Occupational performance coaching for stroke survivors (OPC-Stroke): Understanding of mechanisms of actions

Abstract

Introduction

Occupational performance coaching modified for stroke survivors is a promising new intervention to improve occupational performance post stroke. In the intervention, following client-centred occupational goal-setting, clients are led through strengths-based problem-solving and experimentation. Emotional support, individualized education and goal-focused problem-solving are hypothesized as key elements. Examination of clients’ experiences is necessary to better understand how occupational performance coaching modified for stroke survivors works, and improve its potential effectiveness.

Method

A descriptive qualitative study was embedded in a pilot randomized controlled trial. Semi-structured interviews were completed with seven participants in the treatment arm who received occupational performance coaching modified for stroke survivors. Qualitative content analysis was used for analysis.

Findings

Three categories were identified related to participants’ experiences of occupational performance coaching modified for stroke survivors: (a) the coaching was helpful; (b) the coaching provided opportunity for insightful reflection and (c) a different approach was preferred. Findings also lend support to the critical role of hypothesized key components and theorized mechanisms of action, and demonstrate the overarching role of the therapeutic relationship and the contribution of personal characteristics.

Conclusion

The revised theoretical understanding of occupational performance coaching modified for stroke survivors provides a valuable framework for communicating the actions that occupational therapists take in enabling occupation and emphasizes the role of the therapeutic relationship in client-centred approaches to improving occupational performance post stroke.

Keywords

Client-centred therapy coaching occupational therapy psychological theory social participation stroke rehabilitation

Introduction

Approximately two-thirds of stroke survivors in the United Kingdom leave hospital with a disability (Stroke Association, 2017). Up to 80% of stroke survivors report facing challenges participating in personally valued activities; that is, occupational performance challenges (Public Health Agency of Canada, 2011). The focus of occupational therapy is on enabling occupational performance. However, without readily communicated processes for enabling occupation, occupational therapists may have difficulty maintaining an emphasis on participation in activities that are valued by the client within health systems focused on medical issues and basic functional concerns (Egan et al., 2010). Better understanding of how occupational therapy interventions enable occupation would help occupational therapists explain their work, and allow refinement of these interventions.

Occupational performance coaching modified for stroke survivors (OPC-Stroke) is a promising intervention to enhance occupational performance post stroke. OPC-Stroke is a complex intervention adapted from occupational performance coaching (OPC) (Graham et al., 2010), whereby a therapist coaches individuals to solve problems critical to the achievement of self-identified occupational performance goals. OPC was initially developed in New Zealand for parents of children with occupational performance challenges and has been tested in Canada (Hui et al., 2016), Germany (Kufner and Scholz-Schwaerzler, 2012) and Iran (Kahjoogh et al., 2017). Theoretically, OPC draws from family-centred practice, occupation-centred practice and an enablement perspective, as well as the cognate areas of coaching, solution-focused therapy and adult learning theory (Graham et al., 2009). Intervention begins with parent goal-identification and works to problem-solve solutions rather than address impairment.

In the development of OPC-Stroke, modifications were made to OPC to make the intervention appropriate for use with people who had experienced stroke. Specifically, the concept of social support was used instead of family-centred practice, to broaden the way in which social roles, social systems and supports are considered and to allow the stroke survivor to determine whether he or she wanted to include significant others in goal-setting. In addition, while not focusing on treatment of impairment, OPC-Stroke allows for the possibility of improvement in personal capacities, such as improved hand coordination or cognition, given the potential for recovery after stroke (Wittenberg, 2010). Following application of OPC-Stroke in pilot case studies (Kessler et al., 2014), theoretical mechanisms of OPC-Stroke were identified.

Drawing from humanism (Ashley, 2010) and cognitive and behavioural sciences (social cognitive theory (Bandura, 1977), goal-setting theory (Locke and Latham, 2002) and solution-focused therapy (Berg and White, 2010), adult learning (Collins, 2004) and metacognitive theories (Papaleontiou-Louca, 2008)), OPC-Stroke includes key components of emotional support, individualized education and goal-focused problem-solving. Hypothesized actions are as follows. Provision of emotional support creates a milieu of trust, respect and collaboration for individualized education and goal-focused problem-solving (humanism, adult learning). Metacognitive strategies of consciously reflecting, planning and monitoring are used to facilitate both goal-setting and problem-solving (metacognitive theory, goal-setting theory, adult learning). Highly valued occupational performance goals are developed with participants, enhancing their readiness to engage in and assume responsibility for developing and testing out plans that are designed to promote success (goal-setting theory, social cognitive theory, solution-focused therapy). The experience of success in working towards goals is theorized to enhance goal commitment and striving and lead to the development of self-efficacy for future goal-setting and problem-solving (goal-setting theory, social cognitive theory, solution-focused therapy). The achievement of goals and self-efficacy to apply new knowledge and skills to future goals results in increased overall participation in valued activities (Kessler et al., 2014).

In a recent randomized controlled trial, eight people who had experienced a stroke participated in OPC-Stroke (Kessler et al., 2017). Each participant was seen by one of two occupational therapists who had at least seven years of experience and demonstrated strong interpersonal skills. The therapists received training in coaching principles and techniques, had access to an intervention manual, and were monitored during delivery of OPC-Stroke to ensure fidelity.

