Online awareness: a concept analysis and review of assessment approaches for adults with neurological conditions.

PURPOSE: Self-awareness is a multifaceted phenomenon that comprises two main concepts: general awareness and online awareness. The latter is an emerging concept that requires further consensus on its definition. The aim of this paper is to define the key components of online awareness and identify approaches for measuring this concept for adults with neurological conditions. MATERIALS AND METHODS: Concept analysis using Rodgers' evolutionary method was used to systematically review and summarise relevant literature. Papers were included if they provided a definition of online awareness or method for assessing online awareness for an adult neurological population. RESULTS: Fifty-six papers were included in this review, with 21 online awareness assessment approaches identified. Online awareness was described to occur within the context of task performance, with the definition framework comprising four main aspects: 1/appraisal; 2/anticipation and prediction; 3/monitoring; and 4/self-evaluation. Self-regulation is a related concept that is considered to sit outside the conceptual boundaries of online awareness. CONCLUSIONS: The findings of this analysis highlight the complexity of online awareness and its importance in rehabilitation. Psychometrically robust measures of online awareness that are inclusive of the essential elements of this concept are needed to advance practice in this area.

Online awareness or awareness of performance within the context of an activity should be included in the comprehensive assessment of self-awareness for individuals with neurological conditions.Online awareness is a task-specific phenomenon that is activated in the context of task performance, and requires assessment across a range of tasks and environments.When assessing online awareness, careful consideration is required when selecting tasks to ensure they have the right level of challenge to elicit the need to monitor performance.The heterogeneity of existing online awareness assessments highlights the need to interpret outcomes with caution.Future efforts should be directed towards development of an online awareness assessment that includes key attributes of this concept.

Factors associated with self-awareness impairment in an inpatient brain injury rehabilitation cohort.

BACKGROUND: Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning. OBJECTIVES: To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke. DESIGN AND METHODS: A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups. RESULTS: Participants were 149 adults (18-70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group. CONCLUSION: Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.

Profiling self-awareness in brain injury rehabilitation: A mixed methods study.

ABSTRACTImpaired self-awareness impacts outcomes for individuals with brain injury. Self-awareness is a complex construct, with little known about how its presentation differs across diagnostic groups, or how brain injury-related changes are expressed by individuals in the early phase post-brain injury. This study aims to identify differences and similarities in patterns of self-awareness between patients with different brain injury diagnoses, and provide a clinical account of how individuals with ABI describe changes to themselves arising from brain injury. This is a mixed methods retrospective cohort study involving an audit of medical files that included extraction of data from the Self-Awareness of Deficits Interview. Quantitative and qualitative techniques were used to analyse data from 173 participants. Individuals identified a range of brain injury-related impairments across domains, with greatest difficulty noted with linking impairments to functional implications and setting realistic goals. There were similarities and distinct differences in the expression of changes across diagnostic groups. Two main themes that aligned with self-awareness theory were identified from the data: 1/ Development of self-awareness; and 2/ Dimensions of self-awareness. These interrelated themes demonstrated the multifaceted nature of the clinical presentation of self-awareness, and highlight the need for an individualized approach to cognitive rehabilitation.

Conceptualization of self-awareness in adults with acquired brain injury: A qualitative systematic review.

Self-awareness is an important consideration in cognitive rehabilitation for clinicians working with individuals following acquired brain injury (ABI), with impaired self-awareness linked to poor outcomes. To appropriately target assessment and intervention for self-awareness, its theoretical foundation and definition must be considered. The aim was to identify the definitions, theoretical models and conceptual frameworks of self-awareness in adults with ABI, and how self-awareness is conceptualized within those models. A qualitative systematic review was completed using search terms related to descriptions of models/frameworks, ABI and self-awareness. Data were analysed by narrative synthesis. Thirty-five papers were included in the review. Within these, 13 models, 12 conceptual frameworks and 2 theories were described. The main themes and subthemes conceptualized in the synthesis were: Clinical presentation of self-awareness (classifications and dimensions of self-awareness), development of self-awareness (knowledge, feedback mechanisms, temporal aspects, self-evaluation, enablers, barriers), understanding (dys)function (cognitive processing mechanisms, neurological foundations, causal factors), and practice guidance (assessment and intervention). This review identified an extensive theoretical basis to support conceptualization of self-awareness following ABI, underpinned by a distinction between intellectual awareness, on-line awareness, and psychological denial. Clinical application of an evaluation process that includes these elements would be beneficial to inform the rehabilitation process.

Designing an intervention process that embeds work-focussed interventions within inpatient rehabilitation: An intervention mapping approach.

