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Qualitative analysis of stroke patients' motivation for rehabilitation
Niall Maclean a Department of Public Health Sciences,
Guy's, King's College, and St Thomas's Hospitals Schools of Medicine
and Dentistry, King's College, University of London, London SE1 3QD, b Elderly Care Unit, St Thomas's Hospital, London SE1
7EH
Correspondence to: N Maclean
macleanniall{at}hotmail.com
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Abstract |
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 Top
 Abstract
 Introduction
Methods
Results
Discussion
References
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Objective:
To explore the attitudes and beliefs of
stroke patients identified by professionals as having either "high"
or "low" motivation for rehabilitation.
Rehabilitation professionals commonly believe that motivation of
patients has an important role in determining outcome,1-3 despite the lack of a shared understanding of the term
"motivation."4 Furthermore, rehabilitation literature
shows no consensus on the nature and determinants of
motivation.5 Most of the clinical literature presents
unsupported descriptions of motivation as an individual personality
trait,
6 7
without any empirical analysis of motivation.
Few studies have attempted such analysis. Kaufman suggested that stroke
patients' motivation was increased by their sharing the "ideology"
of rehabilitation.
8 9
Other studies found that patients
sharing this ideology received more attention from rehabilitation
professionals.
2 10
These studies, however, did not focus
on the analysis of motivation and did not explore the attitudes and
beliefs associated with motivation. If motivation for rehabilitation
affects outcome, its nature and aetiology should be better understood.
We explored the beliefs of stroke patients who were identified as
having "high" or "low" motivation for rehabilitation and investigated the determinants of their motivation.
Design:
Qualitative study with semistructured interviews.
Setting:
The stroke unit of an inner city teaching hospital.
Participants:
22 patients with stroke who were
undergoing rehabilitation; 14 with high motivation for rehabilitation
and eight with low motivation.
Results:
All patients thought rehabilitation was
important for recovery. High motivation patients were more likely to
view rehabilitation as the most important means of recovery and to accord themselves an active role in rehabilitation. These patients were
also more likely to understand rehabilitation and in particular to
understand the specialist role of the nursing staff. Many patients reported independence at home as a personal goal, though few low motivation patients related this goal to success in rehabilitation. Information from professionals about rehabilitation, favourable comparisons with other stroke patients, and the desire to leave hospital had a positive effect on motivation. Conversely,
overprotection from family members and professionals, lack of
information or the receipt of "mixed messages" from professionals,
and unfavourable comparisons with other patients had a negative effect.
Conclusions:
There are some differences in beliefs
between stroke patients identified as having low or high motivation for rehabilitation. These beliefs seem to be influenced by the environment in which the patient is rehabilitated. Professionals and carers should
be made aware of the ways in which their behaviour can positively and
negatively affect motivation.
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Methods
Design of study
Top
Abstract
Introduction
Methods
Results
Discussion
References
Semistructured interviews11
were conducted with stroke patients who were undertaking rehabilitation
in the stroke unit of an inner city teaching hospital.
Patients were selected by using "extreme
case sampling," whereby participants considered to be clear examples
of the phenomenon under investigation are recruited.12
Professionals on the stroke unit identified patients considered to have
high or low motivation for rehabilitation. If there was consensus
regarding a patient's motivational status (no more than one
professional dissenting) the patient was recruited. Patients with
severe cognitive or language difficulties or medical conditions held to
affect engagement with rehabilitation (for example, depression) were excluded. After nine months of sampling, categories emerging from the
analysis of the interviews began to repeat and no new categories were
emerging. This was taken to indicate that the most salient issues had
been identified, and sampling was discontinued.13
InterviewsInterviews were conducted by the patient's
bedside at an average of six weeks after the stroke and were tape
recorded and transcribed. Each interview covered the same general
topics, although the patient was free to structure the conversation
within each topic. New topics brought up by the patients were discussed as and when they arose. All interviews were conducted and analysed by
the same researcher (NM), who knew whether patients were described as
having high or low motivation. A random sample of interviews was
analysed by a second member of the study team (PP) to check that there
were no differences in the ways in which high and low motivation
patients were interviewed.
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General topics covered in interviews with stroke patients
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The interviews were analysed by
content.14 Initially, interview transcripts were read for
emergent themes, which were then coded. Care was taken to ensure
the codes accurately captured the respondent's meaning. The codes in
each interview were then compared with those in each other interview to
create broader categories that linked codes across interviews (constant comparison13). Again, care was taken to ensure that these
broader categories did not distort the respondent's meanings. For
example, "it is important to work in rehabilitation"; "my own
effort will bring rehabilitation gains"; and "I work with the
therapists" are examples of codes of emergent themes, and "I have
an active role in rehabilitation" would be the category serving to
link these themes.
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Results |
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Top
Abstract
Introduction
Methods
Results
Discussion
References
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Sample
Fourteen patients were identified as having high motivation and
eight as having low motivation. The table gives details of the
participants.
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Patients' views and beliefs
The role of rehabilitation and the patients' role in
rehabilitation
While all the patients thought that rehabilitation had a role in their recovery, many high motivation patients (and only a
few low motivation patients) believed that rehabilitation had the most
important role. Many patients thought they had an active role in
rehabilitation and thought they had to apply effort to make gains. Only
low motivation patients thought they ought simply to wait for recovery.
