Healthcare professionals’ perspectives on rehabilitating persons with cognitive impairment

Addressing the steep learning curve

HCPs highlighted the importance of receiving specific training that provided them with the knowledge, skills, and attitudes required to rehabilitate persons with CI successfully. Staff were aware that their facility took in patients that are commonly denied access by other rehabilitation programs, and as such, knew that their work was unique. However, when the model of care was first introduced a decade ago, not all staff were enthusiastic about rehabilitating persons with CI. One OT reflected on the process and how the team collaborated to mitigate differences in initial knowledge and comfort levels among staff:

Each individual came in with their own set beliefs about working with this population group, but we were open enough to speak about it. And so, for those team members who were maybe not as comfortable, those that were [comfortable] would go and help out a little bit more. It just took time to build it up... there were lots of hiccups, lots of new learning. [Participant 1, OT]

To assist with enhancing staff’s beliefs, attitudes, and expertise, management organized a 1-day workshop focused on the care of persons with CI when the model was first introduced, where effective assessments and care approaches were shared, including a delirium protocol, so that staff could learn to recognize and treat reversible causes of delirium. This essential training, which included understanding remaining abilities of persons with CI, helped to bring all HCPs to a level of comfort on these topics, as not everyone had received this information in their professional education. In addition, an advanced practice nurse was hired for a year to teach staff how to work with persons with CI, including the provision of bedside mentoring, which they found hugely beneficial. An OT explained:

I found it helpful when we had the nurse consultant who was here, whose expertise was to address this population when we first started out… So I think that [the nurse] helped immensely with the team in being comfortable, and eventually even more comfortable working with this population. [Participant 1, OT]

However, for new staff joining later on, educational sessions were more intermittent, which some participants felt was problematic and proposed e-learning as a solution moving forward.

Mentoring moments

Staff discussed how mentors helped to improve their ability to properly rehabilitate persons living with CI. Mentoring sessions occurred in two ways in this facility: formally, during morning huddles, and informally, initiated by staff when needed to discuss a specific case and decompress. Because of the informal and formal mentorship, staff felt they were supported and that their work was valued. Debriefing sessions, which were also seen as mentoring moments, helped with educating and supporting staff as well. In the unit, team huddles occurred every morning and consisted of a ten-minute meeting with all available HCPs and management to meet and to discuss patients’ issues and safety concerns. Also, when a referral or new patient arrived, the primary nurse would call a meeting to discuss care strategies. In addition, debriefing sessions occurred once the patient was discharged, which gave staff opportunities to discuss what was done well during the stay and what could have been improved.

A PT reflected on how group learning occurred using an interprofessional approach, as well as how collaborating with families was useful in getting to know individual patients better. She explained:

I find that I learn a lot from the people around me, especially those with more experience …. Not just as a physio from physio, but from something a nurse did or an OT did, or maybe the family. The family’s a good resource as well. ‘This is what we do with my mother when she has this tantrum,’ or things like that. [Participant 15, PT]

Staff shared a willingness to adapt and try different care strategies and made suggestions to one another. There was also a realization that clinical skills, knowledge, and experiences accumulated over time.

Being there for one another

Healthy team relationships among coworkers were regarded as crucial in the success of rehabilitating persons with CI. There was a shared understanding of the importance of reliance among coworkers and managers in the rehabilitation of persons with CI. Participants highlighted the need for each team member to be nimble and ready to deal with whatever issues were presented on any given day. Regularly offering help to coworkers was seen as a strategy that helped in creating a supportive and collaborative work environment. When questions were raised, participants explained, a more experienced staff member would step in and guide the colleague who needed assistance.