We sought to examine and refine our understanding of hypothesized mechanisms of action of OPC-Stroke through use of qualitative process evaluation (Moore et al., 2015). Research questions were as follows.

What is the experience of adults receiving OPC-Stroke?

Which components and processes of OPC-Stroke promote achievement of self-identified occupational performance goals?

Method

A descriptive qualitative study (Creswell, 2013) was embedded in a pilot RCT of OPC-Stroke. Quantitative findings are reported elsewhere (Kessler et al., 2017).

Population

Participants met the criteria for inclusion in the pilot RCT (Kessler et al., 2017). Specifically, they had been hospitalized following a first diagnosis of stroke; resided in a non-institutionalized setting; required no more than moderate assistance for communication, memory and problem-solving; were not currently receiving occupational therapy services; and did not have other degenerative neurological diagnoses or a concurrent major depressive or psychotic disorder. All participants received up to 10 1-hour sessions of OPC-Stroke delivered in-person by one of two occupational therapists in the participant’s home over a period of up to 16 weeks. The average number of sessions was 8.6, delivered in an average of 13.75 weeks.

Data collection

Semi-structured interviews were conducted with participants immediately post-intervention to gather information from their perspectives on intervention processes (interactions with the coach, goal-selection, problem-solving), what was helpful and not helpful, and expressed met and unmet needs. The semi-structured nature of the interview ensured information related to the research questions was gathered while allowing participants to elaborate on their experiences. Interviews were carried out in participants’ homes by a research assistant not involved in delivering the intervention. Interviews were audio recorded and transcribed verbatim for analysis.

Data analysis

Two approaches to content analysis, conventional and directed (Hsieh and Shannon, 2005), were used to address the two research questions. Conventional content analysis was used to explore the experience of research participants as this approach is considered appropriate when the purpose is to describe a phenomenon without using preconceived categories (Kondracki et al., 2002). Key thoughts or concepts were allowed to emerge from the data as codes. These codes were then sorted into categories, and dimensions based on relationships and linkages between the codes (Hsieh and Shannon, 2005).

Directed content analysis involves interpreting text through a systematic, deductive process of coding and identifying themes or patterns to examine credibility of a theoretical framework and inform its development (Hsieh and Shannon, 2005). Given the theoretical framework of OPC-Stroke is established and that understanding of participants’ experiences in relation to this framework were sought, directed content analysis was chosen to facilitate further development of the framework, specifically, the key ingredients and mechanisms of OPC-Stroke.

This analytic process began with development of a coding structure based on the theoretical understanding of OPC-Stroke. Operational definitions based on components and processes of OPC-Stroke were developed and reviewed by an auditor familiar with the research but not involved in the analysis (CJD; Hsieh and Shannon, 2005). This coding structure was used to increase the accuracy and consistency of coding (Potter and Levine-Donnerstein, 1999). Data that could not be coded within the initial coding structure were identified and analysed to determine if they represented a new code, or a subcategory or dimension of an existing code (Hsieh and Shannon, 2005).

Analysis began with independent coding by two coders (DK and KB) after all interviews were completed. Formative checks for consistency of coding (Potter and Levine-Donnerstein, 1999) were conducted following the first three interviews and then after all interviews were coded. Memos of discussions, decisions and changes made were noted in an audit trail (Hsieh and Shannon, 2005). Final categories, subcategories and dimensions were determined through an iterative process of review and discussion between the coders. Atlas.ti 7.5.2 (GmbH Scientific Software Development, 2014) software was used to facilitate coding.

During the analysis of the interviews, findings emerged that could not be clarified by the interview content and warranted a more complete understanding of certain participants’ experiences of OPC-Stroke. When this occurred, relevant taped intervention sessions were reviewed to examine the content of the conversation and sequence of events as the intervention progressed. This need for a deeper understanding was not anticipated when planning the study. Therefore, this analysis is considered post hoc.

Findings

Of the eight participants who completed the intervention, seven were interviewed. One participant was not available due to family circumstances. Notes from an exit interview with the participant who withdrew from the study were also considered. In the descriptions below, participants have been given pseudonyms.

Participants’ demographics are presented in Table 1. Quotes for one participant, Christine, are translated from the original French.

Table 1.

Qualitative participants’ demographics.

Pseudonym	Age (years)	Side of CVA	Stroke severity (discharge FIM)	Time since stroke (months)	Living situation	Employment status
Alex	59	Left	106	2	With spouse	Retired post stroke
Christine	69	Left	118	11	Alone	Retired pre stroke
Bev	65	Right	95	9.5	Alone	Retired pre stroke
Doug	51	Right	–	7	With family	Working full time
Lynn	85	Right	–	9	Alone	Retired pre stroke
John	64	Right	113	5	Alone	Retired pre stroke
Ken	64	Right	115	6	With spouse	Retired pre stroke

CVA: cerebrovascular accident; FIM: Functional Independence Measure (range = 18 (totally dependent) to 126 (totally independent)).

Participant experience of OPC-Stroke

The dimensions of categories that represent participant experiences are presented in Table 2, along with exemplar quotes.

Table 2.

Participant experience of OPC-Stroke.

