Specialist Neurological Occupational Therapist Emma Royal works for Buckingham Community Neurological Rehabilitation Service. With around 625 referrals a year, this service provides rehab for clients with a diagnosis of stroke and progressive neurological conditions. Emma works within a team of fifteen clinical staff including occupational therapists, physiotherapists, speech and language therapists and clinical psychologists.
Emma’s service undertook a 4 year project which looked at overcoming barriers to progressing with rehabilitation, using applied behavioural change theory. Here Emma describes the project and resulting outcomes.
In 2014 the clinicians in the Bucks Community Neurological Rehabilitation team were beginning to express frustration that some clients were not progressing within rehabilitation, despite having sufficient physical and cognitive skills to do so. There was recognition of the need to explore the problem together.
A service evaluation was carried out using an Evidence Based Practice Model (Sackett D 2002, Evidence-based medicine: How to practice and teach EBM) to guide discussions and focus activity. The primary approach to rehabilitation at this time was a traditional ‘functional goal setting’ one, however there was a sense that this did not suit all clients referred to the service. As a result of the lack of progression, therapists were left with the feeling that they were not good enough, or did not have adequate skills. In addition it was felt that some clients were experiencing emotional and psychological difficulties which were not necessarily being addressed - and created a barrier to moving forward. Therapists acknowledged that their therapy was not always efficient.
Three questions were created to be addressed over the course of the service evaluation project:
1. Why do these clients not progress?
2. What skills do we need to identify and draw out readiness to change?
3. How do we provide the right therapy to the right client at the right time?
Carrying out searches provided limited evidence related to motivation and progressive neurological conditions. The team did however acquire information on the following factors that hinder and promote behaviour change:
- health belief models
- behaviour change models
- action to change process models and specific skills
- motivational interviewing
- acceptance and commitment therapy.
Over the course of the four year project, the team began to understand that both as individual clinicians and a service as a whole, they needed to think differently about the service provided to clients with neurological conditions. They began to recognise that often clients would enter the service with some degree of emotional and psychological difficulty. These difficulties could mean that a client is not ready to move forward with rehabilitation at all - or that they can move forward and change but to do so would require an alternative type of engagement. This different approach would firstly recognise apprehension and ambivalence to change, and subsequently be able to explore this in order to approach therapy in way that facilitates opportunities for engagement.
All of the therapists at the Bucks Rehab Service learnt skills in motivational interviewing. This is an engagement skill, which enables clients to explore ambivalence to change. Motivational interviewing is one of many different coaching techniques, used within a behavioural change approach.
The team were also able to appreciate the concepts around acceptance and commitment therapy. An acceptance and commitment therapy group has started for clients who despite coaching, are still struggling to move forward with ‘living life well’ with their neurological condition.
Working on this evaluation project as a whole service, has benefited the team enormously. Using the evidence based practice model as a framework enabled every member to ‘buy into’ the project and enabled maintenance of focus and a clear direction. Training in motivational interviewing was delivered to the whole service, in order that clinicians could learn and practise new skills and support each other through the journey. All members of the team have been open minded and embraced a new way of working for the benefit of the client group.
Finally the team produced a series of new pathways that clients can travel along based upon their presentation, enabling more versatility within the service and ultimately assisting the team to adjust their approach to the client. We believe that this model makes for a more efficient and effective service. Ultimately we are receiving positive feedback from clients, mostly associated to feeling listened to and understood for the first time in their journey!
MS in the Media
17 May 2019
- Statin has potential as SPMS drug
- EastEnders MS storyline
My Vespa adventure for the MS Trust
13 May 2019
For his next fundraising adventure, our supporter Nick Jolly will be riding 2,500 miles to Hungary on his Vespa scooter. He tells us about the inspiration behind his challenge.
"When you lose something, it makes you appreciate what you have"
13 May 2019
Danielle MacGillivray stars in our new film, Danielle. Here she tells us about her MS diagnosis, why she wanted to share her story in the film and learning to "appreciate the little things" every single day.