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

The use of groups is common in healthcare. There is a paucity of research which captures patient experiences of group participation. The aims of this study were to explore the perceptions and experiences of people with traumatic brain injury (TBI) about their participation in inpatient occupational therapy rehabilitation groups.A phenomenological approach guided the study. Patients with a TBI who were participating in an inpatient occupational therapy group program were recruited. Data were collected through semi-structured interviews and analysed using content analysis.Fifteen participants consented to the study. Three themes emerged from the data; 1) feeling normal, comfortable and connected; 2) learning by doing, seeing and sharing and; 3) practicalities of groups. Participants highlighted that groups facilitated opportunities to practice skills and prepared them for the real world. Opportunities for interaction and support were also emphasised as positive by participants.Perceptions of patients about participation in groups were generally positive, and as such a consumer-focused approach to healthcare would support the use of occupational therapy groups in TBI rehabilitation.Recommendations from the perspectives of patients include consideration of the selection of group participants, and meeting individual needs and goals within a group setting

Goal-directed, environment-focused, outpatient rehabilitation for people with severe traumatic brain injury: process, effectiveness and influence of context.

Literature: Acquired brain injury (ABI) results in significant personal, psychological, family, economic and social costs including medical, rehabilitation and care costs as well as loss of work. A primary cause of ABI is traumatic brain injury (TBI), which most commonly affects young people (19-25 years) who are in the establishment phase of their life. Research into the efficacy of treatment approaches and most appropriate outcome measures specific to people with TBI undergoing outpatient rehabilitation is scant. Firstly, goal planning and the use of goals is widely practised in neurological rehabilitation, however research investigating the efficacy of goal-directed approaches is very limited. Secondly, although goal planning and assessment tools such as the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scale (GAS) have previously been used, there are no published studies investigating the clinical utility of their combined use in community-based rehabilitation for people with TBI. Thirdly, in practice, outpatient rehabilitation for this client group is conducted in clients’ homes as well as hospital-based clinics (i.e., day hospitals). This reflects a broader shift toward the use of community-based services in health care. Qualitative findings suggest that providing rehabilitation in real-life, home settings may potentially be more beneficial for this client group. A systematic review of studies that compare outcomes of outpatient rehabilitation programs conducted at home with those conducted in outpatient clinic settings was conducted. Previous research had primarily focused on samples of people with stroke, often aged over 65 years. There are no previous controlled studies that investigate the impact of therapy context (real-life home contexts versus outpatient clinic contexts) on outcomes for people with TBI. Aims: The aim of this thesis was to investigate the application of community-based rehabilitation practice for people with TBI. This involved: A) exploring the process of client-centred, goal-directed rehabilitation and outcome measurement in a community-based rehabilitation context, B) determining the effectiveness of goal-directed rehabilitation, and C) investigating the influence of context on rehabilitation outcomes by comparing the effectiveness and experience of rehabilitation in a real-life setting (i.e., home and community) with a day hospital clinic context. The specific aims in terms of the process (Aim A) were: 1. to develop a set of practice principles to guide the rehabilitation of people with ABI living in the community, and 2. to investigate the clinical utility and treatment validity of the combined use of the COPM and GAS. The specific aims in relation to the effectiveness of goal-directed rehabilitation (Aim B) were: 1. to explore the clinical application of goal-directed therapy in community-based rehabilitation from the perspective of clients with TBI, their significant others and their treating occupational therapists, and 2. to compare the amount of clinical change on a range of outcome measures following a baseline and goal-directed intervention phase. The specific aims in terms of the influence of the context of rehabilitation on outcomes (Aim 3) were: 1. to determine whether the amount of clinical change differed when a goal-directed rehabilitation program was delivered in a home-based setting or a day hospital-based setting, and 2. to explore the client, family and therapist perspectives regarding the influence of the context (home and day hospital environments) on rehabilitation. Procedures: This thesis is based on two linked studies. The first was a pilot investigation of rehabilitation practice principles from the perspective of 10 health professionals experienced in working with people with ABI in community settings, using semi-structured interview techniques. Findings of the pilot investigation, and results of a review of available literature, were used to inform the development of a treatment program. The second and main study involved the implementation of the client-centred, goal-directed outpatient occupational therapy rehabilitation program. The study was a repeated measures crossover design with pre-test/post-test measures. Participants were 14 people with TBI recently discharged from inpatient rehabilitation. Following a six week baseline