Category	Dimensions	Exemplars
OPC-Stroke was helpful	Pleasant Personal time	‘It was enjoyable sessions’. (Alex) ‘It was a time I looked forward to, for me’. (Christine)
	Hope/motivation/ Focus for goal achievement	‘Hopeful about being able to […] do these things naturally […]’. (Bev) ‘I thought it really helped because I would try to do different things just to see that I could do it, you know? And it got you back into the mood of doing things’. (John)
	Different perspective	‘Well, she [Coach] tried to help me […] look at a different perspective, […] Okay I don’t have to do it all at once’. (Alex)
OPC-Stroke provided opportunity for insightful reflection		‘I would have done the same, what I did’. (Lynn) ‘It is something I might have been able to do myself’. (Christine)
A different approach was preferred		‘And I thought, “I’d rather have you work on my arm than to talk about this”. But that’s all right’. (Lynn)

Most participants reported that OPC-Stroke was helpful. They looked forward to the occupational therapist coach visits and found them to be a pleasant, personal time that provided opportunity for social contact. Some participants indicated that taking part in the intervention provided hope and motivation, and helped them to focus on their goals and achieve them sooner. Participants also commented that the coach provided a different perspective or way to think about achieving goals.

OPC-Stroke seemed to provide opportunity for insightful reflection. Participants expressed that the new perspective provided through the intervention of the coach helped them reflect on new ways of working towards their goals. A few participants, when reflecting on the intervention, conveyed confidence that they could have achieved their goals on their own. Such expressions of self-confidence seemed to have emerged as a result of reflecting on the intervention and on progress made towards achieving goals. For example, while stating that he likely would have achieved his goals without the coaching, Alex also commented on how the opportunity to reflect on his goals with the coach provided a different perspective.

These statements of confidence led the authors to consider whether the intervention had influenced goal achievement, or whether these participants would have achieved their goals without the intervention. Subsequently, tapes of the coaching sessions were reviewed looking for instances of communications that supported or refuted participants’ statements. These data revealed that participants reframed ideas and strategies that came from the coach during conversations around goals and plans. Participants felt responsible for and built on these strategies followed this reframing. For example, setting goals and then feeling accountable for actions to achieve these goals appeared to create stress for Lynn initially. She required gentle encouragement to take on small steps. As she progressed, she appeared to become more comfortable with integrating options presented by the coach, such as enlisting the help of a friend to help with organizing her home (Session 3).

One participant indicated a different approach was preferred, one that was more focused on remediation of specific motor impairments as opposed to achievement of occupational performance goals.

Components and processes of OPC-Stroke

The established coding framework included the categories of support, education, goals, goal-focused problem-solving and application to new goals. Subcategories and dimensions of categories and subcategories with exemplar quotes are presented in Table 3 and summarized below.

Table 3.

Experience of components and processes of OPC-Stroke.