INTRODUCTION: Returning to work is a goal for many people after brain injury. The failure to return to work after injury brings both economic and personal (quality of life) costs to those living with stroke or brain injury, their families, and society. This study explored the barriers to providing work-focused interventions during hospital-based rehabilitation and co-created solutions with rehabilitation providers to increase the provision of work-focused intervention during inpatient rehabilitation. METHODS: This study used an Intervention Mapping approach (a six-step protocol that guides the design of complex interventions) based on an action research methodology. Focus group data, in addition to best evidence from systematic reviews, practice guidelines and key articles were combined with theoretical models for changing behaviour and clinician experience. This was then systematically operationalised into an intervention process using consensus among clinicians. The process was further refined through piloting and feedback from key stakeholders, and group consensus on the final process. RESULTS: A detailed five phase return to work intervention process for inpatient rehabilitation was developed. The key features of the process include; having one key allied health clinician to coordinate the process, choosing assessments based on pre-injury work demands, emphasising the importance of core work skills and considering the most appropriate service for referral at the conclusion of rehabilitation. CONCLUSION: We used a systematic approach, guided by the intervention mapping approach and behaviour change theory to tailor existing workfocused interventions to the inpatient setting.

Barriers and enablers to aligning rehabilitation goals to patient life roles following acquired brain injury.

BACKGROUND/AIM: Life roles are integral to occupational therapy practice. Goal setting is a method of establishing priorities to measure outcomes. While acquired brain injury can impact a person's ability to fulfil meaningful life roles, the alignment of goals set in rehabilitation to life roles, is unclear. This study aimed to (i) explore the alignment of goals with life roles for people with an acquired brain injury participating in inpatient rehabilitation; and (ii) identify barriers and enablers to life role discussions within a patient-directed goal setting framework. METHOD: A mixed-methods study was conducted on an inpatient rehabilitation unit in Victoria, Australia. Quantitative data were obtained from a retrospective file audit of randomly selected medical records. Qualitative data were collected through: a) interviews with patients and their families; and b) A focus group with occupational therapists. Thematic analysis of both audit data and narrative data was undertaken. RESULTS: Thirty files were examined and demonstrated 33% alignment between goals and life roles. Four interviews were completed with patients, with a family member participating in two of these. Themes identified were: readiness, role concept, recovery concept and goal review. Five therapists attended the focus group. Themes identified were: Patient factors, goal review, expectations, role change and environment. Interview and focus group data identified that barriers to life role discussions included: lack of patient and family readiness, patients' difficulty understanding role concept, focus on impairments and lack of family/ significant others support. Enablers included: having early conversations involving family, regular goal review and use of standardised tools. CONCLUSION: Goal setting in alignment with life roles is important in acquired brain injury rehabilitation, but may be limited. This process can be enhanced by including patients and their significant others in early goal setting conversations, along with regular goal review across the rehabilitation process.

Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury.

BACKGROUND/AIM: When working with individuals following stroke or traumatic brain injury, an important role of the occupational therapist is to assess the impact of cognitive impairment on their ability to engage in occupations and resume important life roles. The aim of this study was to survey therapists' reasons for selection of and challenges with using various cognitive assessment approaches, across the continuum of care, when working with individuals following stroke and traumatic brain injury. METHODS: A cross-sectional survey, completed via post or online, with responses from 209 Australian occupational therapists was conducted. Participants included clinicians working in acute, inpatient rehabilitation and community settings. RESULTS: Occupational performance-based assessments were ranked as the most important assessment method, with 69% of participants reporting using these assessments for more than 75% of their clients with cognitive impairment. Participants identified the lack of quantitative data provided by these assessments as a frequent challenge. The identification of cognitive deficits was the highest ranked reason for using cognitive screens and batteries. Challenges identified with using cognitive screens and batteries included difficulty linking assessment results to occupational performance, and difficulty using results to generate intervention strategies. The majority of participants reported using a combined approach to assessment, and used screens and batteries to support findings of occupational performance-based assessments. CONCLUSIONS: Targeted efforts to further incorporate standardised occupational performance-based methods into clinical practice, research, and ongoing professional development is required to enhance occupational therapy services when working with individuals with cognitive impairment.

Stroke survivor and carer perspectives of the concept of recovery: a qualitative study.

PURPOSE: This study was designed to explore the concept of recovery from the perspectives of stroke survivors and informal carers. The aim of this qualitative study was to identify the main factors that are perceived to contribute to recovery after stroke. METHOD: Data were obtained via focus groups using semistructured questionnaires. One focus group included all participants (n = 14). This was followed by separate focus groups for stroke survivors (n = 8) and informal carers (n = 6). The data from the three focus groups were analysed using thematic analysis, whereby themes and sub-themes were identified and summarised via dual coding. RESULTS: The main theme identified was "individual recovery expectations". The contributing sub-themes were: "essential elements of recovery", "returning home" and "the environment of rehabilitation". The predominant factors to arise from this study surround the concepts of "returning to normality" for the stroke survivor and the "tension of providing care" for informal carers. CONCLUSIONS: This study provides a current description of stroke survivor and carer expectations of recovery. There are diverse and ongoing concerns that can be encountered into the chronic phase poststroke. Models of community-based care should adopt targeted interventions that concurrently consider stroke survivor and carer's individual concepts of recovery. IMPLICATIONS FOR REHABILITATION: • The concept of recovery can differ for stroke survivors, carers and the health professionals that they encounter. • As it is an individual phenomenon, many factors comprise the notion of recovery. • Health professionals need to explore stroke survivor and carer's views about their concepts of recovery, as greater awareness and attention may maximise individual poststroke potential.