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.
Governing neurorehabilitation Cummins, Christine; Payne, Deborah; Kayes, Nicola M.
Disability and rehabilitation,
08/2022, Letnik:
44, Številka:
17
Journal Article
Recenzirano
Odprti dostop
Person centred approaches to rehabilitation are promoted as an ethical means of addressing paternalistic power relations in clinician dominated medical encounters and improving outcomes. However, ...they fail to account for the complex nature of power. We sought alternative ways to explain the use of power in health service provision.
A poststructural discourse analysis using the view of power offered by Michel Foucault was undertaken. Foucault's concept of governmentality is useful to explain the way health services deploy technologies of power to achieve objectives of the state. Governmentality refers to not just political structures but all the strategies and procedures for directing human behaviour.
Our investigation uncovered a web of strategic relationships operating that were both potentially productive and problematic and illuminate how client centred approaches in neurorehabilitation intertwines its subjects in strategic power relationships that involve webs of obligations and responsibilities.
The client-professional relationship promoted in neurorehabilitation as a moral way to practice can be a tool for mastery of one over the other, and assist the client to achieve their desired ends, but also has the potential to marginalise others who are unable to shape themselves into the desired ideal client.
Implications for rehabilitation
This analysis shows how power is subtle and productive in that it produces knowledge and roles for both clients and practitioners.
It demonstrates how neurorehabilitation's disciplinary practices assist the client to achieve their recovery goals.
It reveals how certain clients might be marginalised when they cannot shape themselves into the ideal rehabilitation client.
As a final point we hope that by being aware of how power works in neurorehabilitation, practitioners can become aware of opportunities for challenging disciplinary practices that do not serve the best interest of the client.
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 RehabilitationEngagement 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.
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.
...Key databases (PubMed, Scopus, Cumulative Index to Nursing and Allied Health), snowballing searches, and experts' consultation were the data sources for English-language empirical or conceptual articles published from January 2007-February 2020.
Two independent reviewers selected adult-based articles addressing at least 1 of the 6 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 articles.
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.
A thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by 5 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 3 levels: (1) the person-professional dyad; (2) the microsystem level (typically an interprofessional team, involving significant others); and (3) a macrosystem level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR.
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.
Objective
The aim of this systematic review was to determine the effectiveness of self-guided digital physical activity (PA) and exercise interventions to improve physical activity and exercise ...(PA&E) outcomes for people living with chronic health conditions. Digital health interventions, especially those with minimal human contact, may offer a sustainable solution to accessing ongoing services and support for this population.
Methods
A comprehensive and systematic search was conducted up to December 2021, through seven databases, for randomized trials that evaluated the effect of self-guided web- or internet-based PA interventions on physical activity or exercise outcomes. Included studies had to have interventions with minimal human contact and interaction with participants needed to be automatically generated. All studies were screened for eligibility and relevant data were extracted. Two independent reviewers assessed the risk of bias using the Cochrane risk of bias tool. Standardized mean differences and 95% confidence intervals (CI) were calculated. PA data were pooled, and forest plots were generated.
Results
Sixteen studies met the eligibility criteria and included a total of 2,439 participants. There was wide variation in health conditions and intervention characteristics in mode and parameters of delivery, and in the application of theory and behavioral strategies. Self-reported PA in the intervention group was greater than controls at the end of the intervention standardized mean difference (SMD) 0.2, 95% CI = 0.1, 0.3 and at follow up (SMD 0.3, 95% CI 0.2–0.5). The difference in objectively measured PA was small and non-significant (SMD 0.3, 95% CI −0.2 to 0.9). All interventions included behavioral strategies and ten of the sixteen were underpinned by theory.
Conclusions
Self-guided digital PA&E interventions provided a positive effect on PA immediately after the intervention. An unexpected and positive finding was a sustained increase in PA at follow-up, particularly for interventions where the behavioral strategies were underpinned by a theoretical framework. Interventions with minimal contact have the potential to support sustained PA engagement at least as well as interventions with supervision.
Systematic Review Registration
https://www.crd.york.ac.uk/prospero/
, identifier: CRD42019132464.
To explore the experiences of participants during a six-month, post-stroke telerehabilitation programme.
A qualitative descriptive study to investigate participant experiences of ACTIV (Augmented ...Community Telerehabilitation Intervention), a six-month tailored exercise programme delivered by physiotherapists primarily using readily accessible telecommunication technology. Semi-structured, in-depth interviews were used to collect data, which were analysed using thematic analysis.
Interviews conducted in participants’ homes or a community facility.
Participants were eligible if they had a stroke in the previous 18 months and had participated in ACTIV.
Twenty-one participants were interviewed. Four key themes were constructed from the data: 1. ‘ACTIV was not what I call physio’ (it differed from participants’ expectations of physiotherapy, but they reported many positive aspects to the programme). 2. ‘There’s somebody there’ (ongoing support from the physiotherapists helped participants find strategies to continue improving). 3. ‘Making progress’ (in the face of barriers, small improvements were valued). 4. ‘What I really want’ (participant goals were frequently more general than therapy goals and involved progress towards getting back to ‘normal’).
Although ACTIV was not what participants expected from physiotherapy, the majority found contact from a physiotherapist reduced the feeling of being left to struggle alone. Most participants found a programme with minimal face-to-face contact augmented by phone calls and encouraging text messages to be helpful and acceptable.