Category	Subcategory	Dimensions	Exemplars
Support	Therapeutic relationship	Feeling connected	‘But you know, sometimes you gravitate and she was just a young woman that was very, very personable’. (Lynn)
		Trust	‘[I felt] very comfortable […] and I believe she was comfortable also’. (Christine)
		Collaboration	‘Her approach was one of, you know, I see your side. […] Let’s see what we can do and work together’. (Doug)
		Respect: active listening, sharing ideas, having fun, discussing current reality	‘She’s like a mirror. She’s reflecting what you’re saying, but yet she’s not afraid to say, “Well, what did you think about that? You’ve done that, but was that what you really wanted to do?”’ (Ken) ‘She would say good things, you know. And she had wonderful suggestions and she was willing to listen to my suggestions too’. (Bev) ‘We could laugh’. (Ken)
		Source of motivation: positive approach, feeling accountable	‘She was inspirational. She had a very positive approach’. (Bev) ‘She just would […] get you going by just asking one question…’. (John) ‘I said to myself, “She is coming tomorrow, I have to have something to show her”.’ (Christine)
	Emotional support	Active listening: showing interest, being receptive to ideas	‘But she listens a lot so she – the fact that she’s listening is very important’. (Ken) ‘She was receptive to how I felt about doing the various exercises, and my suggestions on different exercises that I could do’. (Bev)
		Encouragement: non-directive, non-judgemental, validating struggles and achievements	‘She pushed you. Yeah. She got you out of your comfort zone’. (John) ‘[there was] no pressure at all’. (Alex) ‘It was a non-threatening environment to me and very non-judgemental’. (Doug)
	Social support		Bev spoke of how a formal caregiver supported her goal of doing her hair by helping her to use her arm and hand during washing of her hair. Lynn spoke of a friend who helped her with her goal of tidying up and organizing.
Individualized Education		Individualized strategies	‘I used to tend to take just little steps […] Then she [coach] said to try and make my steps longer […] I was afraid I would trip, but lengthening the stride […] works well for me’. (Bev)
		Relevant to participants’ needs and goals	‘And in the hospital, that’s what they said, I should always put the left leg on first. […] She [coach] said, “[…] mostly, that’s the best way to do it. But depending on what clothes you’re putting on, sometimes it’s not always the easiest way”. So, I’d never thought about that’. (Bev)
		Collaborative discussion	‘I would ask for her ideas and she was open to ideas, ways of trying things’. (Bev)
Goals		Chosen by participants	‘The goal came from me, obviously’. (Ken)
		Goals are important and valued: feeling of ownership, formally setting goals was new	‘We talked about trying to achieve the three goals that I had set out to do’. (Bev) ‘Because before I never set goals. If I did something, I did it, but there was nothing written or anything’. (Christine) ‘And like the goal thing and all that. I would never think of that. […] I guess. I thought it was stupid […]. And then I realized, “No, no. Let’s go with this”‘. (John)
		Goals promoted action: directed attention – promoted persistence and action	‘No they [goals] came from me. […] These are things that I could definitely work on and so here’s an opportunity […]. Perfect, let’s do that’. (Doug) ‘Somehow the light goes on and you say, “You got to quit saying I can’t do this”. And you got to try and once you try you get better at it and you keep working on it’. (John)
Goal-focused problem-solving process	Developing and testing plans	Cyclical process, working on small quantifiable goals	‘We set goals each week. […] try to make them quantifiable goals and report it back […] what worked and what didn’t work’. (Doug)
		Learning through testing plans	‘But I made a mistake because I didn’t realize at the time how much effort was involved in driving’. (Ken)
		Coach non-directive: participant choice in planning Agency	‘But, you know, she [coach] said you can always try something different, you know, you don’t always have to do it a certain way’. (Bev) ‘And you could see that in a lot of my decisions I’m doing something […] and then, all of a sudden, I’m changing because I have to cope’. (Ken)
		Challenges related to stroke, other health condition and the environment	‘It wasn’t because I didn’t try. Maybe I still haven’t got enough mobility yet in my hand and my arm’. (Bev) ‘Well, it’s interpersonal but I also have to suppress my feelings of inferiority or my inability to do things. To simple say, “Alright, I’m not taking it personally”’. (Doug)
		Plans not easy	‘I was petrified of the ice. I had never been like that before, where if I slipped and fell I would be in so much trouble’. (John) ‘Relearning to write, well it was difficult’. (Christine)
		Positive approach: persevere, have patience and build confidence	‘The first time I went in the boat it was terrible because I had to crawl in, crawl out and it was worse getting out. Because the boat doesn’t […] stay stable’. (Alex) ‘I don’t get frustrated easily. It is not question of life or death. But I believed that it [progress writing] would be faster than that’. (Christine) ‘[…] maybe I can walk without using a mobility aid smoothly. I’m not too comfortable about doing it by myself yet’. (Bev)
	Success with occupational performance goals	Positive experiences, achievement of goals, progress towards goals	‘But I did it myself [fishing], I got in and out [of the boat]. And so now I went on Saturday all by myself, I had no problems’. (Alex) ‘And then in the process there I got better and I could walk and I went to Toronto for a weekend with all my buddies and we went to a ballgame’. (John) ‘The hair, no. […] Well, I can get a clip in, not too badly. I can’t braid yet but I think that’ll take a while’. (Bev)
		New ways of doing: viewed positively or with reluctance	‘Maybe lying down on the bed, you could get undressed easier. […] So I did that. And it worked, it was easier for me’. (Bev) ‘And it’s not that, oh, I can’t do that. Why? […] So can I do it this way? Can I just take longer to do it?’ (Ken) ‘Oh, I’d love to be able to quilt again. […] I said, “Well, I can’t thread a needle. How in the earth can I ever sew if I can’t thread a needle?” And she [coach] said, “Oh, you can get those little”. I said, “That’s no good because that little thing moves”‘. (Lynn)
		Lack of success	‘I said, “No, it’s not. Cooking, to me, is cooking”. But I’ve done rice and I’ve […] fried something up. Then I decided I’d go to the Red Door and get my food’. (Lynn)
	Personal characteristics	Value of independence	‘I didn’t like having to depend on everybody’. (John)
		Determination	‘I’m pretty determined’. (Bev) ’I’m stubborn, you know. I don’t want to ask for help and I won’t if I don’t have to’. (Alex)
		Positive approach: feeling lucky	‘I’ve been positive. With everybody that I’ve seen, it’s been positive’. (Ken) ‘I’m gonna get it done eventually’. (Alex) ‘I had a very mild stroke. And only after did I realize that I was really, really lucky. […] like my numbness in my arm and my staggering around a little bit, that’s nothing to the people that can’t speak or have no feeling and stuff like that’. (John)
		Rule follower	‘You know, I guess it’s, well, you’re told you should do it this way, you better do it that way, don’t rock the boat’. (Bev)
	Application to new occupational performance goals	Plans to pursue future occupational performance goals	‘I have set small goals for myself. I like to knit. So I did manage to pick up and do knitting […] that’s hard to do, one handed’. (Bev)
		Generalizing use of the problem- solving process with future goals	‘I’d probably try to break things down into smaller pieces again and be like, okay what can we do or small pieces and step towards the main goal over a period of time’. (Doug)
		Plans to apply strategies learned to future goals	‘I guess one of my goals is to be back at the church doing different ministries. I’m doing different ministries, but I’m doing them at my own pace’. (Ken) ‘But just staying […] in the apartment by myself doing the exercise […] is not that motivating. So, I thought if I went to a stay-fit class, […] I would be more enthusiastic’. (Bev)

Support

The category of support was defined to include the subcategories of therapeutic relationship, emotional support and social support.

