From the 67 medical records reviewed, 301 comments were extracted from various disciplines with the majority of comments coming from occupational therapists (Table 1). During the data collection process, authors AC and RT recorded their own interpretations of clinician comments. The client’s demographic data, duration of stay, and cause of injury were also collected (Table 2).
Table 1
Number of comments from disciplines
Clinicians
|
n (%)
|
Occupational therapist
|
103 (34)
|
Nursing
|
56 (19)
|
Speech language pathologist
|
43 (14)
|
Physical therapist
|
28 (9)
|
Medical doctor
|
27 (9)
|
Social worker
|
17 (6)
|
Physical medicine and rehabilitation
|
12 (4)
|
Recreation therapist
|
5 (2)
|
Psychology
|
3 (1)
|
Other
|
7 (2)
|
Notes. Other = Vocational Therapist (1), Care Management (1), Medical Representative (1), Dietician (1), Psychiatry (1), Respiratory Therapist (1), Team Rounds (1)
Table 2
Client demographics from medical records
|
Clients
|
Age (mean (SD))
|
42 (16)
|
Male (n (%))
|
50 (75)
|
Cause of injury (n (%):
|
|
Motor vehicle accident (MVA)
|
40 (60)
|
Fall
|
10 (15)
|
Sports-related injuries
|
8 (12)
|
Accidents
|
5 (8)
|
Other
|
4 (6)
|
Notes. Other = Assault (1), Stab wound (1), Self-injury (1), Unknown (1)
Three themes were identified based on the qualitative analysis of medical record entries, corresponding to clinician responses to clients’ behaviours of self-awareness: 1) recalling and understanding, 2) applying and analyzing, and 3) evaluating and creating. These themes are described below with supporting quotes.
Recalling and Understanding
With this first theme, clinicians adopted an observer role in response to the client’s behaviours relating to self-awareness. Clinicians made statements about their observations of clients’ behaviours and levels of self-awareness, and at times provided descriptions of the degrees of self-awareness impairments. For example, after a session with client 15 (male, age 61) who sustained a TBI through a fall, the physical therapist noted, ‘limitations in rehab: decreased insight, motivation, rigid thinking’. With respect to another client 17 (male, age 48) who sustained a TBI through an MVA, the physical therapist stated that the client did not co-operate during their session, ‘client increasingly focused on wanting to go home and not being 'forced' to do things’. Clinicians with this observer role often provided medical record entries with simple diagnosis or descriptions of the client’s level of self-awareness. For example, speech language pathologist observed their client intact self-awareness, reporting the client’s acknowledgment of speech problems and the strategies available to help. As such, they noted that client 14 (male, age 24), who sustained a TBI through an MVA, was ‘aware of speech difficulties and can also state strategies, however not using strategies consistently’. Within this theme, clinicians reported factually with some descriptive accounts.
Applying and Analyzing
The second theme consisted of clinicians who moved beyond observing the issue by describing the task or activity that in which the client displayed impaired self-awareness, and the subsequent advice they provided the client. A speech language pathologist of client 7 (female, age 61) who sustained a TBI due to a collapse, indicated that despite displaying cognitive-communication impairments during a task, the client was unconcerned about these difficulties. The client’s vocational therapist stated their attempts to mitigate these challenges by offering ‘a draft alternate return-to-work plan with longer timeframe than planned 3-week schedule’. However, the client declined this as she did not feel she required more time before returning to her vocational role. Clinician responses within this theme also included descriptions of the context of the self-awareness behaviours. The physician of client 5 (male, age 48) who sustained his TBI through an MVA expressed concern with the client’s sugar levels:
Client stated he has been doing own sugar adjustment for years, can do it himself. Writer reviewed history of TBI, determined client may be at some risk but client feels able to manage at home safely.
In a different session, the nurse observed the client being unable to generate a reading using the glucometer, The nurse reported the ‘client subsequently refused to make a second attempt despite multiple requests to demonstrate competence with this tool’. In both instances, the clinicians reported that the client presented with avoidance and denial, potentially as coping strategies, in their task performances and described their advice to the client regarding their behaviour of impaired self-awareness.
Evaluating and Creating
Clinicians actively engaged with the client within this third theme, explicitly outlining a comprehensive description about the session, the client’s portrayal of their level of self-awareness, and a follow-up plan. The psychologist of client 64 (female, age 28) who sustained a TBI through an MVA, indicated the abilities they observed and their plan to incorporate resources for the client outside the rehabilitation centre:
Sessions have focused primarily on processing emotional responses to post-injury changes in functioning, relationships, and sense of self. She shows excellent insight into her affective experience and engaged well in sessions. Writer has assisted client in further developing awareness of her emotional responses …writer will follow up with client regarding available mental health resources in her home community and nearby.
Another session with a speech language pathologist of client 66 (male, age 21) who sustained a TBI due to a stab wound noted the areas that the client experienced difficulties. They assessed the client’s awareness regarding these deficits, incorporated their reasons behind their evaluation, and described a plan to consult other clinicians:
Most noted difficulties with visual memory, new learning and prospective memory and spatial memory…Ct noted to overestimate abilities/performance pre and post assessment…Discussed strategies of repetition, talking aloud, and making notes. Liaised with SLP and MD about client's fatigue and low sustained attention in sessions. Plan - focus on assessment of home and community tasks next week.
Within this theme, the clinicians reported their active engagement with the client, the behaviour of the client that helped formulate the advice given, and the next steps needed to help the client.
Relating to Theory
These themes are situated within the revised version of Bloom’s Taxonomy (30) which emphasizes the importance of creating rather than synthesizing, higher levels of cognitive skills, and shifts towards more dynamic classifications. The revised taxonomy proposes a progressive cognitive hierarchy which encompasses six levels: remember, understand, apply, analyze, evaluate, and create. Utilizing this encourages deeper learning and the generalization of skills and knowledge to a variety of tasks and contexts (31). The themes are framed and described within this learning theory as health professionals who aim to develop and achieve high level skills and function require deeper cognitive processing including critical thinking and judgement (31). This can explain the level of learning, implementation of learning, and provide evidence for knowledge translation at each stage of clinician behaviour.
The findings represent three different ways that clinicians reported observations and interventions related to self-awareness that they encountered in their practice. It shows that a lack of self-awareness and insight is recognised by an interdisciplinary team of clinicians and is addressed by each clinician. The first theme describes the observant role of a clinician, in which general comments about the client’s self-awareness are made. This is aligned with the concepts of remember and understand, where clinicians recognize, describe, and summarize what is being observed. This is considered a foundational cognitive skill that represents the beginning stages of learning behaviour. The second theme explores clinician comments that move beyond the general identification of self-awareness and include descriptions of the tasks the client performed, and the advice provided. This theme is described by the concepts apply and analyze which utilizes the clinician’s skills to mitigate challenges, and to further explore and infer the reasoning behind the presentations of impaired self-awareness. Finally, the third theme represents clinicians who actively engaged with clients, providing detailed descriptions of the sessions as well as a follow-up plan. At this stage, clinicians are achieving higher levels of critical thinking and judgement through evaluation and recommendations to create a plan of action for their client.