A Qualitative Study Exploring Professional Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation
Abstract
:1. Introduction
2. Methods
2.1. Study Design
2.2. Recruitment of Participants
2.3. Focus Groups
2.4. Workshops
2.5. Data Analysis
3. Results
3.1. Participants
3.2. Themes
3.2.1. Category 1: Themes Involving Rehabilitation Processes
Theme 1.1: Rehabilitant
Especially in CVA patients, depression is quite common and very often underestimated. ... But this has to be included, because if the mood is not right, there is a very negative impact on the rehabilitation process.
But 1 time 24 minutes is not the same as 24 times 1 minute. And those 24 times 1 minute is what you want in a CRE. You can also spread patients with limited abilities over the day so that they can still continue in therapy, despite their limits.
Theme 1.2: Goals
It starts with a good talk and actually motivating the rehabilitant. Everyone is motivated for something, but maybe not for your goals.
I want to advocate defined clinimetrics. To inform [rehabilitants] properly and measure treatment success.
Theme 1.3: Exercise
So, the question is, how do you integrate exercise components in the daily routine. …. So, I think, this is really, let’s say, the big picture. That we have to change the climate of how we work with the people.
I think group therapy can be very efficient. ... It may help when people practice in a group and you have peer support.
Theme 1.4: Daily Schedule
I would prefer to have one occupational therapist and one physiotherapist on the ward structurally. Who can just help out on the ward from morning to evening, and at the same time provide therapy.
Theme 1.5: Involving Client System
I do think it’s important that the family caregiver has a place and is a natural part of the whole. I also think it’s very important that we are aware that, from the family caregiver’s perspective, there is no end to it.
What I also see a lot ... is that even for family caregivers it is often unclear what they should expect. What the approach will be and what the goal of the rehabilitation ward is. In addition to everything we have already said, I think that explaining and providing information is also an important part of the rehabilitation climate.
Theme 1.6: Nutrition
Nutritional status is another one. Yes, it’s getting more attention now, but it has been underexposed for a very long time I think. And also the link with people sometimes just being too tired to eat properly. And I’m not even talking about the quality and how tasty it is, so to speak.
Theme 1.7: Technology
Well, it has a lot of potential, but the tricky thing is, there are so many applications. Remember you are dealing with elderly people who have difficulty with technology and you have to organize your whole care process in such a way that the technology takes this into account. So, to implement it properly, there are quite a few conditions to meet.
3.2.2. Category 2: Themes Involving Organizational Aspects
Theme 2.1: Environmental Aspects
It is an interaction of a warm environment that is very stimulating and invites to start doing the things required to be able to go home.
When you get to the point in the rehabilitation process that you are able to practice independently on the parallel bars, then you want to do that as often as possible, I’d think. I would like to have that nearby or be allowed to go there on my own to practice. Then I can imagine it being on the ward is convenient.
Theme 2.2: Staff Aspects
If you are referring to interdisciplinary working. That’s a core concept in rehabilitation. You have the specialist expertise in all fields, but you also have to know and be able to borrow from each other’s expertise a little bit.
I think, particularly nursing staff having a rehabilitation focus, and so, encouraging for the patients to do everything possible they can, from the start. So, that may make a significant difference.
That is the problem with the application of such a guideline. For example, the guideline says it’s for stroke, but if someone also has Parkinson’s, or broke his hip last year, you cannot do certain tests. Because it’s obviously impossible.
Theme 2.3: Organizational Aspects
I do think when you have that kind of project group, it does involve regular evaluation. Like, guys, how are the things we started going now? And do we need to adjust, fine-tune anything.
Calling someone patient or client, you emphasize what a person can’t do. If you say person, you avoid this label. It is still someone who tries to live his life in the best way possible.
Theme 2.4: Factors Outside the Ward
It also helps to have people actually go home during rehabilitation. This provides so much information about how they actually function at home. A situation is always different at home.
The question is, if you have a ward with a very good rehabilitation climate, would you not want to admit patients there who, in terms of their care needs, could go home, but for whom the added value of the rehabilitation climate for the rehabilitation is such, that patients choose to be admitted to the department for rehabilitation.
4. Discussion
5. Conclusions and Implications
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A. Topic List
- − What does CRE mean for you?
- − What are your experiences with CRE (positive and negative)?