Therapeutic relationship

The therapeutic relationship was defined in the coding framework as being one of trust, mutual respect and collaboration that promoted readiness to work towards goals. The qualitative data revealed these dimensions of a therapeutic relationship; participants felt connected to and trusting of the coach. Findings indicated that the collaboration and respect shown by the coach were integral to developing this relationship. Participants described the coach as using active listening and reflecting, which conveyed respect and collaboration, and established trust. The coach seemed to nurture this relationship by taking time before and after discussion of goals to listen to and be with participants, sharing ideas, having fun and discussing participants’ current realities.

The therapeutic relationship created by the coach appeared to be a source of motivation and to promote readiness to take actions to pursue goals. This readiness to act was encouraged through use of a positive approach and by participants having a sense of being accountable.

Emotional support

Emotional support was defined in the coding framework as the coach providing encouragement, participants feeling listened to, and the coach being non-critical. Participants’ descriptions illustrate these dimensions of emotional support received from the coach, conveyed through active listening, and providing encouragement and feedback in a supportive, non-directive, non-judgemental manner. In this way, the coach encouraged participants to progress, and provided feedback to validate their struggles and achievements.

Social support

Social support was defined in the coding framework as support from family and other sources that was directly related to goal achievement. Along with emotional support from the coach, participants also spoke of support from family, friends and health professionals that was directly targeted at supporting them to achieve their goals.

Support received form the coach and the availability of social support for goals appeared to be important ingredients to promote goal achievement. Notably, emotional support from the coach was critical for the establishment of a therapeutic relationship.

Education

Dimensions for education were defined in the coding framework as being individualized, being relevant to participants’ needs and goals, and occurring through collaborative discussion.

Findings revealed that education was individualized and relevant to participants’ goals in that it primarily involved discussion of strategies for goal achievement. These strategies included suggestions for adapting approaches to activities and exploring new ways of doing to achieve goals. For example, Ken and his wife described a strategy for energy conservation introduced by the coach in which a visual tool was used to assist with planning energy use for goals and other activities. They reported that this strategy introduced a new way of thinking about fatigue after stroke and for planning activities to respect the fatigue. In some instances, participants reported being introduced to new ideas that contradicted what they had been told during rehabilitation (for example, dressing the affected side first) but were relevant to their current needs. This gave them permission to question further and to develop their own strategies when faced with other challenges.

Participants integrated suggestions or retained them for future consideration, suggesting the relevancy of the information. For example, Lynn spoke about the coach’s suggestion to hire someone to help her clear out stuff from her house. She stated, ‘I might end up doing that, but at the moment, not’. Collaborative discussions involved both the coach and participant sharing ideas and strategies during the problem-solving process.

Goals

The category of goals was defined in the coding framework as including the following dimensions: goals are chosen by participants; having goals is important; goals are valued and important to participants; and goals promoted action through directing attention, triggering action and promoting persistence. Dimensions identified during analysis reflect those identified in the framework but, in some cases, are framed differently (See Table 3).

Findings indicated that the intervention goals were chosen by participants and reflected highly valued activities that were given meaning for personal reasons, social reasons or because the activity was related to their identities.

Having goals seemed to be important for participants. When discussing their goals, several participants used language that indicated feelings of ownership of their goals and responsibility for actions to achieve them. For some participants, formally setting goals was new. Their comments reflect that previously they used a less formal, more implicit approach to determining goals for themselves. One participant (Bev) noted that during her rehabilitation no one had asked her what her goals were. She found the opportunity to set her own goals to be ‘refreshing’.

Identifying goals provided a focus and a trigger for action. In John’s case, having goals seemed to prompt a turning point where he decided to act. Setting goals seemed to assist in directing attention and promoting persistence, which were reflected in participants talking about the need to keep working, take small steps and expend effort to achieve their goals.

Goal-focused problem-solving process

The goal-focused problem-solving process included the predefined subcategories of developing plans, testing plans, having success with occupational performance goals and applying strategies to new occupational performance goals. New subcategories and dimensions emerged during coding. Within the subcategory of testing plans, dimensions that emerged were challenges in achieving goals related to the experience of stroke and demands of the goal, and plans are not easy. Within the subcategory of success with occupational performance goals, dimensions that emerged were new ways of doing, and lack of success for some goals. One new subcategory, personal characteristics, emerged as influencing the goal-focused problem-solving process.

Developing and testing plans

Developing plans was defined in the coding framework as drawing on strengths, resources and positive experiences, and breaking down goals into steps. Testing plans included participants feeling responsible for action, choices and checking on goal progress, and the coach providing guidance while being non-directive. As noted above, the definition of testing plans was expanded during coding to include the challenges faced by participants and their experiences of plans not being easy.

When participants spoke of developing and testing plans to achieve goals, the two ideas were intertwined, reflecting the cyclical nature of the problem-solving process. Participants spoke about setting small goals from week to week, checking in on their progress, re-evaluating and making new plans. Learning occurred through this process, at times drawing on guidance from the coach, who offered a different perspective.

When providing guidance, the coach took a non-directive approach that facilitated decision-making by participants. When describing their experience of OPC-Stroke, participants used the active voice (for example, ‘I chose these goals’), indicating that participants felt a sense of agency or responsibility for taking actions and carrying out their plans.

When discussing testing of plans, participants spoke about physical, cognitive and emotional challenges related to their experience of stroke and other health conditions, and related to negotiating their environment. Several participants indicated that carrying out plans was not easy.