Interdisciplinary collaboration was competently practiced in the facility, as care strategies for patients often spread across several disciplines and required a wide range of expertise. An OT explained how the team’s approach to care delivery was flexible and sometimes meant working outside their disciplinary silos, stating: “You’re not just doing PT or OT duties. You’re interchanging, so everybody on the team would do bits of everything for the patient.” [Participant 5, OT]. Participants explained that the reasons for staff doing “a bit of everything” were twofold. First, patients with CI could present unpredictable needs, which may be immediate, and as such, the nearest staff members’ assistance was required to minimize the risk of a negative consequence. Although there was an appointed primary care team for each patient, everyone in the facility helped one another and contributed to care. Second, the goals to care provision were so intertwined that the staff eventually developed a mindset to work together to reach the collective end goal of rehabilitation and safe discharge.

The development of effective teamwork was associated with the unit’s leadership for setting the tone and enabling this type of collaboration. Participants explained that they never felt they had to manage a difficult case on their own, believing that the more the team and managers worked together to solve a problem, the more successful the team was. This approach yielded positive effects for the team and the patients. Additionally, staff felt a sense of pride seeing patients walk out of the facility with better mobility and, more often than not, better cognition than when they arrived. The improved cognition was often as a result of the delirium triggers having been addressed and treated.

Getting to know the person and setting goals

Participants acknowledged the importance of learning about the patients and their lived experience and using this knowledge in their rehabilitation practice. Knowing the person contributed to setting realistic goals and also gave HCPs a sense of purpose in their work. All patients received a comprehensive geriatric assessment (CGA) upon admission, conducted by various team members, which involved acquiring knowledge about the patient from multiple sources, such as care partners and previously used community support services. A PT further explained: “If they are receiving any support from these services, we contact them, and find out how they presented before the fall, before the fracture.” [Participant 15, PT]

The CGA helped to rule out possible reversible symptoms that needed to be dealt with immediately, as well as with devising a plan of care. Many HCPs attested to the challenges of conducting the CGA on persons with CI. Clinicians suggested that rushing these patients could elicit responsive behaviors (e.g., agitation or aggression); hence, additional time was allocated to conduct CGAs with this group. Some participants found that patients’ cognitive abilities fluctuated more in the acute phases of their stay. Thus, assessments were ongoing to capture these varying levels of function and to be able to adjust goals for the provision of tailored rehabilitation continuously.

One of the components of the PCRM-CI model included delirium management. A nurse explained how they identified and treated delirium in the unit following the protocol and the joy she felt when patients recovered from it:

We’ve had quite a number of patients who have come in and most of the time, [delirium] might just be due to constipation or dehydration. So, after thorough assessment, we’re able to identify these issues, we have guidelines to follow. And usually they start smiling, they start talking back, they’re not as combative, they’re not as aggressive, or as, you know, up and down pacing. And it’s nice when they can actually sit and have a conversation with you. [Participant 14, RN]

Precautions were also taken to mitigate risks such as falls, which sometimes contributed to a delay in meeting the functional goals. For example, staff used bed and chair alarms and a color-coded risk tagging system, where the red code required patients with CI to ambulate in the presence of an HCP or care partner. Hence, patients with a red tag had fewer opportunities to walk than patients without CI in similar circumstances. This issue surfaced as an ongoing challenge that HCPs kept working on to improve rehabilitation care provided for persons with CI.

To learn more about the person and to build the rapport and trust necessary for rehabilitation, patients were assigned a care team made up of a primary nurse, an OT, and a PT upon admission, which remained constant until discharge. Participants considered it essential to have staff consistency as they could observe patterns of what did work or did not work and then incorporate changes to the care plan accordingly. However, several HCPs acknowledged that continuity of staffing was sometimes challenging with patients with responsive behaviors. Participants were grateful to managers who were crucial in monitoring the pulse of the facility and made required modifications in staffing to avoid burnout, such as alternating care assignments.

