Randomised pragmatic waitlist trial with process evaluation investigating the effectiveness of peer support after brain injury: protocol.

INTRODUCTION: Traumatic brain injury (TBI) is an important global health problem. Formal service provision fails to address the ongoing needs of people with TBI and their family in the context of a social and relational process of learning to live with and adapt to life after TBI. Our feasibility study reported peer support after TBI is acceptable to both mentors and mentees with reported benefits indicating a high potential for effectiveness and likelihood of improving outcomes for both mentees and their mentors. OBJECTIVES: To (a) test the effectiveness of a peer support intervention for improving participation, health and well-being outcomes after TBI and (b) determine key process variables relating to intervention, context and implementation to underpin an evidence-based framework for ongoing service provision. METHODS AND ANALYSIS: A randomised pragmatic waitlist trial with process evaluation. Mentee participants (n=46) will be included if they have moderate or severe TBI and are no more than 18 months post-injury. Mentor participants (n=18) will be people with TBI up to 6 years after injury, who were discharged from inpatient rehabilitation at least 1 year prior. The primary outcome will be mentee participation, measured using the Impact on Participation and Autonomy questionnaire after 22 weeks. Primary analysis of the continuous variables will be analysis of covariance with baseline measurement as a covariate and randomised treatment as the main explanatory predictor variable at 22 weeks. Process evaluation will include analysis of intervention-related data and qualitative data collected from mentors and service coordinators. Data synthesis will inform the development of a service framework for future implementation. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the New Zealand Health and Disability Ethics Committee (19/NTB/82) and Auckland University of Technology Ethics Committee (19/345). Dissemination of findings will be via traditional academic routes including publication in internationally recognised peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12619001002178.

Governing neurorehabilitation.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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 rehabilitationThis 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.

The micro-politics of caring: tinkering with person-centered rehabilitation.

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 rehabilitationDeterminations 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.

Making sense of recovery after traumatic brain injury through a peer mentoring intervention: a qualitative exploration.

OBJECTIVE: To explore the acceptability of peer mentoring for people with a traumatic brain injury (TBI) in New Zealand. DESIGN: This is a qualitative descriptive study exploring the experiences reported by mentees and mentors taking part in a feasibility study of peer mentoring. Interviews with five mentees and six mentors were carried out. Data were analysed using conventional content analysis. SETTING: The first mentoring session took place predischarge from the rehabilitation unit. The remaining five sessions took place in mentees' homes or community as preferred. PARTICIPANTS: Twelve people with TBI took part: six mentees (with moderate to severe TBI; aged 18-46) paired with six mentors (moderate to severe TBI >12 months previously; aged 21-59). Pairing occurred before mentee discharge from postacute inpatient brain injury rehabilitation. Mentors had been discharged from rehabilitation following a TBI between 1 and 5 years previously. INTERVENTION: The peer mentoring programme consisted of up to six face-to-face sessions between a mentee and a mentor over a 6-month period. The sessions focused on building rapport, exploring hopes for and supporting participation after discharge through further meetings and supported community activities. RESULTS: Data were synthesised into one overarching theme: making sense of recovery. This occurred through the sharing of experiences and stories; was pivotal to the mentoring relationship; and appeared to benefit both mentees and mentors. Mentors were perceived as valued experts because of their personal experience of injury and recovery, and could provide support in ways that were different from that provided by clinicians or family members. Mentors required support to manage the uncertainties inherent in the role. CONCLUSIONS: The insight mentors developed through their own lived experience established them as a trusted and credible source of hope and support for people re-engaging in the community post-TBI. These findings indicate the potential for mentoring to result in positive outcomes.

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.