Evaluating an interactive acceptance and commitment therapy (ACT) workshop delivered to trained therapists working with cancer patients in the United Kingdom: a mixed methods approach.

BACKGROUND: SURECAN (SUrvivors' Rehabilitation Evaluation after CANcer) is a multi-phase study developing and evaluating an Acceptance and Commitment Therapy (ACT) intervention integrated with exercise and work when highly valued (thus we called the intervention ACT+), for people who have completed treatment for cancer but who have low quality of life. We developed a training programme for therapists working in different psychological services to be delivered over 2-3 days. Our aim was to evaluate the extent to which the training could improve therapists' knowledge and confidence to deliver ACT+ to cancer patients in a trial setting. METHODS: Three interactive workshops were delivered to 29 therapists from three clinical settings in London and in Sheffield. A mixed-methods approach was used. Questionnaires were designed to assess knowledge and confidence in using ACT+ with people who have low quality of life after cancer treatment. They were self-administered immediately prior to and after each workshop. Open text-based questions were used to elicit feedback about the workshops alongside a satisfaction scale. Semi-structured interviews were conducted with a purposive sample of therapists (n = 12) to explore their views about the training more deeply, and how it might be optimised. RESULTS: Quantitative analysis showed that knowledge of ACT, as well as confidence in using the ACT+ intervention in this setting increased significantly after training (28.6 and 33.5% increase in the median score respectively). Qualitative analysis indicated that most therapists were satisfied with the content and structure of the programme, valued the rich resources provided and enjoyed the practice-based approach. Potential barriers/facilitators to participation in the trial and to the successful implementation of ACT+ were identified. For some therapists, delivering a manualised intervention, as well as supporting exercise- and work-related goals as non-specialists was seen as challenging. At the same time, therapists valued the opportunity to be involved in research, whilst training in a new therapy model. CONCLUSIONS: Training can effectively improve the knowledge and confidence of therapists from different clinical backgrounds to deliver a modified ACT intervention to cancer patients in a trial setting.

Educating undergraduate occupational therapy and physiotherapy students in motivational interviewing: the student perspective.

BACKGROUND: Motivational Interviewing (MI) is an evidenced based talking therapy designed to affect client Health Behaviour Change. Previous research indicates that Allied Health Professionals (AHP) can effectively use the approach and training at pre-registration level has been piloted. However, student experiences of training is underexplored. AIM: To explore Physiotherapy and Occupational Therapy students' experiences of training in and implementation of Motivational Interviewing. METHODS: Four focus groups including 24 undergraduates (14 OT and 10 PT) were conducted at the completion of the training and a subsequent clinical placement. Transcribed texts were analysed thematically. Data were triangulated with student written post-it notes and open questions in a post training questionnaire. RESULTS: Two overarching themes were developed from the data. Learning different ways to interact and the challenge of transformation illuminates specific aspects of the training which enabled learning as well as areas of contention. Using the spirit of MI, but not every contact counts highlights the facilitators and challenges of implementation on placements. CONCLUSIONS: Motivational interviewing is a useful addition to training neophyte health students. Key skills were adopted and in some cases transferred into practice. The process of learning indicates areas of potential improvement to enhance relevance of practice scenarios. The transfer to practice is more complex illustrating a need to negotiate professional and institutional expectations which should be considered in training.

Motivational interviewing training for physiotherapy and occupational therapy students: Effect on confidence, knowledge and skills.

OBJECTIVE: To examine the effectiveness of a three-day training programme on knowledge, confidence and fidelity to Motivational Interviewing (MI) delivery in an undergraduate occupational therapy and physiotherapy cohort (n = 25). METHODS: Training outcomes were assessed pre-training, post-training and following a subsequent clinical placement. The Motivational Interviewing Knowledge and Attitudes Test (MIKAT) and an 8-item survey assessed knowledge, attitudes and confidence respectively. MI fidelity was evaluated by a simulated patient interview rated with the Motivational Interviewing Treatment Integrity scale (MITI). Analysis was by one-way repeated measures ANOVA. RESULTS: Self-report measurements indicated increased confidence but no effect on knowledge or attitude. MITI analysis showed superior performance in all four global criteria and an increased frequency of MI adherent behaviours post-training. Positive changes were maintained following clinical placement. MITI summary scores indicated an improvement in question to reflection ratio in line with beginner competency. CONCLUSION(S): Participation in a three-day MI training programme significantly improved student confidence and MI skilfulness. PRACTICE IMPLICATIONS: Where feasible, MI training should be embedded within the curriculum. Further research is needed elucidate the best practices to incorporate teaching this skill set within the curriculum in order to best prepare students to counsel clients in behaviour change in their applied settings.

Mapping the scope of occupational therapy practice in palliative care: A European Association for Palliative Care cross-sectional survey.