Throwing away the cookie cutter

Staff recognized that patients were unique and that individualized rehabilitation approaches required knowledge of the person. The team recognized that patients with CI are not all identical, and thus, cookie-cutter type techniques would not work for persons with CI. The individualized approach that staff took was very important for persons with CI, as this nurse explained:

Even though they are cognitively challenged, and maybe all of them may have dementia, or all of them may have post-op delirium, each individual is different. The way you handle them is different; the way you do the care is very different. So that helps. [Participant 3, RPN]

Staff aimed at incorporating patients’ preferences and unique circumstances into patient care plans as an acknowledgment that many patients have cognitive abilities that can be utilized while rehabilitating them. As an OT explained, working with patients with CI involves, “taking it case by case, you just can’t cookie-cut it.” [Participant 5, OT]

Most staff underscored the importance of flexibility and creativity in working with persons with CI. HCPs learned that therapy does not have to be done in a gym and that it could be done in many ways: standing and painting a picture, walking in a garden, kicking a soccer ball, or playing catch in a chair. Discovering what brought joy into the lives of their patients is what staff uncovered first to find strategies to interact successfully with each patient and to help motivate them. There was a realization that working with persons with CI required a different skill set and that there was no book to follow. One participant shared an example of how they incorporated the knowledge that they were getting about one patient into their rehabilitation approach:

I think she worked as an administrative assistant in a police department, and that she’s from the UK. These are all pieces of her that we were learning about. She would often come and sit with us in our charting room or at the nursing desk, and that was part of how we would get her to come out of her room and walk a little bit. We would go for walks downstairs to get a cup of tea because she loved having her afternoon cup of tea. We went for a walk outside once because she wanted to get fish and chips, so we walked to a pub around the corner. [Participant 7, PT]

Through listening and creativity, HCPs identified new ways to motivate patients, tried new approaches, and changed their routines to accommodate patient preferences and mood. It was not the staff’s schedules that determined when therapy would occur but the patient’s schedule. Creating an individualized routine so that patients remained engaged while not in therapy was also seen as critical for their recovery. To keep patients active, one nurse explained, they were constantly thinking of, “stuff …to keep them busy, distracted, and not feeling lonely.” [Participant 11, RN]. Schedules were sometimes written down on the patient’s whiteboard in order for staff to be aware of when therapists were scheduled and care partners were planning to visit. In this way, any gaps in the schedule would be noticed and dealt with creatively. Individualized approaches also meant that rehabilitation was offered on a continuous 7-day basis for most patients in the facility, including those with CI, to maintain their routine and rehabilitative gains.

Other approaches that were required to make rehabilitation successful were the staff’s ability to relate well to persons with CI, including trying different communication strategies such as changing their body language and/or tone of voice. Participants also found that learning how to connect with patients and finding creative solutions to help them reach their goals were very rewarding.

Planning for a successful discharge

Participants recognized some dilemmas related to discharging patients, such as limited community resources. Most HCPs mentioned that one of the most significant issues while working with persons with CI was deciding if they were ready to go home safely. Participants stated that discussions with care partners about plans for safe discharge started early, as some care partners required significant guidance and time to carry out the recommendations in preparation for discharge. One participant underscored the importance of collaboration to ensure a safe transition upon discharge, stating, “collaboration between our team with the community support, the family or caregivers, and then the client as well, was important for effective discharge.” [Participant 8, PTA]

Staff discussed that they also needed time and guidance to consider patient safety versus patient autonomy and their right to live with risk once discharged home. As another participant explained, the patient’s support system was carefully considered when planning for discharge:

We could have a patient who has a beautiful physical recovery but doesn’t have the supports in the community to safely return home. Or someone who has an absolutely terrible physical recovery, but they’re so well supported that they can still go home. [Participant 7, PT]

Many of these patients achieved their functional goals; however, the staff questioned if their CI may impact their ability to live alone. While each case was debated and available resources, including social support, were assessed, discharging patients safely was sometimes seen as precarious. Achieving some level of team comfort while working through “at-risk” discharges and recognizing the individual team members’ discomforts were seen as important when rehabilitating persons with CI. Discharge planning meant considering each patient’s abilities and outcomes as well as the services that would be available to them in their community. Staff perceived that there were limited resources available to persons with CI once at home and understood that both physical function and social support were important factors to consider.