- − Which subjects should be part of a CRE?
- − Additional topics to discuss in relation to CRE:
- ○
- Therapy intensity
- ○
- Task-oriented exercise
- ○
- Group training
- ○
- Patient-regulated exercise
- ○
- Learning styles and approach
- ○
- Goal setting
- ○
- Team dynamics (multidisciplinary, interdisciplinary)
- ○
- Technologies
- ○
- Enriched environment
- ○
- Informal caregiver participation
- ○
- Diagnoses
- ○
- Measurement instruments
- ○
- Naming
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Expert Groups (n = 4, Participants = 23) | ||
---|---|---|
Nationality | Netherlands | 17 |
Greece | 1 | |
Germany | 2 | |
Australia | 2 | |
Poland | 1 | |
Occupation * | Elderly care physician | 5 |
Rehabilitation physician | 4 | |
Physical therapist | 11 | |
Lecturer | 2 | |
Researcher | 11 | |
Manager | 8 | |
Nurse (practitioner) | 2 | |
Focus Group (para) medical (n = 3, participants = 24) | ||
Occupation | Elderly care physician | 3 |
Occupational therapist | 5 | |
Nurse practitioner | 3 | |
Physical therapist | 8 | |
Psychologist | 1 | |
Speech and language therapist | 3 | |
Head of nursing staff | 1 | |
Focus Group Nursing Staff (n = 3, participants = 28) | ||
Occupation | Nurse | 22 |
Nurse assistant | 4 | |
Nurse aid | 2 | |
Workshops (n = 4, participants = 180 healthcare professionals, e.g., physical therapist, occupational therapist, elderly care physician, nurse) |
Main Theme | Brief Description | Sub-Theme | Description |
---|---|---|---|
Rehabilitant | CRE is suitable for all diagnosis groups. Attention to rehabilitants’ cognitive functioning and resilience and stimulating the self-reliance of rehabilitants are necessary. | Characteristics | Rehabilitants undergo rehabilitation for different diagnoses, e.g., in the fields of neurology, orthopedics, and trauma. They often have multiple diagnoses and are already experiencing a functional decline in the home situation. They are often not familiar with using technologies to perform exercises. Traditionally, rehabilitants and informal caregivers expect to be taken care of during their stay at the rehabilitation ward, and they do not expect to have to perform daily tasks themselves. |
Cognitive aspects | Often, rehabilitants suffer from cognitive problems or delirium. Besides already existing cognitive problems, cognition may decline as a result of the life event or diagnosis for which they are receiving rehabilitation. Neuropsychiatric symptoms such as depression or disrupted stimulus processing occur as a result of a neurological condition. It is important to be aware of these symptoms, as they can affect the rehabilitation process, but also acknowledge that this is an often underexposed and, as a result, under addressed aspect during rehabilitation. Adapting rehabilitation to the needs and learning style of the rehabilitant is important, and professionals must be aware that information and exercises must be offered in different ways. | ||
Resilience | Rehabilitants’ resilience is often low, especially at the beginning of the rehabilitation process. Rehabilitants and informal caregivers need to understand and learn to deal with this. For balance, it is important to create rest moments for rehabilitants, and therapies must be spread out over the whole week, not just provided during working hours. Participants acknowledge this but have difficulty determining how much rest a rehabilitant needs and how to best provide it. | ||
Self-reliance | Although all participants consider it important that rehabilitants have self-management abilities and take control of their rehabilitation, not all rehabilitants are able to do this from the start. To be able to take control, rehabilitants must know what the possibilities are and have the opportunity to practice on their own as well as carry out their own planning. Rehabilitants’ motivation can be improved if they know what is expected of them and what they are working for. | ||
Goals | Individual goals are needed for the rehabilitation process in a CRE. Some rehabilitants need guidance in setting their goals. There is a desire for an appropriate set of measurement instruments for GR. | Goal setting | Shared goals for rehabilitation (rehabilitants, informal caregivers and professionals) are important. Not all rehabilitants are able to express their goals at the start, but with support from informal caregivers, relevant goals can usually be defined. Sometimes, their goals are unrealistic for their level of functioning. Goal setting in smaller steps, with good guidance and communication by the professionals and tailored to the rehabilitants’ needs, will improve the chances that rehabilitants will achieve their goals. One of the main goals of rehabilitants is to work on self-reliance and independence to practice what they need to be able to go home. In addition, professionals should be aware of possible cultural differences in the importance of goals. |
Learning new skills | There is a discussion on teaching rehabilitants new skills. Society increasingly demands digital skills. Although the participants think inpatient rehabilitation is a good moment to learn these new skills, they also admit that not all rehabilitants are willing to learn these skills and rarely succeed in reaching a higher level of independence than before. | ||
