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Psychosocial well-being is key to living well after stroke, but often significantly affected by stroke. Existing understandings consider well-being comes from positive mood, social relationships, self-identity and engagement in meaningful activities. However, these understandings are socioculturally located and not necessarily universally applicable. This qualitative metasynthesis examined how people experience well-being after a stroke in Aotearoa New Zealand. This metasynthesis was underpinned by He Awa Whiria (Braided Rivers), a model which prompts researchers to uniquely engage with Māori and non-Māori knowledges. A systematic search identified 18 articles exploring experiences of people with stroke in Aotearoa. Articles were analysed using reflexive thematic analysis. We constructed three themes which reflect experiences of well-being: connection within a constellation of relationships, being grounded in one's enduring and evolving identities, and being at-home in the present whilst (re)visioning the future. Well-being is multi-faceted. In Aotearoa, it is inherently collective while also deeply personal. Well-being is collectively achieved through connections with self, others, community and culture, and embedded within personal and collective temporal worlds. These rich understandings of well-being can open up different considerations of how well-being is supported by and within stroke services. Psychosocial well-being is critical for people living with stroke. Well-being should be a priority in rehabilitation, however people with stroke indicate they do no consistently receive psychosocial support. It is clear that well-being has strong cultural elements, and understanding what supports well-being in individuals, whānau (those within wider networks who the person with stroke considers important), and wider cultural groups is important. Supporting whānau is crucial as whānau are core to well-being both during and beyond rehabilitation, and their own well-being is impacted by stroke. [ABSTRACT FROM AUTHOR]

Background: Following stroke, a sense of well‐being is critical for quality of life. However, people living with stroke, and health professionals, suggest that well‐being is not sufficiently addressed within stroke services, contributing to persistent unmet needs. Knowing that systems and structures shape clinical practice, this study sought to understand how health professionals address well‐being, and to examine how the practice context influences care practice. Methods: Underpinned by Interpretive Description methodology, we interviewed 28 health professionals across multiple disciplines working in stroke services (acute and rehabilitation) throughout New Zealand. Data were analysed using applied tension analysis. Results: Health professionals are managing multiple lines of work in stroke care: biomedical work of investigation, intervention and prevention; clinical work of assessment, monitoring and treatment; and moving people through service. While participants reported working to support well‐being, this could be deprioritised amidst the time‐oriented pressures of the other lines of work that were privileged within services, rendering it unsupported and invisible. Conclusion: Stroke care is shaped by biomedical and organisational imperatives that privilege physical recovery and patient throughput. Health professionals are not provided with the knowledge, skills, time or culture of care that enable them to privilege well‐being within their work. This has implications for the well‐being of people with stroke, and the well‐being of health professionals. In making these discourses and culture visible, and tracing how these impact on clinical practice, we hope to provide insight into why well‐being work remains other to the 'core' work of stroke, and what needs to be considered if stroke services are to better support people's well‐being. Patient or Public Contributions: People with stroke, family members and people who provide support to people with stroke, and health professionals set priorities for this research. They advised on study conduct and have provided feedback on wider findings from the research. [ABSTRACT FROM AUTHOR]

Background: After a stroke, people can find it challenging to look forward to the future. Hope, a critical resource for recovery, can be threatened and can be supported or diminished through interactions with clinicians. As such, understanding how conversations can support people embarking on life after a stroke is critical. Our study explored how clinicians talk about the future with patients and considered what factors shape how these conversations occur. Methods: This study drew on the Interpretive Description methodology, informed by principles of ethnographic inquiry. We conducted 300 hours of observations and 76 interviews with five people with stroke and 37 clinicians. Data were analysed using the reflexive thematic analysis. Results: We constructed three themes that reflect how clinicians talk about the future with people in inpatient stroke services: (1) constrained temporal horizons, (2) limited talk controlled by clinicians, and (3) opening some doors while closing others. Conclusions: Conversations about the future after stroke were constrained and limited: constrained to short-term futures and limited in what aspects of life after stroke were discussed. Creating conversational and relational spaces where people are supported to look to the future with a sense of possibility, hope, and potential is vital for assisting people to move forward in their lives after their stroke. Given its role in supporting people to move forward in their lives, communication must be seen as a core clinical skill and a clinical intervention in its own right. This qualitative study examines how healthcare practitioners talk about life after stroke with people in inpatient stroke services. [ABSTRACT FROM AUTHOR]

