From dictatorship to a reluctant democracy: stroke therapists talking about self-management

Abstract

PurposeSelf-management is being increasingly promoted within chronic conditions including stroke. Concerns have been raised regarding professional ownership of some programmes, yet little is known of the professional’s experience. This paper aims to present the views of trained therapists about the utility of a specific self-management approach in stroke rehabilitation.MethodEleven stroke therapists trained in the self-management approach participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically.ResultsTwo overriding themes emerged. The first was the sense that in normal practice therapists act as “benign dictators”, committed to help their patients, but most comfortable when they, the professional, are in control. Following the adoption of the self-management approach therapists challenged themselves to empower stroke survivors to take control of their own recovery. However, therapists had to confront many internal and external challenges in this transition of power resulting in the promotion of a somewhat “reluctant democracy”.ConclusionsThis study illustrates that stroke therapists desire a more participatory approach to rehabilitation. However, obstacles challenged the successful delivery of this goal. If self-management is an appropriate model to develop in post stroke pathways, then serious consideration must be given to how and if these obstacles can be overcome.Implications for RehabilitationStroke therapists perceive that self-management is appropriate for encouraging ownership of rehabilitation post stroke.Numerous obstacles were identified as challenging the implementation of self-management post stroke. These included: professional models, practices and expectations; institutional demands and perceived wishes of stroke survivors.For self-management to be effectively implemented by stroke therapists, these obstacles must be considered and overcome. This should be as part of an integrated therapy service, rather than as an add-on.

How is rehabilitation with and without an integrated self-management approach perceived by UK community-dwelling stroke survivors? A qualitative process evaluation to explore implementation and contextual variations

“…There are several barriers to this as noted by different authors, not least that this approach is considered more time-consuming and professionals raise concerns that patients might not have the skills to lead and make decisions about their rehabilitation. [7][8][9] Therapists using an integrated self-management approach in this study were trained to focus specifically on providing opportunities for devising goals together and encouraging individuals to come up with their own ideas, reflecting and problem-solving about what had or had not worked and why. Therapists were encouraged to find ways to incorporate mastery experiences in every therapy session, a key source of self-efficacy.…”

“…As some authors have noted if decision-making is made primarily by healthcare professionals, this can restrict individuals from developing personal control and autonomy. [7][8][9][10] While most rehabilitation purports to be patient centred, the level of collaboration in processes such as goal setting can be inconsistent. 10 In addition, selfmanagement support interventions designed specifically for patients with stroke are relatively rare.…”

“…She seemed like she had got a plan when she came and she was gonna do her plan. (usual care 12) They don't ask, they just tell me what they want me to do and I just do it (usual care 8) Participants gave examples of the type of judgments given by therapists which formed the foundation for session content and priorities chosen.…”

From therapeutic patient education principles to educative attitude: the perceptions of health care professionals – a pragmatic approach for defining competencies and resources

“…Bos-Touwen et al18 demonstrated the importance of recognizing patients’ ability to take care of themselves as a factor affecting self-care practices and nurses’ overall assessment of patients. Norris and Kilbride19 pointed out the perceived challenge that patient empowerment and the loss of control inherent in that type of approach poses to HPs. Lake and Staiger20 reported that HPs rely on five main elements for implementing self-management: collaborative care, self-responsibility, the client’s individual situation, structured support and linking with community agencies.…”

Building Bridges between healthcare professionals, patients and families: A coproduced and integrated approach to self-management support in stroke

“…This requires all of us to relinquish power and work in a way that has equality and partnership at its core (Norris & Kilbride, 2014). In other words, we endeavour to practice what we preach.…”