Observation and measuring | A wide range of measurement instruments indicate the level of function of a rehabilitant, although not many instruments are validated in the population in GR. Therefore, functional observation (live or by recording) is still often used. Participants long for a set of measurement instruments appropriate for the population, which can be used to motivate and inform the rehabilitant about their progress. | ||
Exercise | Exercise intensity in a CRE is as high as possible. This can be achieved by integrating task-oriented exercises, patient-regulated exercises and group training into the daily structure. | Exercise intensity | Exercise intensity should be as high as possible on all days of the week, based on the rehabilitant’s ability. Currently, this intensity is often not high enough. Exercise intensity comprises all activities as part of the rehabilitation. Rehabilitants, informal caregivers and staff should be aware that it is not only the moments with a therapist that are important for the rehabilitation; they need to integrate training into their daily routine. |
Task-oriented exercises | Although you must sometimes start at the level of body functions, therapy in a rehabilitation setting aims at the participation level. Task-oriented exercise is in line with this. For example, tasks can be practiced in activities of daily living, at mealtimes and in hobbies. All staff must have the attitude and the time to stimulate rehabilitants to practice meaningful tasks, which are tailored to their home situation, throughout the day. | ||
Patient-regulated exercises | Patient-regulated exercises can increase exercise intensity and stimulate the rehabilitants’ independence and self-management during rehabilitation. Homework exercises can increase the amount of patient-regulated exercise and can affect how rehabilitants continue to perform exercises after discharge. To stimulate patient-regulated exercise, 24/7 access to training facilities is desirable and informal caregivers and staff should stimulate rehabilitants to practice, although independent exercise is often at a lower intensity than supervised training. | ||
Group training | Group training can be an effective way to increase exercise intensity, but it should be compatible with the goals of the rehabilitant. Training in groups stimulates contact with and learning from others, prevents loneliness, and stimulates rehabilitation. Therefore, it is important that staff members stimulate a positive group process on a rehabilitation ward. | ||
Daily schedule | Within a CRE, the entire day the team needs to be focused on rehabilitation and activities. Exercise is adapted to the pace of the rehabilitant. | Daytime activities | A daily schedule that challenges rehabilitants to take initiative and increase their exercise intensity is desired. When rehabilitants are too passive between therapy moments, this can sometimes lead to cognitive decline. Recreational activities not focused on the rehabilitation goals can keep the rehabilitants motivated, for example, activities with a game element. It is recommended to allow visitors/guests, other than the informal caregivers (who can assist during rehabilitation), only during predefined visiting times. |
Planning | Some rehabilitation wards work with a day planning for the rehabilitants in which all therapies are planned. Some rehabilitants and informal caregivers appreciate this planning, but it often causes problems. Because of external factors, such as hospital visits, the planning needs to be quite flexible. Working without a therapy plan enables responding to the rhythm of the rehabilitant and promotes interdisciplinary cooperation. In addition, it is desirable to have walk-in moments for the therapy so that rehabilitants can take control of when they practice, if they are able to. | ||
Involving client system | Good communication is necessary to involve informal caregivers in the rehabilitation process. They can help in the rehabilitation process, but they should be prevented for overburdening. | Informal caregiver participation | The informal caregivers and their abilities and perceived burden partly determine whether a rehabilitant can go home. They can provide information about the rehabilitant’s previous level of functioning and the goals for the rehabilitation. Although informal caregivers can be seen as fellow practitioners, who motivate and help during the rehabilitation process, staff must prevent overburdening them. Attention must also be paid to bereavement and the informal caregiver’s need for information. Participants would like to see informal caregivers perform tasks in supporting the rehabilitant during rehabilitation similar to what they will be doing at home. |
