You haven't addressed the problem of the stroke medical 'professionals' using the tyranny of low expectations to reduce survivor expectations of recovery and absolve them of their failure to provide full recovery to survivors!
From passenger to driver: an interview study on person-centeredness in clinical reasoning during stroke rehabilitation
Abstract
Purpose
To explore how stroke survivors experience and prefer to participate in clinical reasoning processes in the subacute phase of stroke rehabilitation.
Methods
An explorative qualitative design was used. Individual interviews were conducted with 10 stroke survivors (4 women and 6 men, mean age 68 years) 4 weeks after their stroke, and follow-up interviews were conducted with 6 of them after 10 weeks. The interview settings were the patient’s home during their home rehabilitation, an inpatient and an outpatient rehabilitation unit. A reflexive thematic analysis was performed.
Results
Four themes were identified: discharge as a critical point for participation, describing a stressful time with varying involvement; supportive actions and context as crucial for participation, describing collaboration with the stroke team, the team’s consideration of the stroke survivor’s resources and needs, and a supportive home environment; the importance of goals and follow-up, describing goals as motivational and an unstructured use of goals; and difficulties in participation, describing a lack of dialogue with the stroke team and undetected resources and needs.
Conclusions
The stroke survivors experienced changes in their participation in the clinical reasoning process as their rehabilitation progressed. They moved from perceiving themselves as passengers at the time of their hospital discharge to gradually seeing themselves as the driver of their rehabilitation process. Some person-centered attributes, such as respectful relationships and a health focus, were incorporated into the clinical reasoning, while others, such as a holistic view and shared goal-setting(the only goal in stroke is 100% recovery and don't let your stroke medical 'professional' talk you down from that!), required further emphasis for improved person-centeredness in stroke rehabilitation.
Introduction
In the last decade, person-centered care (PCC) has been strongly advocated in health care [Citation1], although difficulties still exist regarding its implementation in rehabilitation practices. Challenges concern e.g. to enact a holistic approach and not only individualised care considering personal needs and preferences [Citation2]. Health care professionals’ lack of person-centered knowledge and skills, negative attitudes towards shared decision-making, time constraints, and lack of a coordinated and empowering work environment are examples of barriers to implementing PCC [Citation3].
PCC is defined as a partnership between patients, their relatives, and health care professionals and emphasises the importance of knowing the person in the patient role – including the patient’s values, preferences, and needs. Sharing of information, shared deliberation, and shared decision-making are core to the active inclusion of patients in their care [Citation4]. PCC is well aligned and accepted as an espoused means of achieving the goals of stroke care and rehabilitation [Citation5]. More specifically, it is seen as a means to reach the goal of allowing stroke survivors to influence, participate in, and make personal choices regarding their care [Citation6].
Rehabilitation includes interventions to optimise individuals’ functioning and reduce disability in interaction with the environment [Citation7]. Different phases can be identified in stroke rehabilitation in which interdisciplinary stroke teams gather bio-psycho-social information, interpret findings, assess rehabilitation needs, and make decisions on treatment and management [Citation5]. These processes represent ‘a [context-dependent] way of thinking and decision-making in professional practice to guide practice actions’ encapsulated in the concept of clinical reasoning [Citation8]. Considerations and actions in the clinical reasoning process will influence health professionals’ clinical behaviours. Recent developments in clinical reasoning research emphasise contextual factors and a shared process between the professional and the patient [Citation9–12], which aligns with the PCC approach. Person-centered clinical reasoning implies a focus on the individual patient in a certain context and point of time [Citation9], thus, forming the core of person-to-person interactions for health care professionals [Citation11,Citation13,Citation14]. Lately, clinical reasoning has also been studied at the collaborative level, in which clinical reasoning within professional teams forms the unit of analysis [Citation15]. Thus, the current clinical reasoning literature contributes knowledge on professionals’ thinking and clinical actions whereas further research can benefit of addressing the concept of PCC. Contributions from clinical reasoning research can, thus, shed new light on how PCC can be enacted by contributing knowledge on how staff interact and how patients participate in the reasoning process. Integration of PCC attributes in clinical reasoning processes in rehabilitation has demonstrated positive patient outcomes, such as improved satisfaction, acceptance [Citation6], motivation [Citation16], goal achievement, functional capability [Citation17], and occupational performance [Citation6].
However, such integration challenges the traditional biomedically oriented clinical reasoning, which focus on the task and diagnostic reasoning, thereby risk failing to acknowledge holistic and person-centered processes [Citation18]. PCC expands the biomedical dimension by including a biopsychosocial perspective on health, relationship building, respecting the patient as a person, empowering patients to participate in decision-making on their care, and coordination of care [Citation19] to enable patients to live a meaningful life [Citation20]. A PCC approach implies a clinical reasoning process shared by health care professionals and patients in which the patient’s experiences and needs and the health care professionals’ judgements contribute to analyses of findings, management planning and decision-making [Citation9,Citation21]. At present, the literature on patient participation in these aspects is scarce.
Stroke care and rehabilitation is related to the stroke survivor’s recovery time, from the stroke onset, and continuing through the acute inpatient care phase (1–7 days), the subacute rehabilitation phase (7 days to 6 months), and the chronic phase (> 6 months) [Citation22]. Thus, stroke survivors’ needs of care and treatment change over time, requiring that information and management decisions are adapted accordingly [Citation5]. The hospital discharge and the first following months of rehabilitation are critical timepoints, as the stroke survivor experiences new difficulties in their daily life, new social interactions including the stroke team, and sometimes these changes also occur in a new environment [Citation23]. Consequently, the clinical reasoning of stroke teams must acknowledge the stroke survivor’s situation and needs in the various phases and adapt to these changes. A previous study [Citation24] demonstrated that stroke survivors in the acute phase surrendered themselves to care and medical expertise; and as they progressed during the first week of their care, they sought to be more actively involved in the clinical reasoning through information exchange, being asked about their personal needs, and being invited to shared decision-making. Previous studies [Citation16,Citation25–28] during the subacute and rehabilitation phases examined different aspects of patient participation in stroke care and rehabilitation. Their results indicate that key dimensions of patient participation, which are necessary for PCC, such as identification of personal needs, person-centered goal-setting, and shared decision-making do not sufficiently occur in everyday care.
Despite the acknowledged values of PCC, lack of knowledge is a prevailing barrier for PCC and is prevalent on patient, staff and organisational levels [Citation16]. Thus, to overcome this barrier and shed light on how PCC enact in clinical reasoning practice we need to scrutinise clinical reasoning in everyday practice with a focus on how stroke survivors participate in phases of their care and recovery. To reach this, the stroke survivors’ views need to be considered. Therefore, the present study aims to explore how stroke survivors experience and prefer to participate in clinical reasoning processes in the subacute phase of stroke care and rehabilitation [Citation6,Citation16,Citation17].
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