Storytelling as an intervention in traumatic brain injury rehabilitation: a scoping review.

PURPOSE: Storytelling interventions are increasingly being proposed as a tool for rehabilitation after Traumatic Brain Injury (TBI). This review aimed to systematically map intervention details as described in the TBI rehabilitation/recovery literature to better understand why, when and how storytelling is being used in rehabilitation. METHODS: The review team included a storyteller-performer with lived experience of severe TBI, and two academics. Literature searching followed a pre-defined protocol with systematic search strategies and inclusion/exclusion criteria developed through discussion and literature scoping. Included interventions described a deliberate process of creation and sharing of the story. FINDINGS: Thirteen studies met inclusion criteria, describing eleven distinct interventions fitting into four categories: film production, visual art, written publication and song composition. Rationale for the interventions included identity reconstruction, emotional processing, sense-making, and community (re)engagement. Varying levels of specialist materials and facilities were utilized. Most required facilitation by professionals trained in specialist areas such as narrative, art or music therapy. CONCLUSION: Intervention models suggest that storytelling is intended for self-identity reconstruction after TBI and that it can create socially acceptable ways to process difficult experiences and (re)connect with peers, clinicians, families, and communities. Larger-scale trials that test intervention efficacy in relation to documented outcomes are needed.IMPLICATIONS FOR REHABILITATIONStorytelling as part of traumatic brain injury rehabilitation is used to assist with self-identity reconstruction, emotional processing, and clinical issues such as communication and executive functioning.Categories of storytelling intervention include film, visual art, written work and song writing.Collaborative facilitation is key to this process for a traumatic brain injury population.

Return-to-work expectations and workplace supports in New Zealand: injured workers' perspectives.

AIM: Work-disability following musculoskeletal injury causes a significant burden for individuals and healthcare systems. Research into work-disability prevention has investigated the ability of psychosocial factors to predict return-to-work in workers with musculoskeletal injuries. Recent research indicates that both return-to-work expectations and workplace supports influence return-to-work outcome. However, how these mechanisms operate to influence outcome is still largely unknown. METHODS: We undertook a qualitative study involving semi-structured interviews with workers from diverse backgrounds who were undergoing vocational rehabilitation in New Zealand following a musculoskeletal injury. Interviews investigated the injured workers' experiences of workplace supports and asked in-depth about what contributed to their expectations of returning to work. Thematic analysis was used to analyse and interpret the data. FINDINGS: Analysis identified four key themes. We found that what workplace supports were offered and how they were taken up was related to systemic factors, and trust. We also identified a link between the offer of support from the workplace and return-to-work expectations. Finally, the actions of workers' compensation and healthcare providers during workers' recovery were reported to influence supports, expectations and the confidence injured workers experienced in their return-to-work outcome in both overt and subtle ways. CONCLUSION: This study indicated that actions of the workplace, healthcare providers and workers' compensation parties can all influence workplace supports, return-to-work expectations and return-to-work outcome. These findings therefore implicate the actions of these stakeholders in work-disability prevention efforts.IMPLICATIONS FOR REHABILITATIONPositive return-to-work expectations are increasingly shown by research to be related to positive return-to-work outcomes for injured workers.Trust between the worker and the company can underpin the provision of supports for return-to-work, which in turn can influence worker confidence and expectations of return-to-work.Consideration of workplace culture and relationships when healthcare providers interact with employers can be crucial in fostering trust and enabling appropriate workplace supports.The ways in which workers compensation processes are executed can also affect workplace relationships, and therefore influence the provision of appropriate return-to-work supports.

Experiences of vocational rehabilitation and support services for people living with a long term condition: qualitative systematic review.

