Objective:To identify factors influencing clinicians decision-making about ongoing
stroke rehabilitation for people with pre-existing dementia/cognitive
impairment and the impact on clinical practice.Design:Qualitative semi-structured interviews with stroke specialist healthcare
professionals analysed using thematic analysis.Setting:Acute stroke unit, inpatient stroke rehabilitation units, and community
stroke services.Participants:Twenty three professionals from six multidisciplinary stroke teams involved
in decision-making about stroke patients’ rehabilitation potential and
clinical pathways.Results:Factors influencing decision-making about ongoing rehabilitation were (1)
gaining understanding of the individual patient, (2) clinician’s knowledge
of dementia/cognitive impairment, (3) predicting rehabilitation potential,
(4) organizational constraints, and (5) clinician’s perceptions of their
role within the team. Decision-making led to two outcomes, either
accommodating the pre-existing dementia/cognitive impairment within delivery
of rehabilitation or ending rehabilitation for that patient to allocate
limited resources where they were perceived more likely to be effective.
Participants felt that patients with pre-existing dementia/cognitive
impairment had difficulty demonstrating the required rehabilitation
potential within the short timescales available in the current model of
service delivery. Participants identified a need for training to improve
their knowledge and confidence for decision-making and delivery of
rehabilitation for this growing population.Conclusion:Clinicians’ decision-making about ongoing rehabilitation for patients with
prestroke dementia/cognitive impairments is influenced by gaps in their
knowledge and by service constraints. Increased training and more flexible,
patient-centred services would enable clinicians to better accommodate these
patients in rehabilitation.
Objectives:To determine the factors affecting clinical decision-making about which patients should receive stroke rehabilitation.Methods:Data sources (MEDLINE, CINAHL, AMED and PsycINFO) were searched systematically from database inception to August 2018. Full-text English-language studies of data from stroke clinicians were included. Studies of patients were excluded. The included studies were any design focussed on clinical decision-making for referral or admission into stroke rehabilitation. Summary factors were compiled from each included study. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool.Results:After removing duplicates, 1915 papers were identified, of which 13 met the inclusion criteria. Eight included studies were qualitative and one used mixed methods. A total of 292 clinicians were included in the studies. Quality of the included studies was mixed. Patient-level and organizational factors as well as characteristics of individual clinicians contributed to decisions about rehabilitation. The most often described factors were patients’ pre- and poststroke function (n = 6 studies), presence of dementia (n = 6), patients’ social/family support (n = 6), organizational service pressures (n = 7) and the decision-making clinician’s own knowledge (n = 5) and emotions (n = 5).Conclusion:The results highlight a lack of clinical guidance to aid decision-making and reveal that a subjective approach to rehabilitation decision-making influenced by patient-level and organizational factors alongside clinicians’ characteristics occurs across services and countries.
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