The expectation of patients to improve was based on the assumption that patients would move through several phases of rehabilitation, which were: pre-admission; admission and early-stage rehabilitation; main body of rehabilitation; and finally, end-stage rehabilitation with a view to discharging a patient from the ward. This movement, or pathway, reflected the changes patients underwent as they continued to improve in the areas with which they had previously struggled prior to admission. It outlined what was generally believed to be an average or ‘normal’ stay in hospital to receive rehabilitation.
A description of the model four phases of rehabilitation will provide a theoretical blueprint of what could be potentially achieved from receiving professional input during a stay in hospital. The remainder of this chapter will describe the actual experiences of patients and will demonstrate how a fall shifted the trajectory of their expected pathway through the
107
rehabilitation process to such an extent that patients were unable to achieve their optimal level of independent functioning (WHO, 2009).
The sources of information for the four phases included discussions with staff during learning group sessions and insights gained from previously working as a clinician on the two rehabilitation wards.
4.3.1 Pre-admission phase
It was beneficial to know the pre-morbid state of functioning of patients prior to admission so as to give an informal baseline measurement (i.e. the beginning of the pathway). Due to a variety of issues relating to social circumstances, mobility and health, patients were usually identified to be struggling within the community. A health or social care professional had assessed a patient and had regarded them to be at risk, primarily due to a reduced ability to perform functional activities safely. These patients were either not as independent as they once were (or could be), or they required more assistance from carers/relatives.
One of the key factors that needed to be established was if their current state of functioning increased the likelihood of a fall occurring. Therefore, in an effort to pre-empt an incident, such as a fall, patients were admitted into hospital to receive help from health and social care professionals to regain a safe level of independence, including the arrangement of the provision of carers, equipment, home adaptations, or even a different place of living (e.g. a home with easier access or discharge to a care home etc.). Patients were considered to be at their lowest level of ability at this point in time and vulnerable to deteriorating further if their circumstances did not change.
4.3.2 Admission and early-stage rehabilitation phase
The process of admitting patients into hospital was always a busy time, and staff reported the need to perform many duties that included administration/clerking patient details, baseline assessments, screening for falls risks, manual handling assessments, and identifying other patient needs. This was a time for staff to obtain an initial insight into the capabilities of each patient and to determine patients’ manual handling, mobility and falls
108
risk status. It was also a time for patients to acclimatise themselves to the wards and to gain a better understanding of why they were there (ACSQHC, 2009). Alongside this process was the potential to set goals that would provide direction to patients’ rehabilitation.
However, patients’ understanding of the purpose of rehabilitation and goal-planning with ward staff were two leading issues that were identified from the research as being important factors affecting early progress.
After discussing issues with participants related to admission and the early-stages of rehabilitation, it seemed as though patients and staff underwent a period of learning whereby patients expressed their expectations about the service in terms of what they wanted and needed, and staff explained what could actually be provided. This process took the form of both formal and informal interactions between patients and staff which ranged from casual conversations to weekly team meetings and (infrequent) goal-planning sessions.
This was a precarious time for patients and staff as neither had a clear understanding about each other. Staff believed that patients were at their highest state of risk at this early phase of rehabilitation due to the reasons they were admitted. Of equal importance was the fact that patients were now in an environment which brought a whole new set of potential hazards (Titler et al., 2011; Hignett and Masud, 2006) and a different pace of living. It was only natural that patients’ beliefs and attitudes would be in a state of flux and were more susceptible to being shaped by aspects of hospital care (Kloseck et al., 2008). Admission and early-stage rehabilitation was a time when the beliefs and attitudes of patients began to change as their pre-conceived ideas of hospital were either reinforced or altered altogether, in accordance to how well they were integrated into the rehabilitation environment.
4.3.3 Main body of rehabilitation phase
Based upon direct clinical experience and observation of the two rehabilitation wards involved in this study, patients had become more settled into hospital and their rehabilitation programme after the first few weeks since admission. Whether formal goals had been set or not, patients had generally made good progress as demonstrated by less dependence on staff to provide assistance for mobility and functional activities. Throughout the main part of rehabilitation (usually from 2-6 weeks) patients had shown improvements to their overall
109
functioning and showed increasing signs of regaining their independence. For example, in the first 1-2 weeks, a patient might have required a mechanical standing aid to help them to transfer from one position to another, whereas after several weeks in hospital, the same patient would have likely progressed onto the use of some form of mobility aid to help transfer, with or without assistance from staff. A week or two more, usually no assistance would be required, perhaps only supervision. Naturally, progression depended on many factors, including a patient’s medical status, pre-existing conditions, motivation, adherence to therapy etc. However, on the whole, patients demonstrated a vast improvement in comparison to when they were first admitted onto the wards, and continued to show potential in achieving greater independence with further rehabilitation.
4.3.4 End-stage rehabilitation and discharge
The last few weeks spent in hospital were the final stages of rehabilitation. Depending on the needs of the patients, staff would be involved as much as necessary. For example, the ward therapists would continue with mobility and activities of daily living (ADLs) practice so that patients regained as many of their pre-morbid skills/abilities as able. By this time, the majority of patients on the two rehabilitation wards had become independent and only required minimal input from staff. Typically, the factors preventing patients from returning home were the completion of adaptations made to the home, the provision of equipment, or awaiting social care input.
It was recognised by staff, and certain patients, that there was a difference between being independent and achieving ‘optimal’ independence. The former was when a patient had initially attained a level of functioning that meant that staff had to provide minimal supervision or prompting only. No physical assistance was required yet staff continued to exercise caution when patients performed functional activities. Patients had entered a new stage of their overall progress, although staff still considered this to be a fragile time with possible relapses, potentially caused by overconfidence or patients reverting to compensatory strategies and behaviours. Optimal independence came as a result of continued adherence to rehabilitation interventions, providing that practice of good, efficient technique was consistent (Raine et al., 2009). This was a ‘higher’ form of independent functioning whereby patients required no assistance, supervision or prompting from staff.
Patients who had achieved this degree of capability were clearly appropriate to be
110
111
discharged home as they were regarded to be safe and in no further need of professional input.
Discharge planning began in the final stages of a patient’s hospital stay. Members of the health and social care team would discuss the patient’s progress, often with the patient and relatives present. The most appropriate place of living would be decided upon (usually patients’ own homes), as well as if any further care needs or equipment had to be arranged (Reed et al., 2002). Only when patients were considered to be safe were they discharged home, although the concept of being ‘safe’ was always applied on an individual basis. For example, a patient who was fully independent with mobility and ADLs was considered safe to go back to their own home, whereas another patient who did not make as much progress in hospital and was still dependent on others for support would have been “unsafe” to go back to their own home, yet would be “safe” in an alternative environment, such as a residential or nursing care home. Therefore, the health and functional status of patients in the latter stages of rehabilitation largely determined when, where and how they were discharged (Aditya et al., 2003).