PURPOSE: Identify and synthesise qualitative research evidence on activities and processes within formal vocational service provision that contribute to experiences of effective support to gain employment for people living with long term conditions. METHODS: A pre-published protocol was developed using PRISMA guidelines. Seven databases were searched to identify qualitative research. Results of the search were screened against inclusion criteria and for methodological quality. Findings from included studies were extracted and then analysed using thematic synthesis methods. RESULTS: Twenty two studies met the inclusion criteria. Six themes were identified that elucidated factors that contribute to experiences of supportive and effective vocational rehabilitation service delivery: a personalised service with service user preferences at the core; sustainable, timely and ongoing support; proactive collaboration with the employing organisation; peer support, the essential and necessary skills for gaining employment; and critical vocational worker skills, knowledge and attitudes. CONCLUSION: This study demonstrates the utility of synthesising qualitative research to provide insight into the factors that contribute to experiences of supportive and effective vocational rehabilitation services that traverse various contexts. Future high quality qualitative research is required to probe a broader range of long term conditions to better identify the similarities and differences across services and groups.IMPLICATIONS FOR REHABILITATIONAcross qualitative studies, common aspects of "good" vocational services can be identified that contribute to experiences of effective support to gain paid work for people living with long term conditions.Services are experienced positively when they are personalised, flexible, collaborative and take into account both lived experience and knowledge of the person's condition.Vocational rehabilitation services should proactively build collaborative relationships between the job seeker, employing organisation and other agencies and services.Specific skills and services that people living with long-term conditions find particularly helpful include peer support, work-focused skill development and workplace adjustment and accommodations.

Living with a long-term health condition and seeking paid work: qualitative systematic review and thematic synthesis.

PURPOSE: An interplay of complex issues influence opportunities to gain paid work for people living with long-term conditions, but there are patterns that traverse the various contexts. Synthesising findings across qualitative studies can inform vocational rehabilitation approaches. METHODS: Public consultation and PRISMA guidelines were used to develop a protocol and comprehensive search strategy. Seven databases were searched and results screened against inclusion criteria. Included studies investigated either lived experiences of gaining paid work while living with a long-term condition or the socio-cultural factors affecting opportunities for paid work. Findings were extracted from included studies and then analysed using thematic synthesis. RESULTS: Sixty-two studies met inclusion criteria. Identified themes demonstrate that people living with long-term conditions need access to support through the different stages of gaining paid work. This can include considering the benefits and risks of having paid work and negotiating needs in the workplace prior to and during employment. Positive experiences for workers and employers were influential in changing attitudes about the work-ability of people living with long-term conditions. CONCLUSION: Findings emphasise the interplay between socio-cultural norms and the constraints experienced in trying to gain work. Appropriately targeted support can unlock possibilities that are otherwise hindered by these norms.IMPLICATIONS FOR REHABILITATIONPositive experiences of paid work for people living with long-term conditions and those who employ them are important for stimulating future opportunities."Informal" or alternative routes into paid work are experienced as more successful in contending with discrimination.Job seekers living with long-term conditions need access to pre-placement advocacy, support to negotiate work-related needs, and support to negotiate difficulties that arise in the job.Vocational rehabilitation initiatives need to have good collaboration with other health services to ensure consistent messages about seeking and managing work.

A posthuman decentring of person-centred care.

In this paper, we examine person-centred care through a Deleuzian posthuman lens with the aim of exploring what becomes possible when the concepts of both person and care are de-centred. We do so through a consideration of the sets of relations that produce 'the client' in health care contexts. Our analysis maps particular entangled material-semiotic forces producing 'M/michael', a young man with a diagnosis of Duchenne muscular dystrophy, within a rehabilitation clinic. Drawing on Deleuzian notions of assemblage, affect, and becoming we explore 'person-care' as an active production that dynamically enacts persons-as-clients through clinical arrangements. Persons are thus reconceptualised in terms of locally produced subject positions and their care relations, rather than pre-existing beings who can be 'centred' within health services. Paradoxically, by de-centring persons and care, we work to conjure ways to strengthen the aspirations of person centredness to humanise health practices. In doing so, we consider different possibilities for re-imagining clinical work and contribute to debates regarding how healthcare conceptualises and addresses disability, health, and wellbeing. We suggest that such posthuman analyses can open up new ways of understanding and re/forming healthcare.

Effectiveness of vocational interventions for gaining paid work for people living with mild to moderate mental health conditions: systematic review and meta-analysis.

