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The theme of collaboration included the subthemes ‘control of the session and the environment’, ‘managing inputs from different stakeholders’ and ‘power dynamics’. These sub-themes were influenced by the environment and the level of rapport developed. Collaboration between the therapist and the PWA could establish conditions which enhanced functional communication learning. Collaboration helped to develop more positive emotions and establish rapport, which empowered and motivated PWA.

5.5.1 Power dynamics

HCPs pointed out how power dynamics between PWA and HCPs differed between ward- and home-based contexts. For example, HCP 21 discussed how HCPs put themselves in a position of power in hospital settings. She shared how disempowered she felt while in hospital as a patient and how much worse she imagined this experience would be without a medical background. HCPs felt that being in the PWA’s home shifted this power balance, with PWA more empowered in the home context.

‘I think patients often particularly maybe more elderly patients on a hospital ward look at the staff as the authority figures

They will kind of meekly go along with what people say and staff aren’t always very good at asking the patient what they really want to do

Once they are in the home environment they are a lot more comfortable and a lot more vocal about what is important to them or not

What they want to do and what they don’t want to do Rapport Environment Rehabilitation materials Emotions Rehabilitation procedures Collaboration

They are making more decisions about their care which is different to when you are in hospital which is nice’ (HCP 20)

The HCPs acknowledged the presence of a different dynamic in home-based rehabilitation. This change in power dynamics could sometimes be difficult for the HCP as they needed to be flexible with their rehabilitation sessions. The HCPs felt it was important for them to be open-minded in rehabilitation and to be willing to adapt to the client’s wishes and views. Despite it sometimes meaning that the HCPs needed to adapt, they felt it was important as it helped to centralise the PWA and their views.

‘A different dynamic to working in the hospital environment because obviously you are kind of in their environment and you have to adapt to their life in a way and how they work in their own home’ (HCP 20)

5.5.2 Control of the session and the environment

PWA were empowered to control the rehabilitation sessions more in their own home environment and the HCPs felt that it was very important that this shift occurred. This change in control from HCP to PWA sometimes did occur organically through the shift in power dynamics and ‘ownership’ of the environment.

‘Em because my experience working in the ward Em patient can be more em frustrated

More frustration, helpless on wards

Em not being able to go out, not being able to going to the toilet by themselves Can feel a bit helpless but

Eh in the home setting they feel they are more in control’ (PWA 13)

Joint control was also established through establishing rapport and a conscious choice on the part of the HCP to capitalise on a person’s environment in assessments and rehabilitation activities. Collaborative goal setting through listening to and valuing the PWA’s opinion also helped to shift the balance of control.

‘It’s their therapy session and if they want to

Try to communicate that they have had problems logging I don’t know onto their own computer or they have had problems trying to identify something in their fridge then that is just as important as it is important to them and it’s practical to their everyday life so You can eradicate that and sort it out and give them some strategies and help them with that you are helping them with their stress aren’t you and

Trying to smooth it out again for them so it is not a massive problem’ (HCP 15)

There were times when HCPs found it difficult that they could not exert more control over the session; for example, when they felt that changes to the environment could have been beneficial to the rehabilitation activity, such as the removal of distractions in the home like

noisy pets and family; difficulties manoeuvring in tight spaces; or not being able to change the positioning of furniture.

5.5.3 Managing inputs from a range of stakeholders

HCPs’ involvement and management of families in the ESD context could be a barrier to or a facilitator of learning. Families were important to the PWA, making them more comfortable in their home and acting as an important resource and support in the rehabilitation process.

‘Em but I also think that it is nicer in terms of their rehab because you have got their families or carers or friends or important people in their life are around who you can involve in their treatment’ (HCP 20)

However, managing families could also pose a challenge to HCPs in the home environment as HCPs did not want to appear rude, but also wanted to ensure that they were listening to the PWA and their wishes and not the families’. Due to the rebalancing of power in the home environment, where the PWA and their family held more power, it could sometimes be difficult for the HCPs to manage the families’ input in the sessions. The HCPs also wanted to respect the family and not be insensitive to them either.

‘Em but I think it’s difficult when you’ve got a family member who is probably jumping in all the time and you are trying to communicate with the patient rather than those that are involved with them and that can be tricky depending on how severe it is’ (HCP 10)

Figure 9. Connections between themes: collaboration

Collaboration Rehabilitation

materials

Rapport Environment