DOI: https://doi.org/10.21203/rs.3.rs-1606031/v1
Background: Impaired self-awareness (i.e., lack of insight) is experienced by most individuals after a moderate to severe traumatic brain injury (TBI). These individuals do not recognize their abilities and limitations which can negatively impact daily life and function. Although there are evidence-based approaches to improve self-awareness after TBI, it is not known how clinicians respond and address this impairment in an inpatient rehabilitation setting.
Objective: To examine how clinicians report, assess, and provide intervention for impaired self-awareness after TBI.
Methods: A retrospective chart review was conducted on interdisciplinary rehabilitation clinician entries for individuals with TBI (n=67) who received inpatient rehabilitation within a five-year period (2014-2019). A reflexive thematic analysis approach was used to analyse the data.
Results: Three themes were generated to explore clinician responses to their clients’ impaired self-awareness: 1) ‘recalling and understanding’ described clinicians observing client behaviours and expressions of self-awareness, 2) ‘applying and analyzing’ identified clinicians providing relevant tasks and advice to clients, and 3) ‘evaluating and creating’ described clinicians actively interacting with clients by providing feedback, guided prompts, and a follow-up plan.
Conclusion: Clinicians described varied responses to clients’ impaired self-awareness after TBI. Findings may help to develop research priorities and integrated knowledge translation initiatives to increase evidence-based practice for impaired self-awareness after TBI.
Moderate to severe traumatic brain injury (TBI) can alter a person’s physical ability, cognitive function, and behaviours(1, 2) An individual may encounter issues with balance, memory, or fatigue, causing long-term challenges that affect community re-integration and participation (3–5). These issues often persist and can lead to life-long physical, cognitive, and psychological consequences (6). Many individuals with TBI experience impaired self-awareness after TBI (7). Self-awareness is conceptualised as a person’s knowledge of their abilities and limitations (8). Estimates of up to 97% of individuals with moderate to severe TBI have displayed decreased self-awareness (9). The Dynamic Comprehensive Model of Awareness (DCMA) proposes self-awareness as having two components: offline awareness or the knowledge one has prior to the task (metacognitive knowledge), and on-line awareness, the ability to self-monitor and modify behavior during and after a task (8). The DCMA postulates a dynamic relationship between the offline and online components, and together these concepts explain how disruptions in self-monitoring processes and metacognitive knowledge can influence an individual’s perception of their abilities when completing a task (8). This can result in behaviours such as exhibiting poor judgement, creating unrealistic goals, and choosing to participate in activities beyond their capabilities (7, 10, 11). Deficits in self-awareness are particularly challenging to address during rehabilitation as individuals do not recognize their limitations and therefore may not engage in therapy or use compensatory strategies (10, 12, 13). As such, these individuals can experience difficulties in performing self-care activities, maintaining personal relationships, and sustaining a productive life (5, 14, 15).
Rehabilitation therapy for self-awareness has been identified as an essential component of multi-disciplinary rehabilitation for people with TBI (16, 17). In order to assess self-awareness, clinicians can use various comprehensive assessments (18). Assessing impairments in self-awareness through standardized or non-standardized assessments are considered a priority by clinicians and are important to promote successful outcomes (18, 19). There are evidence-based approaches to provide intervention for self-awareness after brain injury, such as meta-cognitive strategy training. This can include teaching individuals to monitor their performance, identify and correct errors, and to generate strategies (20) through interventions such as the use of video-based feedback (21) and pause-prompt praise (22, 23). The multi-context approach (24) aligns closely with metacognitive training and proposes strategies that promote generalization (transferring of skills form one task to another) to enhance functional performance (25). The key component to the multi-context approach is metacognitive training to facilitate self-awareness and self-regulation, as being able to monitor performance across different activities and contexts is crucial when generalizing skills (25). Notably, clinical practice guidelines recognize metacognitive strategy training as a priority to address in rehabilitation (19).
Despite valid and reliable outcome measures for self-awareness and the evidence-based interventions to improve self-awareness after TBI, there is limited implementation and uptake in clinical practice (26). One study (26) surveyed clinicians on the importance of self-awareness, and the use of instruments to assess impaired self-awareness. While this study reported high levels of assessment use, very few used assessments specific to self-awareness. There is a gap between evidence-based recommendations and current clinical practice, in part due to clinicians’ knowledge or skills in conducting assessments and providing interventions.
The objective of this study is to explore how clinicians are reporting, assessing, and treating self-awareness in inpatient rehabilitation settings in British Columbia, Canada. By conducting a chart review of clinician responses to clients with moderate to severe TBI and analysing qualitatively, this study aims to understand the behaviours and responses of clinicians when addressing self-awareness.