OBJECTIVES: To evaluate the effectiveness of vocational interventions to help people living with mild to moderate mental health conditions gain paid work. METHODS: Systematic review of international, peer-reviewed literature. Development of the prepublished protocol and search strategy was done in consultation with stakeholder reference groups consisting of people with lived experience of long-term conditions, advocates and clinicians. We searched academic databases MEDLINE, EMBASE, PsychINFO, AMED, CINAHL, Proquest Dissertations and Theses database, and Business Source Complete for controlled trials comparing a specific vocational intervention against a control intervention or usual care, published between 1 January 2004 and 1 August 2019. Two authors independently screened search results, extracted data and appraised studies using the Cochrane risk of bias tool. RESULTS: Eleven studies met inclusion criteria. Seven studies investigated Individual Placement and Support (IPS) modified for people who were not in intensive mental health treatment services. These studies occurred settings such as community vocational rehabilitation services, a housing programme and community mental health services. The studies provided very low quality evidence that people who receive IPS-style vocational rehabilitation are more likely to gain competitive employment than people who receive usual care (risk ratio 1.70, 95% CI 1.23 to 2.34, seven studies, 1611 participants). The remaining four studies considered cognitive behavioural therapy or specific vocational rehabilitation interventions designed to fit a unique context. There was insufficient evidence from these studies to draw conclusions regarding the effectiveness of non-IPS forms of vocational rehabilitation for people with mild to moderate mental health conditions. DISCUSSION: The meta-analysis showed a clear intervention effect but low precision, and more high-quality studies are needed in this field. There is currently very low quality evidence that IPS-style intervention results in more participants in competitive employment compared with 'usual care' control groups in populations with mild to moderate mental health conditions.

Problematizing 'productive citizenship' within rehabilitation services: insights from three studies.

Background: The idea that everyone should strive to be a 'productive citizen' is a dominant societal discourse. However, critiques highlight that common definitions of productive citizenship focus on forms of participation and contribution that many people experiencing disability find difficult or impossible to realize, resulting in marginalization. Since rehabilitation services strive for enablement, social participation, and inclusiveness, it is important to question whether these things are achieved within the realities of practice. Our aim was to do this by examining specific examples of how 'productive citizenship' appears in rehabilitation services.Methods: This article draws examples from three research studies in two countries to highlight instances in which narrow understandings of productive citizenship employed in rehabilitation services can have unintended marginalizing effects. Each example is presented as a vignette.Discussion: The vignettes help us reflect on marginalization at the level of individual, community and society that arises from narrow interpretations of 'productive citizenship' in rehabilitation services. They also provide clues as to how productive citizenship could be envisaged differently. We argue that rehabilitation services, because of their influence at critical junctures in peoples' lives, could be an effective site of social change regarding how productive citizenship is understood in wider society.Implications for rehabilitation'Productive citizenship', or the interpretation of which activities count as contributions to society, has a very restrictive definition within rehabilitation services.This restrictive definition is reflected in both policy and practices, and influences what counts as 'legitimate' rehabilitation and support, marginalizing options for a 'good life' that fall outside of it.Rehabilitation can be a site for social change; one way forward involves advocating for broader understandings of what counts as 'productive citizenship'.

Recovery and adaptation after traumatic brain injury in New Zealand: Longitudinal qualitative findings over the first two years.

Knowledge about the impacts of traumatic brain injury (TBI) and aspects that influence recovery and adaptation are key to understanding how best to provide appropriate services. Whilst injury experiences have been documented, factors that help or hinder recovery and adaptation over time and across injury severities remain unclear. We present overarching findings addressing these matters in a large longitudinal qualitative study of recovery and adaptation following TBI. People experiencing TBI (n = 52) and their significant others (n = 37) were interviewed at 6-, 12- and 24-months post-injury. Data were thematically analysed cross-sectionally and longitudinally. Two overarching themes were captured in the analysis: making room for recovery and cultivating important resources. Themes comprise circumstances and processes that changed and developed over time in different ways for different participants. Key complexities within the overarching themes included the notion of "acceptance" and the role it played in allowing for recovery and adaptation; and the concept of "self" as a resource aiding recovery, but one that is perpetually at risk due to the intersection between the functional and social effects of the injury. Developing concepts of TBI recovery and living with TBI were central processes across diverse participants, but necessarily individualised in how they could be enacted.