Communication | Communication is a key aspect in involving informal caregivers. Rehabilitants and informal caregivers need to be informed about the principles of a CRE so that they know how important it is to practice during daily activities and which extra exercises they can perform during the rehabilitation process. This information must be presented in a way suitable for the rehabilitant and informal caregiver. It is also important to give information about the disease for which they are undergoing rehabilitation and about the new skills they must learn. | ||
Nutrition | Nutritional status partly determines the rehabilitation capability, therefore a balanced diet is necessary. | A rehabilitant’s nutritional status partly determines their rehabilitation capability. Rehabilitants are not always aware of this relationship and do not consume enough protein-rich foods. It is important to realize a balanced diet with products that are as common as possible, so rehabilitants will be able to continue the diet at home. Pleasant mealtimes stimulate good intake, and joint meals are therefore seen as standard. It is important to pay attention to the energy levels of a rehabilitant. Intake or swallowing can be negatively affected if a rehabilitant is too tired. | |
Technology | Technology develops very fast and contributes to safe and challenging rehabilitation. | Domotics | Domotics, e.g., systems to automatically measure body functions or fall signaling, can help to offer security, privacy, and night rest to rehabilitants and can also be time-saving for professionals. An important condition is that privacy is guaranteed and that the security of the system can also be guaranteed at home. |
eHealth | Although the use of eHealth is currently limited, it can be useful in the future as a supplement to exercising, monitoring, safety, and feedback options. Nowadays, many applications are not yet suitable for the target group or are not always applicable during functional activities. In addition, eHealth is developing very fast, making it difficult for healthcare professionals to keep abreast of all possibilities. |
Main Theme | Brief Description | Sub-Theme | Description |
---|---|---|---|
Environmental aspects | The environment on a rehabilitation ward is safe and invites rehabilitants to practice as much as possible. | Building aspects | The environment on a rehabilitation ward should resemble the domestic situation as much as possible so that rehabilitants feel stimulated, free, and able to practice meaningful, functional tasks. There should be therapy rooms on the ward for interdisciplinary team dynamics and the participation of informal caregivers. It is advisable to have the possibility to screen off part of the room for privacy. Walking distances to the bedrooms should be considerable, and there should be handrails, chairs, and exercise facilities in the corridors and a possibility to go outside. For different levels of stimulus processing, there must be variation in rooms with more and less stimulus. Opinions differ as regards the desire for single or multi-bedrooms. Single bedrooms offer privacy and a quiet environment, whereas multi-bedrooms offer contact with other rehabilitants. A sliding wall can offer a solution. The bedroom should be furnished in a way that the rehabilitant is stimulated to get out of bed. |
Ambiance | The ambiance should enthuse rehabilitants and make them feel safe enough to work on their recovery. Most participants think a cozy, homely ambiance is important to stimulate rehabilitants to practice, have contact with fellow rehabilitants, and encourage each other to practice. Relaxing activities should be scheduled in addition to therapy moments. | ||
Staff aspects | All team members work in an interdisciplinary way and stimulate rehabilitants to practice throughout the day. | Team mix | The team should be sufficiently ‘mixed’ in terms of rehabilitation skills and experience. Recommended professionals in the rehabilitation team are: nurses, physical therapists, occupational therapists, psychologists, social workers, case managers, dieticians, speech and language therapists, physicians (elderly care or rehabilitation), and volunteers. Some participants think the nurse needs a name that better reflects the role of a therapeutic rather than caring nurse, for example, “rehabilitation coach”. Regardless of the name, the nurse must be seen as a therapeutic team member. |
Team dynamics | In an interdisciplinary team, each discipline has expertise in a particular area, but team members can look beyond the boundaries of their own field. All disciplines are equal, and there is no (in)formal hierarchy. Working in smaller teams, taking courses together, and therapists working directly on the ward are ways to improve interdisciplinary dynamics. The rehabilitant and their informal caregiver must also be part of the team. Multidisciplinary consultation in the presence of the rehabilitant is preferred and is often used to coordinate rehabilitation goals. | ||
Attitude of staff | All employees should have an empathetic, motivating attitude in order to involve informal caregivers and stimulate rehabilitants to practice throughout the day. They, therefore, need to be able to see training opportunities in daily activities. The approach of the team is coordinated, so rehabilitants always know what to expect. Staff members ideally choose to work in the field of rehabilitation, are flexible, can set priorities, have an interdisciplinary mindset, and are stress resistant. | ||