A retrospective chart review was conducted, using medical records of clients who received rehabilitation from GF Strong Rehabilitation Centre in British Columbia, Canada. Ethics approval was obtained by the Research Ethics Board of the University of British Columbia. Given the study methodology, informed consent was waived by the ethics committee. The data are reported using the COnsolidated Criteria for REporting Qualitative research (COREQ) (27).
A convenience sample of medical records of 67 clients were obtained from GF Strong Rehabilitation Centre, ranging from the years 2014 to 2019. Inclusion criteria for medical records were clients: 1) with a moderate to severe TBI, 2) aged over 19 years, and 3) receiving in-patient care. Authors AC and RT reviewed the medical records and extracted comments written by clinicians of different disciplines regarding the client’s self-awareness. Comments were extracted if they made statements about assessments, interventions, behaviours, or recommendations relating to a client’s impaired self-awareness.
All authors of this study were female. The authors who collected data, AC and RT, were a masters’ and undergraduate students, enrolled in a clinical graduate program and a bachelor’s program respectively. Author RM is a graduate research student while author JS is an academic researcher. All authors were situated at the University of British Columbia and have previous research experience.
A reflexive thematic analysis was used to generate themes (28). An inductive approach was applied, using the five phases: 1) familiarization with the data, 2) generating initial codes, 3) generating themes, 4) reviewing potential themes, and 5) defining and naming themes. First, author RM reviewed researcher interpretations of the clinician comments by authors AC and RT. Second, initial codes were generated using latent coding, hence enabling researcher RM to play an active role in the interpretation of each code. Third, three themes were generated as codes were clustered together, with the themes revised overtime. Last, all themes were named to acknowledge the three different ways in which clinicians address their clients’ self-awareness.
The research team employed a trustworthiness strategy which involved multiple researchers in the data analysis process (29). After each coding stage by author RM, the other authors of this paper provided input and reviewed the codes and themes, hence providing different perspectives about the data. An iterative process was applied throughout the analysis process as the themes were developed.
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).
|
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)
|
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.
This study identified three themes that explore how clinicians address self-awareness in a rehabilitation setting: ‘recalling and understanding’, ‘applying and analyzing’, and ‘evaluating and creating’. All three themes of clinician behaviours indicate the key role of conducting assessments and providing interventions for self-awareness after TBI. Findings provides insight to the varying types of responses and differing degrees of understanding of evidence and implementation.
The importance of observation was evident in the theme of ‘recalling and understanding. By observing a client’s task performance, clinicians target a client’s online awareness that is activated during a performance (32). This is essential as to choose the best treatment plan, clinicians need to recall relevant knowledge and understand whether clients can self-monitor and adjust their behaviour accordingly. However, using this form of assessment is not common as an online survey identified only 5.5% clinicians who assess self-awareness after a brain injury by using unstructured observations (26).
With the second theme ‘applying and analyzing’, clinicians moved beyond simply describing the behaviours or stating the client’s self-awareness by providing a descriptive account about their session and reporting on the task and advice delivered. Clinicians facilitated occupation-based sessions aligned to client-based goals (e.g., driving skills, cooking tasks, work-oriented activities). Clinicians’ reports within this theme align to research indicating that selecting tasks that correspond with the clients’ personal goals help to improve participation and motivation during rehabilitation resulting in improvements in self-awareness (33, 34). The clinician comments indicate an attempt to identify barriers that the client faced and offer task-specific advice and direction. However, research suggests that employing occupation based- metacognitive strategy training may be more effective than directing clients to adjust their behaviour, as administered by the clinicians with this theme (35). Additionally, the use of techniques such as self-monitoring, self-correcting, and self-evaluating may guide the client to clearly associate this strategy with functional gains (36). This aligns with the DCMA, as this model offers an occupation-based explanation for self-awareness, hence improving one’s awareness during a performance can result in improvements in their metacognitive knowledge (8).
With the third theme, ‘evaluating and creating’, clinicians actively interacted with clients by providing verbal feedback, encouraging use of strategies, and exploring external resources to facilitate improved self-awareness. Clinicians in this theme primarily used verbal feedback within an occupation-based approach. Research suggests that additional forms of feedback (e.g., video-based feedback) can add to the efficacy of feedback interventions (21). This theme was most aligned with clinical practice guidelines on cognitive rehabilitation as all the guidelines reviewed suggested behavioural interventions, the use of feedback, and group therapy to address self-awareness and insight (37).