Optimising qualitative longitudinal analysis: Insights from a study of traumatic brain injury recovery and adaptation.

Knowledge about aspects that influence recovery and adaptation in the postacute phase of disabling health events is key to understanding how best to provide appropriate rehabilitation and health services. Qualitative longitudinal research makes it possible to look for patterns, key time points and critical moments that could be vital for interventions and supports. However, strategies that support robust data management and analysis for longitudinal qualitative research in health-care are not well documented in the literature. This article reviews three challenges encountered in a large longitudinal qualitative descriptive study about experiences of recovery and adaptation after traumatic brain injury in New Zealand, and the strategies and technologies used to address them. These were (i) tracking coding and analysis decisions during an extended analysis period; (ii) navigating interpretations over time and in response to new data; and (iii) exploiting data volume and complexity. Concept mapping during coding review, a considered combination of information technologies, employing both cross-sectional and narrative analysis, and an expectation that subanalyses would be required for key topics helped us manage the study in a way that facilitated useful and novel insights. These strategies could be applied in other qualitative longitudinal studies in healthcare inquiry to optimise data analysis and stimulate important insights.

Socially constructed 'value' and vocational experiences following neurological injury.

PURPOSE: Paid work is seen as a key outcome in rehabilitation. However, research demonstrates that because of normative expectations in the job market and workplace, experiences of disability can be intensified in a work context. We sought to explore this issue in more depth by analysing the effects of societal constructions of worker 'value' within individual case studies of people with acquired neurological injury. METHOD: Instrumental case study of four heterogeneous participants, employing a discourse analysis approach. RESULTS: Participants described a perpetuation of discourses in which a disabled body or mind itself is seen to qualify, disqualify or limit a person's value in employment. Nevertheless, interviews also highlighted discourses that constructed other worker identities: based on pre-injury identities, life experiences and other aspects of self. The contrasts between individuals illustrated how worker identities, when situated within broader societal discourses of worker 'value', can either constrain or expand the vocational opportunities available to individuals who experience disability. However, current and historical interactions about worker 'value' shaped the identities genuinely available to each individual. CONCLUSION: Understanding how societal discourses enable and constrain worker identities may be vital to (a) facilitating valid opportunities and (b) navigating situations that could unintentionally hinder vocational possibilities. Implications for Rehabilitation This study shows how worker identities, situated within societal discourses of worker 'value', can constrain or broaden vocational opportunities available to individuals who experience disability. Barriers to gaining, maintaining and developing in employment could be re-envisaged in terms of what is limiting a person's ability to embody an enabling identity. A knowledge of both societal discourses and individuals' interactions with them may be vital to facilitating opportunities that users of rehabilitation services experience as valid options. This knowledge can also provide information with which to navigate situations that could potentially (sometimes unintentionally) constrain vocational possibilities.

Development of a new tool to evaluate work support needs and guide vocational rehabilitation: the work-ability support scale (WSS).

PURPOSE: This article outlines our overall approach, qualitative work, and pilot testing to develop a tool to facilitate identification of level of support needs and assist in planning for vocational rehabilitation interventions. METHODS: A set of foundation principles drawn from literature and previous critiques of work-ability assessment tools were used to guide a set of studies to develop a new tool. A review of the literature regarding factors that influence work-ability, qualitative interviews and focus groups with a range of stakeholders in the return-to-work process, and pilot testing in different settings were used to develop the Work-ability Support Scale (WSS) to a stage where it had face validity, usability and acceptability for a range of key stakeholders and was ready for further testing. RESULTS: Qualitative work and pilot testing enhanced the proposed tool with a series of changes and refinements to the content, structure and scoring framework. The current version of the tool is presented. Inter-rater reliability is presented elsewhere. CONCLUSION: Core principles and stakeholders' views (injured or sick workers, employers, case managers and health professionals) support current tool design. Although further testing is required, the WSS appears to hold potential for use in the assessment of vocational rehabilitation needs.

