Felicity A. S. Bright

Implementing a client-centred approach in rehabilitation: an autoethnography

Purpose: Client-centred practice is widely considered a key element of rehabilitation. However, there is limited discussion of how it should be implemented. This study explored how client-centred practice was operationalized during a clinical trial of innovative goal-setting techniques. Method: This study drew on principles of co-autoethnography. The personal experiences of three clinical researchers were explored to identify insights into client-centred practice, and seek understanding of this within the broader socio-cultural context. Data were collected through group discussions and written reflections. Thematic analysis and coding were used to identify the dominant themes from the data. Results: The primary way that client-centred practice was operationalized was through listening in order to get to know, to uncover and to understand what was meaningful. Four strategies were identified: utilizing mindful listening, allowing time, supporting clients to prioritize what is meaningful and viewing the therapists’ role differently. Conclusion: While technical competence in rehabilitation is important, our study suggested a starting point of ‘being with’ rather than ‘doing to’ may be beneficial for engaging people in their rehabilitation. We have highlighted a number of practical strategies that can be used to facilitate more client-centred practice. These approaches are consistent with what clients report they want and need from rehabilitation services. Implications for Rehabilitation At face value, clinical practice may appear to be client-centred. However, critical reflection of existing practice suggests that in reality, it is not well operationalized. Prioritizing getting to know the client, their story and what is meaningful to them appears fundamental to client-centred practice. A number of strategies may facilitate this process, including mindful listening on the part of the clinician and allowing time. Structures and processes need to be instituted to support implementation of client-centred practice. Autoethnography is an approach that may support clinicians’ to reflect on their practice.

A conceptual review of engagement in healthcare and rehabilitation

Abstract Purpose: This review sought to develop an understanding of how engagement in healthcare has been conceptualized in the literature in order to inform future clinical practice and research in rehabilitation. A secondary purpose was to propose a working definition of engagement. Methods: EBSCO and SCOPUS databases and reference lists were searched for papers that sought to understand or describe the concept of engagement in healthcare or reported the development of a measure of engagement in healthcare. We drew on a Pragmatic Utility approach to concept analysis. Results: Thirty-one articles met the criteria and were included in the review. Engagement appeared to be conceptualized in two inter-connected ways: as a gradual process of connection between the healthcare provider and patient; and as an internal state, which may be accompanied by observable behaviors indicating engagement. Conclusion: Our review suggests engagement to be multi-dimensional, comprising both a co-constructed process and a patient state. While engagement is commonly considered a patient behavior, the review findings suggest clinicians play a pivotal role in patient engagement. This review challenges some understandings of engagement and how we work with patients and highlights conceptual limitations of some measures. Implications for Rehabilitation Engagement appears to be a multi-dimensional construct, comprising both a co-constructed process and a patient state. Conceptualizing engagement as a co-constructed process may help clinicians be more aware of their role in patient engagement and sees the responsibility to engage shift from the patient to the therapeutic dyad. Challenges in engagement may be a prompt to reflect on how the clinician is working and whether different ways of working may be beneficial.

Understanding Hope After Stroke: A Systematic Review of the Literature Using Concept Analysis

Abstract Purpose: Hope is said to be important in recovery from illness or injury, supporting adjustment, perseverance, and positive outcomes. There has been little exploration of hope in people after stroke. This is reflected in the literature, which lacks consistent definition and terminology. This purpose of this article is to clarify the concept of hope after stroke and to synthesize the findings to propose a working model of hope. Method: A systematic literature search was completed. Articles were included if they explored hope from the perspective of people with stroke or if hope was reported as a key finding in a study. Coding, analytic questions, and matrices were used to extract data and to compare, contrast, and synthesize conceptualizations, processes, and outcomes of hope. This was guided by a concept analysis methodology. Results: The literature search identified 20 articles that met the inclusion criteria. Analysis of these articles suggested hope was conceptualized in 3 interrelated ways – as an inner state, as being outcome-oriented, and as an active process. Findings suggested that internal and external resources contributed to the development of hope. Hope was perceived to be linked with positive outcomes and functioned as a motivator and source of strength through recovery. Hope reflected elements also found in the concepts of expectations, goals, and optimism. Conclusion: This novel approach to analysis has furthered the understanding of hope. It has proposed a working model of hope that could be used by clinicians in considering hope with their clients and patients.

Hope in people with aphasia

Background: Hope is considered to be important for health, recovery, and rehabilitation outcomes in a range of healthcare populations. Little is known about hope in people following stroke, and even less is known about hope in people with aphasia following stroke as they are commonly excluded from research in this field. Aims: This study aimed to explore how hope was experienced by people with aphasia following stroke during the post-acute period of rehabilitation, and to identify factors influencing the experience of hope. Methods & Procedures: This study utilised an Interpretive Description methodology. Data were collected through semi-structured interviews with five people with aphasia. Supported conversation techniques were used to facilitate full contribution of participants. Data were analysed using a number of approaches—coding, thematic analysis, narrative construction, diagramming, and memoing. Outcomes & Results: Hope was experienced in two ways. Simply ‘having’ hope was a broad but passive sense of hope which appeared to be the primary, constant form of hope. Actively hoping was an active, future-oriented form of hope that was experienced intermittently by participants. The experience of hope appeared dynamic and complex and seemingly influenced by three primary factors: uncertainty about the future; viewing hope as double-sided; and a sense of disruption. These were in turn influenced by a persons past experiences, present reality and perceived future. Conclusions: Hope is considered important by people with aphasia. It appears related to how people engage in rehabilitation and may be influenced by clinicians. As such, it is a concept that therapists should be aware of. Suggestions for how clinicians may consider and address hope are provided and discussed.

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.

Co-constructing engagement in stroke rehabilitation: a qualitative study exploring how practitioner engagement can influence patient engagement:

Objective: To explore how practitioner engagement and disengagement occurred, and how these may influence patient care and engagement. Design: A qualitative study using the Voice Centred Relational Methodology. Data included interviews, focus groups and observations. Setting: Inpatient and community stroke rehabilitation services. Subjects: Eleven people experiencing communication disability after stroke and 42 rehabilitation practitioners. Interventions: Not applicable. Results: The practitioner’s engagement was important in patient engagement and service delivery. When patients considered practitioners were engaged, this helped engagement. When they considered practitioners were not engaged, their engagement was negatively affected. Practitioners considered their engagement was important but complex. It influenced how they worked and how they perceived the patient. Disengagement was taboo. It arose when not feeling confident, when not positively impacting outcomes, or when having an emotional response to a patient or interaction. Each party’s engagement influenced the other, suggesting it was co-constructed. Conclusions: Practitioner engagement influenced patient engagement in stroke rehabilitation. Practitioner disengagement was reported by most practitioners but was often a source of shame.

Exploring Relational Engagement Practices in Stroke Rehabilitation Using the Voice Centred Relational Approach

Abstract While discussions on patient engagement commonly focus on patient behaviors, a small body of research highlights the patient-practitioner relationship as critical in engagement. Understanding this relationship might be facilitated through a relationally-oriented methodology. The Voice Centred Relational Approach is one such qualitative methodology. Within this paper, we present one turn in a long conversation about this methodology. Drawing on our longitudinal observational study of engagement practices in stroke rehabilitation in New Zealand, we explicate how a theoretical framework can inform how the Voice Centred Relational Approach is enacted in the research process, from entering the field to dissemination. We detail how we adapted the associated analytic techniques (the Listening Guide and i-poems) for use with multiple forms and sources of data. We propose that the underlying relational ontology and relational orientation of this methodology makes it a useful approach in researching relational practice in healthcare.