period, participants received six weeks of intervention at their home (A) and six weeks of intervention in a day hospital clinic (B), in addition to receiving their regularly scheduled day hospital occupational therapy program. To counterbalance order effects, participants were randomly allocated to a treatment setting sequence of home first (AB), or day hospital first (BA). Participants’ program goals were set and all outcome assessments, including goal achievement, occupational performance, psychosocial integration, participation and environmental factors, were conducted by a researcher who was not involved in the treatment and was blinded to the treatment sequence. Each participant’s program was carried out to completion by one occupational therapist who was not told about the research hypothesis. The clinical utility of the combined use of GAS and the COPM was explored using parametric statistics and descriptive analysis. To determine whether the goal-directed intervention program was effective, scores post baseline and intervention phases were compared using non-parametric statistics. To determine whether there was a difference in outcomes dependent on treatment context, descriptive and non-parametric comparative analyses were used to compare change scores post the home and day hospital treatment phases on all outcome measures. The experience of the rehabilitation program and different rehabilitation contexts, from the perspective of the participants, their significant others and the treating therapists, was explored using semi-structured interviews. Two separate qualitative analyses of the interview data were conducted. First, to explore the application of goal-directed therapy, interview responses to questions relating to goal planning and goal-directed therapy were analysed thematically using the principles of the framework method. Second, to explore the interviewee’s opinions about the influence of the therapy context, the interview data were approached with a specific question, namely “how does the therapy environment (home and day hospital) impact on the process and outcomes of therapy?”. Interview data relating to this question were analysed using a manifest content analytic approach. Findings: In terms of the process of community-based rehabilitation for people with ABI living in the community, key practice principles identified by therapists in this field included the need for; 1. environment-focused and contextually appropriate rehabilitation, 2. a collaborative approach and inclusion of others in the rehabilitation process, especially the person’s support network, and 3. the use of a client-centred, goal-directed approach. In terms of the clinical utility of the combined use of the COPM and GAS in goal planning and assessment, results indicated that both measures were sensitive to change. Their combined use resulted in participants almost unanimously perceiving their goals as client-centred, despite most participants demonstrating moderate or severe impairment to self-awareness. Goal achievement was similar when participants were grouped according to no/mild, moderate or severe impairment to self-awareness. In terms of program effectiveness, the goal-directed rehabilitation program resulted in significant improvements in goal attainment, occupational performance, and psychosocial reintegration. Qualitative findings emphasised the value of goals in providing structure and motivation, the importance of goal ownership, and the importance of family involvement. A challenge of goal-directed therapy included the impact of cognitive difficulties and reduced self-awareness on goal planning. In terms of the influence of therapy context, the quantitative differences in gains made in home and day hospital settings were not statistically significant, with the exception of higher levels of client satisfaction with therapy at home. Qualitative findings in relation to the influence of therapy context on rehabilitation process and outcomes highlighted the experience of home-based therapy as more relaxing, normal, satisfying and effective compared with day hospital-based therapy. The home environment was described as a facilitator of a client-centred, functional approach, a closer therapeutic alliance, and greater therapeutic benefits, whereas the day hospital environment was described as a barrier to these processes. The day hospital environment was also described as a facilitator of: opportunities for patients to socialise with old friends and staff; easy access to a range of remedial activities; professional support for therapists; and better efficiency due to no travel time for therapists. Conclusions: The use of a client-centred, goal-directed approach is effective in assisting people with TBI undergoing outpatient rehabilitation to make clinically significant gains in performance. A therapist-facilitated, structured goal planning process in which the client, therapist and significant others work in partnership, can enhance the process of goal planning and goal-directed community rehabilitation. Impairment to self-awareness and reduced participation in goal planning, which is commonly reported in this population, may necessitate a therapist-led approach during initial goal planning. However, this approach does not necessarily result in a lack of goal identification, goal achievement or lack of participation in community rehabilitation. Furthermore, the COPM and GAS were sensitive to change, and their combined use in planning goals and measuring progress within this population was effective in enabling objective, therapist assessment of performance of individualised, client-centred goals. In terms of the treatment context, client outcomes were equivalent whether therapy was carried out in a day hospital or home setting. However, people with TBI and their family members largely preferred receiving therapy in the home setting for practical and psychological reasons.