Establishing a person-centred framework of self-identity after traumatic brain injury: a grounded theory study to inform measure development.

OBJECTIVE: To develop a theoretically sound, client-derived framework to underpin development of a measure reflecting the impact of traumatic brain injury (TBI) on a person's self-identity. DESIGN: Grounded theory, based on transcription of audio recordings from focus group meetings with people who have experienced TBI, analysed with constant comparative methods. SETTING: 8 different urban and rural communities in New Zealand. PARTICIPANTS: 49 people (34 men, 15 women), 6 months to 36 years after mild-to-severe TBI. RESULTS: The central concept emerging from the data was that of desiring to be or having lost a sense of being an integrated and valued person. The three main subthemes were: (1) having a coherent, satisfying and complete sense of oneself, (2) respect, validation and acceptance by others and (3) having a valued place in the world. CONCLUSIONS: This study reinforces the notion that change in self-identity is an important aspect of life after TBI, and provides information on what this concept means to people with TBI. In order to scientifically evaluate relationships between self-identity and other aspects of health (eg, depression, quality of life), and to test the effect of interventions to address problems with self-identity after TBI, a quantitative tool for evaluation of this construct is required. Themes from this research provide a foundation for the development of a measure of self-identity grounded in the language and experience of people with TBI.

Interrogating discourse: the application of Foucault's methodological discussion to specific inquiry.

Discourse analysis following the work of Michel Foucault has become a valuable methodology in the critical analysis of a broad range of topics relating to health. However, it can be a daunting task, in that there seems to be both a huge number of possible approaches to carrying out this type of project, and an abundance of different, often conflicting, opinions about what counts as 'Foucauldian'. This article takes the position that methodological design should be informed by ongoing discussion and applied as appropriate to a particular area of inquiry. The discussion given offers an interpretation and application of Foucault's methodological principles, integrating a reading of Foucault with applications of his work by other authors, showing how this is then applied to interrogate the practice of vocational rehabilitation. It is intended as a contribution to methodological discussion in this area, offering an interpretation of various methodological elements described by Foucault, alongside specific application of these aspects.

Foucault, the subject and the research interview: a critique of methods.

Research interviews are a widely used method in qualitative health research and have been adapted to suit a range of methodologies. Just as it is valuable that new approaches are explored, it is also important to continue to examine their appropriate use. In this article, we question the suitability of research interviews for 'history of the present' studies informed by the work of Michel Foucault - a form of qualitative research that is being increasingly employed in the analysis of healthcare systems and processes. We argue that several aspects of research interviewing produce philosophical and methodological complications that can interfere with achieving the aims of the analysis in this type of study. The article comprises an introduction to these tensions and examination of them in relation to key aspects of a Foucauldian philosophical position, and discussion of where this might position researchers when it comes to designing a study.

Perspectives on quality of care for people who experience disability.

BACKGROUND AND OBJECTIVE: Quality of care is considered to be of central importance in healthcare, disability services and rehabilitation. People experiencing disability often access a range of health and social care services; for some, these services are integral parts of daily life. Little research has explored perspectives of disabled people regarding what constitutes good quality care. This qualitative study aimed to explore and synthesise these perspectives to build a better picture of what constitutes good-quality care for disabled people in New Zealand. DESIGN AND PARTICIPANTS: Qualitative focus groups and interviews were conducted with a range of participants including people with physical, sensory and/or intellectual impairment; informal and formal carers; and health and social care professionals. Data analysis used constant comparison methods as described in Strauss and Corbin (1998) to determine the factors of most importance and how they contributed to quality of care in health and social care services from the perspectives of people who use these services. FINDINGS: Thirty-one participants took part, representing a range of ages and disabilities. Three main themes identified from data analysis were: (1) technical competence of care service and professionals; (2) a 'human' approach to service provision; and (3) context-appropriate response to needs. CONCLUSIONS: Findings offer a service-user perspective on what makes a difference to quality of care for people experiencing disability. They suggest that to provide context-appropriate care which addresses individual needs, the right mix of technical competence and a 'human' approach to care is needed. The mix required for the 'right' balance may depend on the type of service.