Furthermore, a patient’s circumstances before the hip fracture incident influenced staff’s decision on the discharge destination. For example, the lack of adequate income, housing conditions, and community or social support could all make someone’s life precarious. Sometimes patients were assessed and determined not to be independent enough to go home; however, care partners wanted them home regardless. For others, the patient appeared able to manage at home, and yet care partners could not take the patient in due to limited resources. Consequently, participants explained how some patients could remain in limbo for a while or transfer to a long-term care home.

On occasion, patients visited the facility after discharge, and staff commented on the positive transformations they had seen after the person was back in their own environment. Seeing patient improvement, either physically or cognitively, in addition to seeing them reintegrate back to their routine, and community was mentioned as one of the greatest rewards for HCPs.

Partnering in the rehabilitation experience

Staff discussed the importance of creating a partnership with care partners to ensure successful outcomes when rehabilitating persons with CI. It was described as vital to involve care partners in patient care from the beginning of hospitalization to enable a smooth transition back home, so care partners were welcomed to the facility and were asked to review care strategies. A participant argued that care partner involvement was beneficial for patient care and successful transitions back into the community, recounting, “Family members are welcome in the room… We engage the family to assist, that way when the patient is going home, it is not so frightening for them.” [Participant 2, RPN]. Care partners were also encouraged to participate in rehabilitation by spending time with the patient, for instance, by having them take their relative for a walk. Staff kept care partners informed on what was occurring during the stay so that they remained aware of their progress and of any issues arising. An OT explained:

It sounds as if we’re just doing this within the team, but there’s always somebody keeping family members abreast of everything. There are always follow-up updates, and if there’s a fall, there’s always a phone call to the family member. [Participant 5, OT]

Staff explained that they kept care partners updated regarding patients’ progress, both formally and informally. Formal meetings with care partners were scheduled when staff could not informally connect to provide updates. These meetings were used to welcome care partners to the facility, observe how HCPs provided care, review care strategies with care partners, and discuss patient goals to plan for a smooth transition back home. It was also essential to follow up on any questions raised by care partners in order to create a working partnership.

By creating this partnership, care partners who were either in denial or unaware of the patient’s cognitive status before rehabilitation had an opportunity to become aware and be educated on CI by staff members. While care partners were informed that a hip fracture heals over time, the team also had initial conversations about the patient’s cognition and its long-term impact on recovery. This initial conversation was not taken lightly as it set the tone for team patient–care partner relationships, which helped to develop reasonable goals and devise a sustainable discharge plan. Participants explained how these initial conversations were useful to assess and discuss how the individual and their care partners accepted, coped, and dealt with a diagnosis of dementia and/or delirium.

Supporting care partners to prepare for discharge

Staff aimed at providing the necessary education and resources for the patients’ care partners to ensure a smooth transition home and at collaborating with community supports to attain additional services if necessary. To support a successful transition home, relatives were taught how to administer medication, transfer patients, understand delirium, and communicate and interact with patients. Participants believed that providing education using adult learning principles in various formats (e.g., audio and visual) was very important. One nurse reflected on this process and on the importance of learning about each patient’s situation, stating:

We can advise on using tools like a walker properly. If they need more support, then we have to ask the social worker to set something up and inform the family member. The family member sometimes lives separately, and they don’t know what [the patient] is doing or what they need. So we find out how we can help there. [Participant 13, RPN]

For HCPs, explaining and exploring the risks of going home to care partners was also important, as each care partner may have a different level of comfort with varying levels of risk. Trial weekends (i.e., when patients go home with care partners for the weekend) were instituted at the facility to help care partners understand the levels of risk and comfort. These weekends helped determine if anything else needed to be done prior to discharge.

Staff found it challenging when no care partners were present in the patient’s life or when there were difficulties attempting to contact care partners. A patient’s CI was not the only factor to affect the patient’s outcome; participants observed that a strong and supportive network of care partners allowed patients to continue to improve once at home.