Occupation-based, client-centred approach to goal planning and measurement

Goal planning is a commonly used practice in rehabilitation; however, approaches vary with no gold standard. Despite its widespread use in rehabilitation, research on the effectiveness of goal-planning approaches is still an emerging area (Levack et al., 2006). This chapter seeks to describe and discuss a client-centred, occupation-based approach to goal planning, as well as present recent evidence related to the clinical utility and effectiveness of this approach with clients in a rehabilitation setting. By the end of this chapter, it is expected that the reader will have knowledge about what occupation is and the potential benefits of occupation-based goal planning, how occupational therapists use occupation as therapeutic tool in rehabilitation, how occupation can form the basis for goal planning in rehabilitation, client-centred practice, the Canadian Occupational Performance Measure (COPM) and the clinical utility of the combined use of the COPM and goal attainment scaling (GAS) to plan goals and structure a rehabilitation programme. This chapter will also discuss the application of and challenges to applying client-centred goal planning in teams, challenges of goal planning in different rehabilitation environments and strategies to enhance consideration of environmental factors when goal planning

Goal setting approaches and principles used in rehabilitation for people with acquired brain injury: A systematic scoping review

Primary objective: To identify goal setting approaches used with people with acquired brain injury (ABI) in the working age range.Methods: Database searches were conducted in Medline (via Ovid) (1960-May 2014), CINAHL (1982-May 2014), Cochrane Library (1996-May 2014) and PsycINFO (1840-May 2014). Systematic scoping review of databases identified studies that described or evaluated goal setting approaches, which were classified as informal or formal. Methodological quality appraisal was completed with all studies that evaluated a goal setting approach. Key practice principles were extracted from evaluation studies using a content analytic approach to identify key themes.Results: Of the full text articles included (n = 86), 62 described a goal setting approach and 24 evaluated a goal setting approach. Formal goal setting approaches were used in 77% of studies. The most common practice principles extracted describe goal setting in ABI rehabilitation as being client-centred, collaborative, measurable and realistic and as incorporating proximal goals or providing a link to therapy.Conclusion: Use of formal goal setting approaches appears more prevalent in research studies compared with routine clinical practice. There is a strong theme in the literature that client-centredness and collaboration are necessary components of effective goal setting

Refining a clinical practice framework to engage clients with brain injury in goal setting

Client-centred goal setting is fundamental to occupational therapy practice and has been increasingly embraced by all rehabilitation practioners. Goal setting in clinical practice is a highly individualised process and may be more challenging with people with acquired brain injury. However, research examining practice is limited. We developed the Client-Centred Goal Setting Practice Framework to explain how client-centred goals are developed in brain injury rehabilitation. This framework was based on interview data and may reflect practitioner's theoretical knowledge rather than goal setting processes used in routine practice. The aims of this study were to explore the application of the framework to every-day practice, examine the extent to which goal setting was client-centred and refine the framework.A mixed methods approach was employed. Participants were community dwelling clients with ABI and their practitioners, drawn from a hospital outpatient service and community private practices. The communication exchange between practitioners and clients during routine goal setting was audio-recorded, transcribed verbatim and analysed using framework analysis. Quantitative measures evaluated the client-centredness of goals.A total of 65 goal setting sessions with 36 clients and 17 practitioners (n\ua0=\ua08 occupational therapists) were analysed. The three goal setting phases of the framework and associated processes and strategies were represented. The 'establishing trust' process was interwoven throughout all phases and an additional strategy, 'social connection' was identified.The framework provides preliminary evidence about the core processes and strategies which uses establishing trust to engage clients with ABI in goal setting, and may be a useful tool to guide client-centred goal setting practice in similar services

Clinician perceptions about inpatient occupational therapy groups in traumatic brain injury rehabilitation

Primary objective: The aim of the study was to explore the experiences and perceptions of clinicians about the benefits, challenges and processes of facilitating inpatient occupational therapy groups in traumatic brain injury (TBI) rehabilitation including peer-to-peer interactions and use of goals. Design and method: A qualitative, methodology, guided by a phenomenological approach was utilized with data collected from focus groups comprising 26 clinicians working in occupational therapy in three inpatient rehabilitation settings: brain injury, spinal injury and geriatric rehabilitation in order to identify aspects unique to brain injury rehabilitation. Data were analysed using the framework analysis method. Findings: Three overarching themes emerged; 'good fit', 'the things clinicians do' and 'patient-to-patient. Clinicians indicated that structured group formats, careful planning and communication facilitated positive group dynamics and ensured groups met individual needs. Cognitive impairments following TBI and challenging behaviours were identified to impact on group processes, and clinician skills and confidence were important in managing these. Peer-to-peer support and learning was described as a key benefit of group rehabilitation. Conclusions: Groups in TBI rehabilitation create opportunities for peer-to-peer support and learning, and contribute positively to rehabilitation but group facilitator skills are critical. Practical strategies for facilitating groups in TBI rehabilitation are suggested

Group-based delivery of interventions in traumatic brain injury rehabilitation: a scoping review

Whilst there are potential advantages of group-based interventions in rehabilitation, facilitation of groups for patients following traumatic brain injury (TBI) has challenges due to the complexity of impairments experienced. This paper aims to review the literature concerning therapy groups within TBI rehabilitation.A scoping review with systematic searching of relevant databases and review of reference lists of included studies was conducted. Key search terms included brain injury, group and rehabilitation OR therapy OR intervention. Studies were included if at least some participants had a TBI diagnosis and they investigated rehabilitation interventions conducted in a group setting. Articles were collated, summarised and key findings are presented.The total number of included articles was 99. The results indicated group interventions are widely practised in TBI rehabilitation. Existing research consists mostly of pre-post intervention studies addressing cognitive impairments with outpatient participants. Most studies have identified significant positive changes on some targeted outcome measures suggesting group interventions are effective.Studies of the effectiveness of interventions targeting 'real-world' activities and participation-based goals are under-represented in the TBI rehabilitation literature. Further research investigating the effectiveness of group processes and the perceptions of patients and clinicians is warranted to guide clinical practice. Implications for Rehabilitation Group-based interventions are common in TBI rehabilitation, usually targeting cognitive skills and impairments. The majority of studies demonstrated positive changes pre-post group interventions on some outcome measures. Few studies directly compare the outcome of an intervention delivered in a group setting to the same intervention delivered in an individual setting. Patients perceive group interventions to be beneficial for sharing experiences and reducing isolation, receiving help and feedback and, assisting with adjustment and adaptation to life after TBI, however, this research is limited. Greater emphasis on group-delivered interventions that target 'real world' activities, or participation may be beneficial with this population. Further research regarding consumer experiences and processes that facilitate effective group interventions in TBI rehabilitation is recommended