Background: Engagement is commonly considered important in stroke rehabilitation, with some arguing it is essential for positive patient outcomes. An emerging body of research indicates the practitioner influences engagement through their ways of relating, communicating and working with the patient. People experiencing communication disability may face particular challenges with engagement as a practitioner's communication and interactional patterns may limit their ability to engage. Aims: To understand how rehabilitation practitioners worked to engage people experiencing communication disability throughout the course of rehabilitation. Methods & Procedures: A qualitative study using the Voice Centred Relational Approach. Longitudinal observational and interview data were gathered from 28 practitioners and three people experiencing communication disability in inpatient and community stroke rehabilitation services. Data were analyzed using the Listening Guide. Outcomes & Results: Engagement was a relational practice on the part of the rehabilitation practitioner. It was underpinned by a relational philosophy and characterized by three core processes: embedding relational work throughout rehabilitation; getting to know the patient and working in ways valued by the patient; and communicating using relational dialogue and supported conversation. Practitioners wove these together with their technical, disciplinary-based work and rehabilitation tasks. Conclusions & Implications: Patient engagement was constructed through relationships and strongly influenced by the practitioners' way of thinking about and enacting practice, challenging the idea that engagement is solely an intrinsic patient state and behaviour. The findings raise questions about which aspects of rehabilitation work and communication are most valuable when working to engage people experiencing communication disability. Viewing engagement as a relational practice and understanding the different ways this is enacted may support practitioners to reflect on their understandings of engagement, their patient's engagement, their ways of working, and the frames and philosophies that surround and influence their practice.

While discussions on patient engagement commonly focus on patient behaviors, a small body of research highlights the patient-practitioner relationship as critical in engagement. Understanding this relationship might be facilitated through a relationally-oriented methodology. The Voice Centred Relational Approach is one such qualitative methodology. Within this paper, we present one turn in a long conversation about this methodology. Drawing on our longitudinal observational study of engagement practices in stroke rehabilitation in New Zealand, we explicate how a theoretical framework can inform how the Voice Centred Relational Approach is enacted in the research process, from entering the field to dissemination. We detail how we adapted the associated analytic techniques (the Listening Guide and i-poems) for use with multiple forms and sources of data. We propose that the underlying relational ontology and relational orientation of this methodology makes it a useful approach in researching relational practice in healthcare.

Background and Aims: Therapeutic connections enhance patient experience and outcomes after neurological injury or illness. While we have some understanding of the components necessary to optimise therapeutic connections, these have developed from western-centric ideals. This study sought to explore the perspectives of Māori brain injury survivors, and their whānau (wider family and community), to develop more culturally informed understandings of what matters most for Māori in the development and experience of therapeutic connection. Design and Methods: A bicultural approach underpinned by principles of Kaupapa Māori Research was used. Whānau views and experiences were gathered through wānanga (focus groups). These perspectives were analysed drawing on Māori methods of noho puku (self-reflection), whanaungatanga (relational linkage) and kaitiakitanga (guardianship). Findings: Three wānanga were held with 16 people – 5 brain injury survivors and 11 whānau members. The phrase 'therapeutic connection' did not resonate; instead, people spoke of meaningful connections. For rehabilitation encounters to be meaningful, three layers of connection were acknowledged. The elemental layer features wairua (spirit) and hononga (connection) which both underpinned and surrounded interactions. The relational layer reflects the importance of whānau identity and collectivism, of being valued, known, and interactively spoken with. Finally, the experiential layer consists of relational aspects important within the experience: relationships of reciprocity that are mana-enhancing and grounded in trust. These layers are interwoven, and together serve as a framework for meaningful connections. Conclusions: Meaningful connections in neurorehabilitation are underpinned by wairua and hononga; are multi-layered; are enabled through interactions with people, practice, process and place; are inclusive of whānau and resonate with Māori worldviews. The primacy of wairua and whānau within an interconnected view of health, challenges individualistic notions inherent in western health models and deepens existing understandings of meaningful connections in neurorehabilitation which can guide future rehabilitation research, teaching and practice. [ABSTRACT FROM AUTHOR]

Background and Aims: Engagement is increasingly recognised as important for maximising rehabilitation outcome following stroke. However, engagement can be challenging when neurological impairment impacts a persons' ability to activate the regulatory processes necessary for engagement and in the context of a changed self. We explored engagement in stroke rehabilitation from the perspective of people with stroke with a primary focus on identifying key processes that appeared important to engagement in stroke rehabilitation. Design and Methods: This study drew on Interpretive Description methodology. Maximum variation and theoretical sampling were used to capture diversity in the sample and access a depth and breadth of perspectives. Data collection included semi-structured interviews with people with stroke (n = 19). Data were analysed through a collaborative and iterative process drawing on range of analytical tools including coding, memoing, diagramming and group discussions. Findings: Our findings highlight that engagement is a complex, nuanced, responsive, flexible and inherently two-way process. Developing connections appeared central to engagement with connections taking various forms. The most fundamental was the therapeutic connection between the person with stroke and their practitioner as it provided the foundation on which to build other connections. Connection was made possible through five collaborative processes: Knowing, Entrusting, Adapting, Investing and Reciprocating. Conclusions: Engagement is a social and relational process enabled through an inherently person-centred approach and active and ongoing reflexivity – highlighting the importance of a humanising approach to care where aspects of self, care and emotion are evident, for both the person with stroke and their practitioner. [ABSTRACT FROM AUTHOR]