While participants did not directly speak about drawing on strengths, resources and positive experiences, they did speak of the need to persevere, have patience and build confidence.

Success with participation goals

Success with participation goals was defined in the coding framework as participants feeling positive about achievements, achieving goals, or making progress towards goals. During coding, new ways of doing and lack of success were added as dimensions under this subcategory.

Despite the challenges faced, all participants indicated that they experienced success either through achieving or making progress on their goals. When participants did not fully reach a goal, they indicated that they felt they would be able to achieve their goals with more time. Several participants spoke about accomplishing their goals through new ways of doing. These new ways were chosen by participants and included different adaptive approaches, pacing, or taking more time to complete tasks.

For a couple of participants, new ways of doing represented an overall new approach or attitude to thinking about planning and achieving future goals. On the other hand, some participants struggled to adopt new habits or ways of accomplishing activities that were different than the ones they were accustomed to before the stroke. For example, Lynn was reluctant to explore new ways that may enable her to resume quilting using one hand. For Lynn, disinclination to adopt new ways of doing activities seemed to contribute to her feeling of not achieving certain goals despite apparent progress. To an outside observer, she appeared to have made progress on her goal of cooking; for example, she made rice pudding but was not able to take it out of the oven safely until it cooled. From Lynn’s perspective, the need to adapt her approach to cooking (letting it cool before taking it out of the oven) did not fit with her criteria for goal achievement. Instead she chose a completely new way of doing (ordering out) to ensure she had food to eat. While Lynn appeared to be satisfied with the overall outcome, she did not redefine her goal (cooking) and therefore it was not achieved.

Personal characteristics

Personal characteristics emerged as influencing participants’ approaches to problem-solving. Findings indicated that participants valued independence, which appeared to be a strong motivator for the pursuit of goals. Related to the value of independence, several participants described themselves as having determination to reach their goals. A couple of participants commented on having a positive approach and feeling lucky compared to other people who had experienced stroke. Similarly, a couple of participants expressed their confidence in their abilities. Some characteristics were malleable. For example, Bev described herself as a ‘rule follower’ prior to the intervention. However, the intervention process seemed to provide her with permission to explore and break rules.

Application to new participation goals

The final step in the problem-solving process is the application of learned strategies and processes to future participation goals. Three dimensions related to this application were identified: plans to pursue future occupational performance goals; generalizing use of the problem-solving process with future goals and plans to apply strategies learned to future goals.

Findings indicated that participants defined future goals as new goals, continuing to work on goals they had not yet achieved and maintenance of achieved goals. A few participants spoke about using strategies that they had applied to past goals and about applying the problem-solving process, including breaking things down into small steps and evaluating outcomes.

For some participants, external accountability or support seemed to be needed on an ongoing basis because routines established during the intervention lapsed when it was finished. Ken described starting to walk regularly when the coach was visiting but not keeping this up afterwards due to ‘laziness’. Others found accountability and stimulation through joining an exercise class.

In summary, the goal-focused problem-solving process involved a cyclical process of developing and testing plans that included working on small goals, learning and overcoming challenges. Although this process was not easy, participants referred to keeping a positive approach, feeling agency or responsibility for actions, and experiencing success in achieving goals. Personal characteristics and integration of new ways of doing influenced the problem-solving process and definition of success. Some participants were able to apply learned strategies and processes to future occupational performance goals. They continued to work towards goals, utilized a problem-solving process or applied learned strategies to new goals.

Discussion

Participants’ experiences of OPC-Stroke lend support to the components and theorized mechanisms of action of the intervention. Reflecting on the above analysis, revisions were made to the theoretical understanding of how OPC-Stroke works (see Figure 1).

Figure 1.

Revised theoretical understanding of how OPC-Stroke works.

The themes identified through the conventional content analysis examining participants’ experiences of OPC-Stroke align with the proposed mechanisms of action which were supported in the directed content analysis. The findings of being helpful; providing a different perspective; providing hope, motivation and a focus for goal achievement; and enhancing self-efficacy indicate that emotional support, individualized education and goal-focused problem-solving were key interacting ingredients. Directed content analysis revealed that participants perceived that the provision of emotional support was critical to the formation of a therapeutic relationship where they felt trust, respect and collaboration. The therapeutic relationship provided a milieu in which participants felt safe and motivated to select personally valued goals and engage in the problem-solving process to work towards achieving these goals. These findings are consistent with those of studies examining the impact of the therapeutic relationship, also referred to as the alliance. In a metasynthesis of psychotherapy research, Horvath (2001) attributed over half of the beneficial effects of psychotherapy to the quality of the alliance. In a systematic review, Hall et al. (2010) found that a positive alliance was consistently correlated with improved pain, disability and treatment satisfaction in physical rehabilitation. This study provides further support for the idea that openness to clients’ goals with a non-judgemental, collaborative relationship is highly valued by people who have experienced stroke (Brown et al., 2014).

Figure 1 illustrates how the therapeutic relationship provides an important background to the process of change in OPC-Stroke. The support received through this relationship and individualized education on specialized strategies seemed to be critical for engaging in the goal-focused problem-solving process and achieving goals.

