Abstract
Actively involving patients in decision-making has been suggested as a way to increase the quality and patient-centredness of rehabilitation. Patients’ physical and mental well-being and their commitment to decisions about their rehabilitation may improve if they are fully engaged in the clinical decision-making process. While goal setting has traditionally utilised paper-based tools such as the Canadian Occupational Performance Measure (COPM), novel technologies such as mobile apps provide new mechanisms for goal setting. The purpose of this thesis was to examine how technology might facilitate a patient-centred approach to shared decision-making when setting rehabilitation goals.
Three studies were undertaken: one scoping review and two empirical studies. The scoping review mapped the extant literature on the use of technology for supporting goal setting in adult rehabilitation and evaluated the impact on patient outcomes. A search of five databases (MEDLINE, CINAHL, AMED, Scopus and ProQuest Dissertations and Theses) from inception to May 2020 identified 27 studies reporting on research about 16 relevant technologies. Data were extracted and synthesised using scoping review methods. The majority of identified technologies were designed to improve self-management, with limited goal setting as an adjunct to this core function. Only a few technologies were identified that had been explicitly developed to support collaborative rehabilitation goal setting. One of these technologies was a Japanese mobile app called the ‘Aid for Decision Making in Occupational Choice’ (ADOC). Research on ADOC supported the notion that this app could be an important tool for collaborative decision-making in goal setting for rehabilitation, but the app had yet to be tested in an English-language context.
The second study was a qualitative descriptive study which included eight patients and eight healthcare professionals in inpatient rehabilitation, focusing on their perceptions and experiences of using ADOC to set goals in clinical practice. Findings indicated that ADOC was considered a valuable tool by both groups, that it facilitated shared decision-making, that it changed patient perspectives on what was possible and healthcare professionals’ perspectives on what was important regarding rehabilitation goals. However, some limitations of this approach were identified, including technical issues with ADOC, such as incompatibility with organisational information technology systems, and organisational issues such as time constraints on goal setting with ADOC.
Building on these findings, a third study was conducted using participatory action research (PAR) methods to gather information about ADOC’s utility as a tool for collaborative goal setting in community-based stroke rehabilitation and the strategies required to successfully implement this technology in practice. The PAR methodology consisted of an iterative cycle of planning, action, observation, and reflection. Participants were three team leaders and 23 healthcare professionals. This study involved working with the participants to understand their experiences of using ADOC and the issues related to usual goal setting processes, all while adhering to the main characteristics of PAR – integrating scientific investigation into participant education and action. The key findings of this study revealed that for ADOC to be successfully integrated into practice, it had to be simple and easy to use, adopted as an optional tool with selected patients, and with processes developed to incorporate it into daily clinical workflow. Furthermore, the PAR process helped participants rediscover the value of collaborative goal setting and become more aware of organisational constraints on implementing novel technologies in clinical settings.
Overall, this thesis has confirmed that the mobile app ADOC has the potential to be a highly relevant digital tool for shared decision-making in rehabilitation goal setting and may well improve patient-centred service provision – and therefore quality of service delivery – for selected patients in rehabilitation. This thesis offers insights and recommendations for future design, development, and integration of sophisticated novel digital tools in healthcare.