Purpose: In this paper, we critically investigate the implementation of person-centered care with the purpose of advancing philosophical debates regarding the overarching aims and delivery of rehabilitation. While general agreement exists regarding person centered care's core principles, how practitioners reconcile the implementation of these principles with competing practice demands remains an open question. Materials and methods: For the paper, we drew on post-qualitative methods to engage in a process of "diffractive" analysis wherein we analyzed the micro-doings of person-centered care in everyday rehabilitation work. Working from our team members' diverse experiences, traditions, and epistemological commitments, we engaged with data from nine "care events" generated in previous research to interrogate the multiple forces that co-produce care practices. Results: We map our analyses under three categories: scripts mediate practice, securing compliance through "benevolent manipulations", and care(ful) tinkering. In the latter, we explore the notion of tinkering as a useful concept for approaching person centered care. Uncertainty, humility, and doubt in one's expertise are inherent to tinkering, which involves a continual questioning of what to do, what is best, and what is person centered care within each moment of care. The paper concludes with a discussion of the implications for rehabilitation and person-centered care. Determinations of what constitutes good, better, or best rehabilitation practices are inevitably questions of ethics. Person-centered care is promoted as good practice in rehabilitation because it provides a framework for attending to the personhood of all engaged in clinical encounters. Post-critical analyses suggest that multiple interacting forces, conditions, assumptions, and actions intersect in shaping each rehabilitation encounter such that what constitutes good care or person-centered care cannot be determined in advance. "Tinkering" is a potentially useful approach that involves a continual questioning of what to do, what is best, and what is person-centered care within each moment of care. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusions\nIMPLICATIONS FOR REHABILITATIONRehabilitation plays a critical role in minimising disability after stroke, with the concept of “challenge” proposed to be essential to rehabilitation efficacy and outcomes. This review unpacks how challenge is conceptualised in stroke rehabilitation literature from the perspectives of physiotherapy, occupational therapy, speech-language therapy and people with stroke. A secondary purpose was to provide a definition of challenge that is applicable to stroke rehabilitation.Principle-based concept analysis was utilised to examine challenge within the stroke rehabilitation literature. Forty-two papers were included. Data analysis involved immersion, analytical questioning, coding and synthesis to elicit the conceptual components of challenge.Challenge was understood as a multidimensional and dynamic concept with three facets: nominal, functional and perceived challenge. Functional and perceived challenge were integral to optimal challenge. Optimal challenge was central to enhancing the outcomes and experiences of people with stroke, in rehabilitation and everyday life.Challenge is a key concept which, when carefully optimised to the person’s ability and experience, may positively influence their learning, recovery and engagement after stroke. This review lays a conceptual foundation for better understanding, operationalisation and advancement of challenge, offering important implications for addressing the growing burden of stroke disability, through rehabilitation.Challenge involves a multifaceted, multidimensional and dynamic interaction between the task, the person’s ability and their subjective experience.The therapist and the person’s perspective should collectively shape the process of co-creating a challenge that is truly optimal for the person.Therapists should consider both functional and perceived approaches to operationalising challenge with the person.Challenge involves a multifaceted, multidimensional and dynamic interaction between the task, the person’s ability and their subjective experience.The therapist and the person’s perspective should collectively shape the process of co-creating a challenge that is truly optimal for the person.Therapists should consider both functional and perceived approaches to operationalising challenge with the person. [ABSTRACT FROM AUTHOR]

Abstract: Background: Engagement is commonly considered important in stroke rehabilitation, with some arguing it is essential for positive patient outcomes. An emerging body of research indicates the practitioner influences engagement through their ways of relating, communicating and working with the patient. People experiencing communication disability may face particular challenges with engagement as a practitioner's communication and interactional patterns may limit their ability to engage. Aims: To understand how rehabilitation practitioners worked to engage people experiencing communication disability throughout the course of rehabilitation. Methods & Procedures: A qualitative study using the Voice Centred Relational Approach. Longitudinal observational and interview data were gathered from 28 practitioners and three people experiencing communication disability in inpatient and community stroke rehabilitation services. Data were analyzed using the Listening Guide. Outcomes & Results: Engagement was a relational practice on the part of the rehabilitation practitioner. It was underpinned by a relational philosophy and characterized by three core processes: embedding relational work throughout rehabilitation; getting to know the patient and working in ways valued by the patient; and communicating using relational dialogue and supported conversation. Practitioners wove these together with their technical, disciplinary‐based work and rehabilitation tasks. Conclusions & Implications: Patient engagement was constructed through relationships and strongly influenced by the practitioners’ way of thinking about and enacting practice, challenging the idea that engagement is solely an intrinsic patient state and behaviour. The findings raise questions about which aspects of rehabilitation work and communication are most valuable when working to engage people experiencing communication disability. Viewing engagement as a relational practice and understanding the different ways this is enacted may support practitioners to reflect on their understandings of engagement, their patient's engagement, their ways of working, and the frames and philosophies that surround and influence their practice. [ABSTRACT FROM AUTHOR]