However, while the therapeutic relationship is an important component, the relationship by itself is not sufficient for change (Castonguay et al., 2006). While initially conceptualized as separate components, participants conveyed that emotional support, individualized education and goal-focused problem-solving were interconnected and experienced as an integrated package. Although theoretically these components are conceptualized separately and training in them occurs in a stepwise fashion, participants experienced them as interconnected. That is, provision of emotional support is intertwined with individualized education and the goal-focused problem-solving processes. Individualized education is provided in the context of, and directly related to, the problem-solving process.

Participant-selected goals were highly valued and thereby served to direct attention, and promote action and persistence during the cyclical problem-solving processes (Locke and Latham, 2002). Although most participants experienced challenges in developing and testing plans, they were able to experience success and build confidence through achieving or partially achieving their goals. They also seemed to be generalizing use of strategies learned and the problem-solving process to achieve other goals.

Personal characteristics such as valuing independence and determination and readiness to explore new ways of doing were also revealed as important components for success in achieving goals. Alternately, a desire for a more expert-driven approach to remediation of impairment led to decreased satisfaction with progress towards goals. Therefore, personal characteristics was added as a component in the theoretical understanding.

Thus, as illustrated in Figure 1, the combination of factors, within the context of a therapeutic relationship, are important for the process of developing knowledge, skills and self-efficacy to attain current and future occupational performance goals. The OPC-Stroke process is dynamic and evolving as the person goes through the problem-solving process and experiences success in progressing towards his or her occupational performance goal.

This revised theoretical understanding of the ingredients and mechanisms of OPC-Stroke will have two important uses. First, it provides a valuable framework for communicating the actions that occupational therapists take in enabling occupation. Notably, it demonstrates the value of a therapeutic relationship to supporting clients’ work towards achieving their occupational performance goals. While this aspect of care is generally described as important (Taylor et al., 2009), these findings indicate that it is a key ingredient in enabling participation in valued activities. Similarly, the role of individualized education and a problem-solving process in supporting attainment of occupational performance goals is also demonstrated. As such, the theoretical understanding of OPC-Stroke provides explicit methods for integrating and operationalizing aspects of client-centred care.

Second, these results will be extremely helpful in the next stages of testing of OPC-Stroke. Specifically, this knowledge will be useful in refining training of therapists prior to the delivery of OPC-Stroke and assuring treatment fidelity.

Future research to increase the understanding of the components and mechanisms of action of OPC-Stroke needs to examine variables such as the dose required for clients to be able to pursue goals without the ongoing support of the coach and the most effective approach to providing individualized education. The coach seemed more active in suggesting strategies than was planned in OPC (Graham et al., 2009). It may be that more active suggestion of strategies is needed following stroke, given the potential for cognitive impairment and fatigue. It would be important to explore the impact on future problem-solving of providing suggestions as opposed to guiding clients to find their own strategies.

Limitations

The generalizability of these results is limited to people receiving OPC-Stroke who have had mild to moderate strokes, as stroke survivors with moderate to severe functional deficits were excluded. OPC-Stroke is a verbal metacognitive approach, requiring ability to share ideas and participate in problem-solving. Although the aim was to exclude only those with more severe cognitive and communicative deficits, participants in this study had only mild functional deficits. Therefore, those with moderate to severe functional deficits were not represented in this study.

This study did not explore participants’ experiential knowledge and skills obtained as the result of living with stroke. This information would have strengthened the examination of mechanisms of action of OPC-Stroke through considering individual contexts in more detail.

Also, the study results indicate that not everyone is keen on the top-down nature of OPC-Stroke, which raises the question of what should be done in this instance. One participant indicated that she would have preferred a more impairment-focused approach. This participant remained in the study and worked towards some of her occupational performance goals, and found positive aspects of the intervention. However, there was one other participant in the RCT who withdrew from the study after four sessions who likely shared this feeling. During her exit interview, this participant indicated that she was hoping to have more direction with regards to specific exercises she could do to improve her strength and balance. Further exploration would need to be carried out to determine whether tailoring OPC-Stroke to meet the needs of those who prefer to focus on impairment may be helpful for people who may not be ready for an occupation-focused approach, including how and when to identify this preference and tailor the approach.

Conclusions

This study provides insight into the experience and mechanisms of a complex intervention, OPC-Stroke, designed to promote participation in valued activities following stroke. The importance of the therapeutic relationship is highlighted, as well as the integration of the components of emotional support, individualized education and goal-focused problem-solving. These results provide occupational therapists with a more precise way of talking about the ingredients and mechanisms of this client-centred, occupation-focused approach to improving participation in valued activities post stroke. This will be helpful in both practice and further research on this intervention.

Key findings

The therapeutic relationship is important to facilitate re-engagement in valued activities after a stroke.

Individualized education and a problem-solving process promotes goal attainment for people who have experienced stroke.

What the study has added

This study provides a valuable framework for communicating actions occupational therapists can take to enable occupation, and emphasizes the role of the therapeutic relationship in client-centred approaches.

Supplemental Material

Semi structured interview - Supplemental material for Occupational performance coaching for stroke survivors (OPC-Stroke): Understanding of mechanisms of actions

Online appendix

Footnotes

Acknowledgements

We would like to acknowledge Dr. Kate Bigney for her contributions to coding of interviews and Katrine Sauvé-Schenk and Diane Peters-Wood for delivering the intervention.