Training requirements | Medical guidelines are not always suitable for geriatric rehabilitants. Staff must be able to deal with this by using evidence-based practice principles, building sufficient experience and having additional training in geriatrics. | ||
Organizational aspects | Implementing a CRE requires a shared vision on rehabilitation, and a project group to supervise the process. Even though internationally the organizational aspects differ, the concept of CRE is suitable to get the most out of rehabilitation. | Vision | It is important that all professionals (including management) have a shared vision on geriatric rehabilitation and make informed decisions. |
Administration | Participants experience that too much time is spent on administrative tasks, partly due to incompatible systems and regulations—time that could be spent on the rehabilitants and their rehabilitation. | ||
Regulations and funding | Participants feel that the rehabilitation system is driven by the way it is funded, which differs internationally. Optimal rehabilitation cannot always be offered due to insufficient reimbursement. Unfavorable decisions are sometimes unavoidable within the therapies. Participants experience a negative effect of regulations regarding privacy and liability in the rehabilitation process. | ||
Safety | Participants think rehabilitants and informal caregivers need to be safe to practice. The approach of the professionals and the design of the building may affect this safety positively or negatively. Despite some international differences, participants agree that pushing the boundaries, taking calculated fall risk, and using technical innovations to prevent risks will improve rehabilitation. | ||
Different settings | There are international differences in the setting in which rehabilitation for older persons is offered, and whether it is separate from rehabilitation for younger adults. However, these differences are secondary: the concept of a rehabilitation environment must start at the hospital ward and should continue after discharge in a slightly modified form. | ||
Naming | Sometimes, the word rehabilitation “hotel” is used for a rehabilitation ward, which may create expectations of being pampered instead of there being hard rehabilitation work perform. Using the word “patient” emphasizes being ill. Using the word “person” or “rehabilitant” stimulates looking at a person’s abilities. | ||
Implementation | Implementing a CRE requires a balanced team, and all team members must agree on the need for the implementation of a CRE. A project group or initiator should supervise the implementation of themes within CRE, work on time management and keep everyone enthusiastic. It takes a lot of time for a new method to become fully embedded in the daily routine. | ||
Factors outside the ward | The discharge process must be well prepared and supervised. Home visits allow rehabilitants to practice meaningful tasks in their own environment and be prepared for discharge. | Outpatient rehabilitation | It is important to visit the home environment during inpatient rehabilitation because the situation at home can be different from the rehabilitation ward. It is best for rehabilitants to practice meaningful tasks in their own environment. However, some participants think rehabilitating in a good CRE can have added value. |
Discharge process | It can be beneficial to guide the transition home by continuing the rehabilitation process by the same professionals in outpatient rehabilitation. Rehabilitants and informal caregivers sometimes think they are not ready to be discharged, while professionals think they can manage at home. It is important to keep communicating about the discharge process. Additionally, longer rehabilitation can sometimes be beneficial to increase a rehabilitants’ independence, which subsequently leads to lower healthcare costs in the long term. |
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Tijsen, L.M.J.; Derksen, E.W.C.; Achterberg, W.P.; Buijck, B.I. A Qualitative Study Exploring Professional Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation. J. Clin. Med. 2023, 12, 1231. https://doi.org/10.3390/jcm12031231
Tijsen LMJ, Derksen EWC, Achterberg WP, Buijck BI. A Qualitative Study Exploring Professional Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation. Journal of Clinical Medicine. 2023; 12(3):1231. https://doi.org/10.3390/jcm12031231
Chicago/Turabian StyleTijsen, Lian M. J., Els W. C. Derksen, Wilco P. Achterberg, and Bianca I. Buijck. 2023. "A Qualitative Study Exploring Professional Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation" Journal of Clinical Medicine 12, no. 3: 1231. https://doi.org/10.3390/jcm12031231
APA StyleTijsen, L. M. J., Derksen, E. W. C., Achterberg, W. P., & Buijck, B. I. (2023). A Qualitative Study Exploring Professional Perspectives of a Challenging Rehabilitation Environment for Geriatric Rehabilitation. Journal of Clinical Medicine, 12(3), 1231. https://doi.org/10.3390/jcm12031231