While discussions on patient engagement commonly focus on patient behaviors, a small body of research highlights the patient-practitioner relationship as critical in engagement. Understanding this relationship might be facilitated through a relationally-oriented methodology. The Voice Centred Relational Approach is one such qualitative methodology. Within this paper, we present one turn in a long conversation about this methodology. Drawing on our longitudinal observational study of engagement practices in stroke rehabilitation in New Zealand, we explicate how a theoretical framework can inform how the Voice Centred Relational Approach is enacted in the research process, from entering the field to dissemination. We detail how we adapted the associated analytic techniques (the Listening Guide and i-poems) for use with multiple forms and sources of data. We propose that the underlying relational ontology and relational orientation of this methodology makes it a useful approach in researching relational practice in healthcare. [ABSTRACT FROM AUTHOR]

Purpose: This review sought to develop an understanding of how engagement in healthcare has been conceptualized in the literature in order to inform future clinical practice and research in rehabilitation. A secondary purpose was to propose a working definition of engagement. Methods: EBSCO and SCOPUS databases and reference lists were searched for papers that sought to understand or describe the concept of engagement in healthcare or reported the development of a measure of engagement in healthcare. We drew on a Pragmatic Utility approach to concept analysis. Results: Thirty-one articles met the criteria and were included in the review. Engagement appeared to be conceptualized in two inter-connected ways: as a gradual process of connection between the healthcare provider and patient; and as an internal state, which may be accompanied by observable behaviors indicating engagement. Conclusion: Our review suggests engagement to be multi-dimensional, comprising both a co-constructed process and a patient state. While engagement is commonly considered a patient behavior, the review findings suggest clinicians play a pivotal role in patient engagement. This review challenges some understandings of engagement and how we work with patients and highlights conceptual limitations of some measures. [ABSTRACT FROM AUTHOR]

Background: Hope is a critical resource for people with aphasia after stroke, sustaining people though times of distress and uncertainty and providing motivation. In the first months after stroke, hope is vulnerable to different influences, and people can struggle to identify and work towards hopes for the future. We have little knowledge about how people with aphasia experience hope in the longer term after stroke., Objectives: To identify how people with aphasia experience hope 1 year after stroke and how hope may change in the year after stroke., Methods: The study used an Interpretive Description methodology. Interviews were conducted with four people with aphasia who had been interviewed 1 year previously. These were analysed using content analysis., Results: All people reported a broad sense of hope for the future. They described an active process of recalibrating their early poststroke hopes through a process of reflecting on past progress, current function and what they considered might be possible and desirable in the future. People were able to develop 'new' hopes that were meaningful and seemingly achievable when they had a sense of a possible, desirable future. Those who struggled to see a possible future maintained a hope that things will be good. Social supports, a sense of progress, engagement in meaningful activities and interactions appeared crucial in helping people (re)develop hopes for their future., Conclusions: Hope and hopes for the future gradually changed after stroke. Hope, identity and social connectedness were closely entwined and could enable people to both dwell in the present and move towards desired futures. This research suggests clinicians should prioritise creating hope-fostering environments which support people to develop hope for their future., (© 2019 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.)

Purpose: Client-centred practice is widely considered a key element of rehabilitation. However, there is limited discussion of how it should be implemented. This study explored how client-centred practice was operationalized during a clinical trial of innovative goal-setting techniques., Method: This study drew on principles of co-autoethnography. The personal experiences of three clinical researchers were explored to identify insights into client-centred practice, and seek understanding of this within the broader socio-cultural context. Data were collected through group discussions and written reflections. Thematic analysis and coding were used to identify the dominant themes from the data., Results: The primary way that client-centred practice was operationalized was through listening in order to get to know, to uncover and to understand what was meaningful. Four strategies were identified: utilizing mindful listening, allowing time, supporting clients to prioritize what is meaningful and viewing the therapists' role differently., Conclusion: While technical competence in rehabilitation is important, our study suggested a starting point of 'being with' rather than 'doing to' may be beneficial for engaging people in their rehabilitation. We have highlighted a number of practical strategies that can be used to facilitate more client-centred practice. These approaches are consistent with what clients report they want and need from rehabilitation services.