Australia New Zealand Clinical Trials Registration Number: ACTRN12612000464864
•The use of readily accessible technology to augment rehabilitation after stroke was acceptable to people who received a six-month programme.•People found text contact maintained a therapeutic bond with their physiotherapist.•Remote contact decreased the perception of being left to manage alone after discharge from physiotherapy.
Understanding personal experiences of real-world walking for stroke survivors could assist clinicians to tailor interventions to their clients' specific needs. We explored the research questions: ..."What does real-world walking mean to people after stroke and how do they think it can be better?"
Using an Interpretive Descriptive methodology, we purposively sampled eight stroke survivors who reported difficulty walking in the real-world. We sought diversity on key participant characteristics. Participants were interviewed using a semi-structured guide. Data were analysed with thematic analysis.
Many found real-world walking, particularly in the outdoors, created opportunities for freedom from dependence and a visible step by step progress, which generated hope for future recovery. Conversely, when participants did not experience sufficient progress, they expressed negative emotions. Participants strove to overcome challenges to their walking goals using everyday routines, planning skills, and confidence building experiences to motivate themselves. They also drew on, and extended, social resources highlighting the relational aspects of real-world walking.
Walking in their real-world provided a meaningful, desirable, but challenging goal for participants that required significant emotional effort. Successful progress in real-world walking builds confidence and hope and can contribute to psychological wellbeing by providing opportunities for successful mastery and social connectedness.
IMPLICATIONS FOR REHABILITATION
Real-world settings can be unpredictable which makes walking in the real-world after stroke demanding.
Positive experiences of walking in the real-world can provide significant psychological benefits to stroke survivors.
Many survivors need to carefully concentrate on the act of walking in outdoor settings.
Pre-planning routes, confidence-building experiences and developing daily routines may help patients overcome these challenges.
Purpose: In this paper, we critically investigate the implementation of person-centered care with the purpose of advancing philosophical debates regarding the overarching aims and delivery of ...rehabilitation. While general agreement exists regarding person centered care's core principles, how practitioners reconcile the implementation of these principles with competing practice demands remains an open question.
Materials and methods: For the paper, we drew on post-qualitative methods to engage in a process of "diffractive" analysis wherein we analyzed the micro-doings of person-centered care in everyday rehabilitation work. Working from our team members' diverse experiences, traditions, and epistemological commitments, we engaged with data from nine "care events" generated in previous research to interrogate the multiple forces that co-produce care practices.
Results: We map our analyses under three categories: scripts mediate practice, securing compliance through "benevolent manipulations", and care(ful) tinkering. In the latter, we explore the notion of tinkering as a useful concept for approaching person centered care. Uncertainty, humility, and doubt in one's expertise are inherent to tinkering, which involves a continual questioning of what to do, what is best, and what is person centered care within each moment of care. The paper concludes with a discussion of the implications for rehabilitation and person-centered care.
Implications for rehabilitation
Determinations of what constitutes good, better, or best rehabilitation practices are inevitably questions of ethics.
Person-centered care is promoted as good practice in rehabilitation because it provides a framework for attending to the personhood of all engaged in clinical encounters.
Post-critical analyses suggest that multiple interacting forces, conditions, assumptions, and actions intersect in shaping each rehabilitation encounter such that what constitutes good care or person-centered care cannot be determined in advance.
"Tinkering" is a potentially useful approach that involves a continual questioning of what to do, what is best, and what is person-centered care within each moment of care.
Objective:
This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained.
Data sources:
...EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies.
Review methods:
Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data.
Results:
Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3–6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (–0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were.
Conclusions:
A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.
To describe the amount, range, and key characteristics (e.g., publication years, methods, topics) of the person-centered rehabilitation literature in adults with physical impairments.
Following the ...published scoping review protocol, papers were identified through: three major databases, snowball searches and expert consultation. Two independent reviewers have identified English-language papers on adult person-centered rehabilitation according to six pre-defined inclusion categories - theoretical, quantitative and qualitive research papers are included; and then have extracted their key characteristics (e.g., aims, methods, participants). Descriptive statistics, regression and content analyses were used to synthesize the results.
Of 5912 deduplicated records initially screened, 170 papers were included: 136 empirical, including 13 systematic reviews. Empirical papers had data from 15264 clients and 4098 providers, in total. Yearly publications grew significantly from 2009 to 2018 (r
2
= 0.71; b = 1.98: p < 0.01). Publications were unevenly distributed by countries (e.g., United States' publications per population was 44 times lower than New Zealand's). Most papers focused in more than one profession, setting-type or health conditions. Finally, many empirical papers (n = 67) studied implementation of person-centered rehabilitation approaches, including its effect.
This scoping review synthesizes key characteristics and publication trends in the person-centered rehabilitation literature on adults with physical impairments, a growing but unchartered territory thus far. This large and diverse body of literature can ground further person-centered rehabilitation practices and research, including toward building a transdisciplinary, trans-service model of person-centered rehabilitation.
Implications for rehabilitation
The person-centered rehabilitation literature on adults with physical impairments, especially the empirical one, has been growing significantly over time, despite inequitably distributed per countries.
Rehabilitation stakeholders, including practitioners, have a growing amount of literature in which they can rely for the operationalization and implementation of person-centered rehabilitation approaches into routine practice.
Based on our work, person-centered rehabilitation emerges as a practice requirement that cuts across professional and other rehabilitation silos.
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