Experience of recovery and outcome following traumatic brain injury: a metasynthesis of qualitative research.

PURPOSE: To explore the use of qualitative metasynthesis to inform debate on the selection of outcome measures for evaluation of services provided to adults with traumatic brain injury (TBI). METHOD: Fifteen databases were searched for qualitative research published between 1965 and June 2009, investigating the lived experience of recovery following TBI acquired during adulthood. Two reviewers independently screened all abstracts. Included studies were evaluated using methodological criteria to provide a context for interpretation of substantive findings. Data were extracted and synthesised by three reviewers, using QSR NVivo to assist with data management. RESULTS: From 23 studies, eight inter-related themes were identified to describe the enduring experience of TBI: 1) mind/body disconnect; 2) disconnect with pre-injury identity; 3) social disconnect; 4) emotional sequelae; 5) internal and external resources; 6) reconstruction of self-identity; 7) reconstruction of a place in the world; 8) reconstruction of personhood. CONCLUSION: Currently, there are outcome measures for some but not all of the issues identified in qualitative research on surviving TBI. In particular, new outcome measures may be required to evaluate experiences of loss of personal identity, satisfaction with reconstructed identity and sense of connection with one's body and one's life following TBI.

Factors contributing to work-ability for injured workers: literature review and comparison with available measures.

PURPOSE: Despite a range of factors being proposed in research literature to be key to 'work-ability', agreed definitions and boundaries of this concept are lacking. This review sought to identify and clarify key factors thought to contribute to individual work-ability, then compare these against existing measures of work-ability for people with injury. METHOD: A literature search was undertaken based on principles of systematic review. MEDLINE, AMED, Scopus and Web of Science databases were searched. All potentially relevant articles were obtained and, if they met inclusion criteria, evaluated for quality. The search was expanded and repeated to identify currently available measures of work-ability for people with injury. These measures were then compared against components from the first search. RESULTS: Thirty-four articles were obtained from the first search, and 23 provided information about factors that contribute to work-ability. Six broad categories were identified: physical, psychological, cognitive, social/behavioural, workplace factors, and factors outside the workplace. The follow-up search identified 10 measures. No one measure captured all six identified categories. CONCLUSIONS: Components contributing to work-ability go beyond the ability to perform particular work tasks. Measures intended to be used to inform vocational rehabilitation arguably need to consider all these factors to maximise likelihood of a sustainable return to work.

Understanding decisions about work after spinal cord injury.

INTRODUCTION: Research has consistently shown that many people with spinal cord injury (SCI) do not return to work (RTW), despite evidence that being employed is associated with better quality of life, participation and physical and psychological well-being. While some factors associated with RTW outcome have been identified, very little is known about what influences people's own decisions about their employment following SCI. This qualitative study sought to identify factors that influenced decisions about whether and when to RTW for people with SCI. METHODS: Participants were recruited through rehabilitation and support services in Aotearoa/New Zealand, and sampling sought to capture variation in the population, particularly with regard to pre-injury occupation, physical impairment, age, ethnicity and education. In-depth interviews were conducted which were audio-taped and transcribed. Interviews were analysed using rigorous methods drawn from grounded theory. RESULTS: Thirteen participants took part in the research. Findings identified four main themes that synthesised experiences about what influenced decisions about employment after SCI: (1) ability to work (given work demands and current resources); (2) presence of responsibilities or pressures that compete with work; (3) access to a suitable job; and (4) whether work was of enough benefit to the individual to be worth pursuing. CONCLUSIONS: Findings illustrate the complexity of decisions about working after SCI, and provide a framework that health and vocational professionals may find useful to inform discussions with their clients. Findings also provide a basis for further research into interventions to support people to make informed decisions about employment after SCI.