BACKGROUND: Occupational therapists play an integral role in the care of people with life-limiting illnesses. However, little is known about the scope of occupational therapy service provision in palliative care across Europe and factors influencing service delivery. AIM: This study aimed to map the scope of occupational therapy palliative care interventions across Europe and to explore occupational therapists' perceptions of opportunities and challenges when delivering and developing palliative care services. DESIGN: A 49-item online cross-sectional survey comprised of fixed and free text responses was securely hosted via the European Association for Palliative Care website. Survey design, content and recruitment processes were reviewed and formally approved by the European Association for Palliative Care Board of Directors. Descriptive statistics and thematic analysis were used to analyse data. Setting/respondents: Respondents were European occupational therapists whose caseload included palliative care recipients (full-time or part-time). RESULTS: In total, 237 valid responses were analysed. Findings demonstrated a consistency in occupational therapy practice in palliative care between European countries. Clinician time was prioritised towards indirect patient care, with limited involvement in service development, leadership and research. A need for undergraduate and postgraduate education was identified. Organisational expectations and understanding of the scope of the occupational therapy role constrain the delivery of services to support patients and carers. CONCLUSION: Further development of occupational therapy in palliative care, particularly capacity building in leadership and research activities, is warranted. There is a need for continuing education and awareness raising of the role of occupational therapy in palliative care.

Complexity theory as an approach to explanation in healthcare: a critical discussion.

The reception of complexity theory in health care is characterised by a tendency to reify the idea of a complex system, which is basically an abstraction. This paper argues for three principal theses: first, to invoke complexity, to refer to complex systems, is to proffer a form of explanation; second, in the context of the social sciences, the form of explanation that complexity represents belongs to a family of explanations which the recent theoretical literature associates with social mechanisms; and, third, complexity explanations refer to a specific type of social mechanism, whose features differentiate it from the other members of the family. The most significant of these features is the jettisoning of the default link between order and design, which is precisely the principle omitted by an influential series of papers in the BMJ. Having defended these claims, the paper presents a brief case study illustrating the analysis.

Palliative and end-of-life care for people with stroke.

PURPOSE OF REVIEW: Stroke is a devastating illness. Significant progress has been made in the prevention, acute treatment and rehabilitation of stroke. Yet many people still die from stroke. The role of palliative and end-of-life care for stroke has received considerably less attention. This review presents an overview of the current understanding of palliative and end-of-life care for people with stroke. RECENT FINDINGS: The impact of stroke is wide-ranging and long lasting. It affects both patients and those who become their caregivers. Those who are dying from stroke experience a similar symptom profile to many other dying people. Palliative care services involved in care of stroke patients are more frequently involved in issues related to communication and difficult decisions related to food and fluids. Caregivers have significant needs, particularly around information provision, communication and involvement in, or consultation about, decision-making. Those who survive the immediate aftermath of a stroke are often left with significant psychological and social limitations in addition to physical disability. SUMMARY: It is clear that patients with stroke have palliative care needs. Palliative and end-of-life care services can contribute to the care of people with stroke, and their families, but the way in which stroke and palliative care services should interlink remains unclear.

Rehabilitation in end-of-life management.

PURPOSE OF REVIEW: Loss of ability to manage daily activities is source of significant distress for palliative patients. In the context of end-of-life care, rehabilitation contributes to patients' sense of autonomy, self-worth, and social participation. The present article provides an overview of recent advances in rehabilitation in end-of-life management, drawing on papers published during 2009. RECENT FINDINGS: Palliative patients have rehabilitation needs including difficulties with activities of daily living, disruption to usual routines and roles, and anxieties about being a burden to others. These needs are not adequately identified, leading to patients receiving less than optimal help in living with disability. Research shows that rehabilitation interventions such as exercise programmes have beneficial effects on fatigue and quality of life. In delivering rehabilitation, staff attitudes are important and should support patients' views of themselves as worthwhile, resourceful individuals. SUMMARY: Adequate screening procedures are necessary to identify functional difficulties so that appropriate help might be provided. There is now a growing body of work on the therapeutic benefits of exercise. There is a need for further experimental studies with larger samples to demonstrate effectiveness of interventions, as well as for qualitative studies examining the mechanisms of rehabilitation.

Narrative vigilance: the analysis of stories in health care.

The idea of narrative has been widely discussed in the recent health care literature, including nursing, and has been portrayed as a resource for both clinical work and research studies. However, the use of the term 'narrative' is inconsistent, and various assumptions are made about the nature (and functions) of narrative: narrative as a naive account of events; narrative as the source of 'subjective truth'; narrative as intrinsically fictional; and narrative as a mode of explanation. All these assumptions have left their mark on the nursing literature, and all of them (in our view) are misconceived. Here, we argue that a failure to distinguish between 'narrative' and 'story' is partly responsible for these misconceptions, and we offer an analysis that shows why the distinction between them is essential. In doing so, we borrow the concept of 'narrativity' from literary criticism. Narrativity is something that a text has degrees of, and our proposal is that the elements of narrativity can be 'sorted' roughly into a continuum, at the 'high narrativity' end of which we find 'story'. On our account, 'story' is an interweaving of plot and character, whose organization is designed to elicit a certain emotional response from the reader, while 'narrative' refers to the sequence of events and the (claimed) causal connections between them. We suggest that it is important not to confuse the emotional persuasiveness of the 'story' with the objective accuracy of the 'narrative', and to this end we recommend what might be called 'narrative vigilance'. There is nothing intrinsically authentic, or sacrosanct, or emancipatory, or paradigmatic about narrative itself, even though the recent health care literature has had a marked tendency to romanticize it.