Research ethics

This research project was approved by the Ottawa Hospital (20120844-01H; 2013), Bruyère Continuing Care (M16-12-045; 2012) and the University of Ottawa Research Ethics Boards (A01-13-02; 2013). All participants provided written informed consent to participate in the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the University of Ottawa Brain and Mind Research Institute. The first author was supported during this research by a Canadian Institute for Health Research Vanier Canada Doctoral Scholarship.

References

Ashley

(2010) Humanistic contributions to pluralistic practice. In: Martin

(ed.) Therapy and Beyond: Counselling Psychology Contributions to Therapeutic and Social Issues, Chichester, West Sussex; Malden, MA: Wiley-Blackwell, pp. 123–138.

Bandura

(1977) Self-efficacy: Toward a unifying theory of behavioural change. Psychological Review 84(2): 191–215.

Berg

White

(2010) Constructivist therapies. In: Porchaska

Norcross

(eds) Systems of Psychotherapy: A Transtheoretical Analysis, Belmont, CA: Brooks/Cole, pp. 432–447.

Brown

Levack

McPherson

et al. (2014) Survival, momentum, and things that make me “me”: Patients’ perceptions of goal setting after stroke. Disability & Rehabilitation 36(12): 1020–1026.

Castonguay

Constantino

Holtforth

(2006) The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, Practice, Training 43(3): 271–279.

Collins

(2004) Education techniques for lifelong learning: Principles of adult learning. Radiographics 24(5): 1483–1489.

Creswell

(2013) Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, 4th ed. Thousand Oaks, CA: SAGE.

Egan

Kubina

L-A

Lidstone

et al. (2010) A critical reflection on occupational therapy within one Assertive Community Treatment team. Canadian Journal of Occupational Therapy. Revue Canadienne D’ergothérapie 77(2): 70–79.

GmbH Scientific Software Development. (2014) Atlas.ti.

10.

Graham

Rodger

Ziviani

(2009) Coaching parents to enable children’s participation: An approach for working with parents and their children. Australian Occupational Therapy Journal 56(1): 16–23.

11.

Graham

Rodger

Ziviani

(2010) Enabling occupational performance of children through coaching parents: Three case reports. Physical & Occupational Therapy in Pediatrics 30(1): 4–15.

12.

Hall

Ferreira

Maher

et al. (2010) The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy 90(8): 1099–1110.

13.

Horvath

(2001) The alliance. Psychotherapy 38(4): 365–372.

14.

Hsieh

Shannon

(2005) Three approaches to qualitative content analysis. Qualitative Health Research 15(9): 1277–1288.

15.

Hui

Snider

Couture

(2016) Self-regulation workshop and occupational performance coaching with teachers: A pilot study. Canadian Journal of Occupational Therapy 83(2): 115–125.

16.

Kahjoogh

Kessler

Rassafiani

et al. (2017) Occupational performance coaching for mothers of children with cerebral palsy: A case report. International Journal of Therapy & Rehabilitation 24(5): 218–222.

17.

Kessler

Egan

Dubouloz

C-J

et al. (2017) Pilot trial findings of occupational performance coaching for stroke survivors. American Journal of Occupational Therapy 71(3): 7103190020p1–7103190020p7.

18.

Kessler

Ineza

Patel

et al. (2014) Occupational performance coaching adapted for stroke survivors (OPC-Stroke): A feasibility evaluation. Physical & Occupational Therapy in Geriatrics 32(1): 42–57.

19.

Kondracki

Wellman

Amundson

(2002) Content analysis: Review of methods and their applications in nutrition education. Journal of Nutrition Education and Behavior 34(4): 224–230.

20.

Kufner

Scholz-Schwaerzler

(2012) Occupational Performance Coaching (OPC) Eine ergotherapeutische Intervention für die klientenzentrierte Elternarbeit [Occupational Performance Coaching (OPC): An occupational therapy intervention for client-centered potential cooperation]. Ergotherapie & Rehabilitation 51(12): 17–22.

21.

Locke

Latham

(2002) Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American Psychologist 57(9): 705–717.

22.

Moore

Audrey

Barker

et al. (2015) Process evaluation of complex interventions: Medical Research Council guidance. British Medical Journal 350: h1258.

23.

Papaleontiou-Louca

(2008) Metacognition and Theory of Mind, Newcastle, UK: Cambridge Scholars Publishing.

24.

Potter

Levine-Donnerstein

(1999) Rethinking validity and reliability in content analysis. Journal of Applied Communication Research 27(3): 258–284.

25.

Public Health Agency of Canada (2011) Tracking Heart Disease and Stroke in Canada – Stroke Highlights 2011. Available at: www.phac-aspc.gc.ca/cd-mc/cvd-mcv/sh-fs-2011/index-eng.php (accessed June 30, 2017).

26.

Stroke Association (2017) State of the Nation: Stroke Statistics January 2017. London, UK; Stroke Association. Available at: https://www.stroke.org.uk/system/files/sotn_2018.pdf (accessed 1 February 2018).

27.

Taylor

Lee

Kielhofner

et al. (2009) Therapeutic use of self: A nationwide survey of practitioners’ attitudes and experiences. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association 63(2): 198–207.

28.

Wittenberg

(2010) Experience, cortical remapping, and recovery in brain disease. Neurobiology of Disease 37(2): 252–258.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.07 MB