group.

CONCLUSION

We describe the interaction between three mechanism processes involved in triadic relationships between disabled people, family members, and support workers. Attention is now required to explore strategies to negotiate the resource/tension balance particular to each group.

Development of a functional electrical stimulation cycling toolkit for spinal cord injury rehabilitation in acute care hospitals: A participatory action approach

The purpose of our study was to develop a toolkit to facilitate the implementation of functional electrical stimulation (FES) cycling for persons with a newly acquired spinal cord injury (SCI) in the acute care inpatient hospital setting. The researchers and community members used participatory action as a research approach to co-create the toolkit. We held two focus groups to develop drafts, with a third meeting to provide feedback, and a fourth meeting to evaluate the toolkit and determine dissemination strategies. Toolkit development followed the Planning, Action, Reflection, Evaluation cycle. We used an iterative design informed by focus group and toolkit consultant (SC) feedback. In focus group discussions, we included FES cycling champions (JK, DW) who led acute care implementation. Focus group members, recruited through purposive sampling, had to 1) have an understanding about FES cycling in acute care for SCI and 2) represent one of these groups: individual living with SCI, social support, hospital manager, clinician, therapist, researcher, and/or acute care FES cycling champion. Twelve individuals took part in four focus groups to develop a toolkit designed to facilitate implementation of FES cycling in SCI acute care in Edmonton, Alberta. Group members included an individual with lived experience, three acute-care occupational or physical therapists, three acute-care hospital managers, and five researchers. Two physical therapists also identified as clinical FES cycling champions. Following an inductive content analysis, we identified four main themes: 1) Health care provider toolkit content and categories, 2) Health care provider toolkit end product, 3) Collaborations between groups and institutions and 4) Infrastructure. Interested parties who utilize FES cycling in acute care for SCI rehabilitation agree that toolkits should target the appropriate group, be acute care setting-specific, and provide information for a smooth transition in care.

Managing the move from assisted to independent living: an inclusive qualitative study among adults with cerebral palsy

PURPOSE

To understand aspects important to adults with severe cerebral palsy (CP) as they prepare to move from assisted to independent living and to create an appropriate intervention.

MATERIALS AND METHODS

An inclusive qualitative study was conducted together with adults with severe CP (Gross Motor Function Classification Scale 4-5) preparing to move to independent living. It included semi-structured interviews which were recorded, transcribed, and analyzed by two occupational therapists to create themes. The themes were reviewed and adjusted by the partners in a group context.

RESULTS

Seven partners aged 23-47 years (median= 35 years, standard deviation = 10; 4 female) participated. Four themes arose with sub-themes: (1) house management (finances, meals, maintenance, and housework), (2) interactions and boundaries (with a caregiver, family, friends, and romantic partners), (3) schedules (work, leisure, volunteering, education, and health management), and (4) "my way" (autonomy, independence, and self-advocacy; emotions and group power). These themes expressed the concerns of the partners and formed the basis of a group intervention before their move from assisted to independent living.

CONCLUSIONS

The inclusive research revealed themes the partners raised that expressed their concerns; these became the basis for a group intervention to prepare for their move from assisted to independent living.

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.

Embedding the living well toolkit into service delivery - A complex process

Objective

To embed the Living Well Toolkit package and to understand how it was implemented at each site and to explore the experiences of users.

Methods

The toolkit package was introduced in four rehabilitation settings using a tailored implementation process negotiated with each site. The varied data sources were analysed drawing on directed content analysis.

Results

Clients with neurological conditions and clinicians initially weighed the merits of the toolkit package. A positive weighing up was prerequisite for deciding to use. Clinicians described considerable thought and planning to make the toolkit package fit and flow in clinical practice. Users of the toolkit package described ways in which it shaped their thinking.

Conclusion

Implementation of the toolkit package was a complex process for clinicians and services, involving ongoing work to optimise its impact relative to the client and context. Clinicians and clients who used the toolkit package described positive changes, congruent with person-centred communication.

Innovation

The Living Well Toolkit is freely available for all to use. Clinicians who used reflective and responsive thinking to make the toolkit package work found it provided them with a broader perspective of the client.

Pilot trial of The Living Well Toolkit: qualitative analysis and implications for refinement and future implementation

Background

Following a neurological event, people’s long-term health and well-being is hampered by a system that struggles to deliver person-centred communication and coordinated care and fails to harness individual and family capability to live well with the condition. We aimed to implement and evaluate a toolkit package to support these processes for people with long-term neurological conditions.

Methods

This is a multi-phased study drawing on the principles of participatory research. In this pilot phase, the toolkit package was introduced to clinicians, who introduced it to clients in four neurorehabilitation settings (inpatient and community-based). Individual and focus group interviews were carried out with clients (n = 10) and clinicians (n = 9). Data were categorised by the four components of Normalisation Process Theory (NPT), and data within each component was then coded inductively. This analysis was used to inform revisions to the toolkit package and wider implementation processes.

Results

There was widespread support for the principles underpinning the toolkit package from clients and clinicians. However, it was less clear how the client toolkit could support these principles in clinical practice which impacted buy-in. The flexibility of use of the client toolkit, which we encouraged, made it difficult for clinicians and clients to be clear about its purpose and for clinicians to operationalise in practice. Clinicians and clients identified a number of barriers that limited the time, energy and work users were able or prepared to invest, to the extent that uptake of the toolkit package was modest. Use of the toolkit package appeared more likely when clinicians perceived it to augment existing processes (e.g. goal setting) rather than detract from ‘doing’ therapy. This analysis was used to inform revisions to the toolkit package, including simplification of the client toolkit, development of videos with examples of use and a modular and reflective training package for clinical services. The refinements were intended to improve sense-making and minimise the cognitive barriers associated with implementation of a new intervention.

Conclusion

Understanding how supporting the client toolkit could add value to the therapeutic encounter was necessary for clinicians to invest time and perceive the worth of the toolkit package.

Trial registration

ANZCTR: ACTRN12614000537651. Registered 21 May, 2014.

Implementation in rehabilitation: a roadmap for practitioners and researchers

Purpose: Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners.Methods: Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings.Results and Conclusions: Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation.Implications for rehabilitationEffective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them.Understanding context for implementation is critically important and using theory can facilitate development of understanding.Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change.Sustainability requires regular revisiting of the interconnected steps.