The clinician-client relationship is an important element in rehabilitation and is highlighted in all themes. With the theme ‘applying and analyzing’, the clinician-client relationship appeared strained as clients often denied or rejected the advice of the clinician. Medical records notes within this theme describe the clinician as a director with limited client-centred engagement. The client’s defense mechanisms, as described by the clinicians, may be an indication of the need of more support from the clinician, as they may not be ready to understand or accept the reality of their impairments which aligns with previous literature (14, 38, 39). Self-awareness can be positively associated with depression and negatively associated with self-esteem for individuals with TBI (40). As such, impaired self-awareness can be a protective mechanism, as being aware of the post-injury reality may threaten their sense of self and cause emotional distress (41). In this way, it is even more important to build a positive therapeutic relationship between the client and their clinician as they engage in activities that may threaten self-concept and heighten defensive reactions (42). Selecting tasks that are ‘emotionally neutral’ at the beginning can aid in creating a safe environment for the client, as clients may not place a high value on such tasks (8).
There were limited documented assessments of self-awareness assessment use with clinicians reporting on client’s levels of awareness, task-specific challenges, and interventions for self-awareness. This aligns with the findings of an online survey study, as 77% of clinicians reported not using instruments to assess self-awareness after a brain injury (26). This may be due to factors such as time constraints (43) or lack of knowledge. The time needed to administer a self-awareness test depends on the participant, as clients who have a higher level of cognitive fatigue may need a longer period of time to complete the assessment. Clinicians may not have required training to address self-awareness during rehabilitation, as demonstrated in a survey study in which clinician identified self-awareness as the one of the top three preferences for professional development and the leading barrier in providing successful rehabilitation to clients (16).
Research indicates that TBI rehabilitation is most effective if delivered through a holistic, multidisciplinary team (16, 44). This study identified 17 different clinician disciplines that interacted with clients who experienced changes to their self-awareness. This interdisciplinary rehabilitation structure is essential to assess and treat impaired self-awareness, as it affects all aspects of an individual’s rehabilitation progress, ranging from cognitive issues to their physical abilities (45). The biopsychosocial model of awareness indicates there are interacting factors at a biological, psychological, and social levels that can influence individuals’ presentation of self-awareness deficits (46). For example, individuals may display denial, minimisation, or avoidant coping strategies, which are the result of defensive mechanisms at the psychological level. These individuals may benefit most from psychologists or counsellors to understand the meaning of the impairments and denial reactions (47). Alternatively, an individual that displays impaired self-awareness on community re-integration tasks (e.g., crossing the road) may benefit from occupational therapy intervention to facilitate metacognitive strategy training within an occupation-based framework. As a result, having an interdisciplinary framework emphasises the idea of a holistic need in rehabilitation.
The main limitation in this study was the possibility that the clinician report in the client medical record differed from what occurred in the session. Clinicians may have been less descriptive in documentation within medical records due to factors such as time constraints, which may not reflect their behaviour and responses in the session itself. For example, specific details about type of activities, observations, or feedback provided may not have been included in the medical records in some entries. This can be due to the fact that clinicians may be addressing impaired self-awareness informally through the completion of other tasks and activities where self-awareness may not have been the focus, resulting in unreported accounts of impaired self-awareness. In addition, changes in clinicians due to external factors (i.e., vacation, sick days, etc.) may result in missed reports of impaired self-awareness in the medical records as some clients may rely on compensatory strategies to conceal their deficits. However, these findings can provide key information for future researchers to develop a longitudinal observational study of clinician behaviour when engaging with clients with impaired self-awareness.
This study identified three themes using a reflexive thematic analysis approach that illustrate clinicians’ responses to self-awareness behaviours within an inpatient rehabilitation setting. These findings may facilitate the implementation of self-awareness assessments and interventions in rehabilitation settings.
Consolidated Criteria for Reporting Qualitative Research (COREQ)
Dynamic Comprehensive Model of Awareness (DCMA)
Motor vehicle accident (MVA)
Traumatic Brain Injury (TBI)
Ethics Approval and Consent to Participate
Ethics approval was obtained by the Research Ethics Board of the University of British Columbia. All methods were performed in accordance with the relevant guidelines and regulations outlined in the ethics application. This study used a retrospective chart review methodology; therefore, informed consent was waived by the ethics committee.
Consent for Publication
Not applicable.
Availability of Data and Materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
Competing Interests
The authors declare that they have no competing interests.
Funding
This study was funded by the Hampton New Faculty Grant at the University of British Columbia.
Authors’ Contributions
AC and RT collected the data from medical records with oversight and supervision from JS. RM analyzed, interpreted, and coded the data. RM consulted with JS, AC and RT regarding themes. RM is the major contributor in writing the manuscript. All authors read and approved the final manuscript.
Acknowledgements
Not applicable.