A few high motivation patients
emphasised the importance of learning to perform rehabilitation exercises in the manner specified by therapists. Only low motivation patients, however, spontaneously reported not understanding the nature
of rehabilitation exercises. Though walking was the most commonly
reported goal of rehabilitation, some patients reported not
understanding the therapeutic process leading towards that goal: "The
ultimate aim is to get me walking . . . I don't
understand the steps. How they [the physiotherapists] plan it"
(patient 14, low motivation).
The role of nurses in rehabilitationMany high motivation
patients (but no low motivation patients) spontaneously claimed that
they understood the specialist role of the stroke unit nurses in
rehabilitation: "A lot of the nurses are cruel to be kind. `There's
the bowl, there are your washing things, get on with it'
. . . I think that's essential" (patient 20, high
motivation). Some of these patients criticised nurses for not being
more involved in rehabilitation or for overprotecting the patient. In
comparison, some low motivation patients spontaneously claimed not to
understand the nurses' role in rehabilitation and expressed
frustration that the nurses didn't do things for them.
Independence as a rehabilitation goalMany high motivation
patients were worried about depending on others after they left hospital. Most of these patients thought that progress in
rehabilitation meant developing independence in activities of daily
living. Some low motivation patients also expressed independence as
a goal, although few linked this goal to progress in rehabilitation.
Influences on patients' beliefs
Some patients spontaneously reported that a range of factors
affected their beliefs about rehabilitation.
A few patients reported overprotection from
family members or stroke unit nurses, or both, which made them feel
"stupid" and incapable. One low motivation patient, who expressed independence as a goal, described how her daughter convinced her that
rest (not rehabilitation) was the most appropriate treatment.
Comparisons with other patientsOne patient took the
example of a stroke patient who recovered well as a source of
confidence in her own recovery. Other patients, however, reported
feeling depressed at the fact they were not rehabilitating as well as other patients.
Information from professionalsThe information-giving role
of the professionals on the stroke unit was emphasised by many high
motivation patients and comparatively few low motivation patients. Some
high motivation patients described how information from staff led their
thinking away from any "magic" solution to their problems (for
example, "miracle drugs"), to focus instead on taking an active
role in rehabilitation. One such patient reported how information about
the rehabilitation plan helped to keep him determined: "I'm
determined, yes. The physios are very good here, they're very
encouraging and they explain things to you. Cos you don't know what
the plan is, do you, unless they tell you. So then you know all the
pain and everything is worth it" (patient 17, high motivation). Other
high motivation patients explained how information helped them to
understand rehabilitation goals and to recognise when they were making
progress. This provided reassurance that rehabilitation was working.
The need for information and supportMany low motivation
patients reported anxieties that they thought stemmed from a lack of
information and support from professionals on the stroke unit. One
patient described how she felt less personally involved because she did
not understand her rehabilitation exercises, and another described
being too afraid to participate in rehabilitation because of her lack
of understanding. She thought information and encouragement from
therapists would help. Some patients who wanted to leave hospital also
reported uncertainties over how they would cope at home. One related
this anxiety to what he perceived as a lack of information from staff
and described how this compromised his desire to participate in
rehabilitation: "These doctors don't give you too much information
. . . only say `Oh you're going home' and that's it
. . . And when it happens again, that's it, back to
square one, which would be a waste of time going to a gym
. . . it's a strain on your mind all the time, we're
doing this for nothing" (patient 9, low motivation). In addition, a few low motivation patients felt unable to speak out against what they
saw as the stroke professionals' decisions, for fear of being rejected
by staff.
Mixed messagesA few low motivation patients
described some of the stroke unit professionals as giving out unhelpful
"mixed messages." One patient reported that physiotherapists
encouraged her to work at rehabilitation. On returning to the ward,
however, she thought the nurses discouraged such effort by putting
her to bed. This resulted in confusion regarding the correct way to behave. "The help was good downstairs [in the physiotherapy gym] but when I come up here, I go to bed again so what can I do?
. . . So I don't know what is good or bad
. . . I just don't know . . . you
can't bother people just because you want to learn how to walk"
(patient 5, low motivation). Another low motivation patient doubted the
point of physiotherapy as her leg had been injured when nurses were
putting her in a wheelchair. This patient also reported feeling less
inclined to attend rehabilitation when she discovered that her goal of
returning home was deemed unrealistically high. Another low motivation
patient described feeling obliged to let the nurses wash him as this
was the "law" in the hospital.
Desire to leave hospitalAlmost all the patients wanted to
leave hospital as quickly as possible. In addition, some cited this
desire as a main motivating factor for doing rehabilitation exercises.
Most of these patients resented the institutional feel of the hospital.
Some complained that the ward environment was depressingly unstimulating.
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Discussion |
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Top
Abstract
Introduction
Methods
Results
Discussion
References
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Advantages of study
The value of qualitative methods in researching patient attitudes
is well recognised.15
Semistructured interviews that allow patients considerable
control over the conversation are an efficient way to investigate an
underresearched topic and to allow patients to explain their beliefs
accurately in their own terms.
Limitations of study
Our sample excluded patients with severe linguistic or cognitive
impairments and patients diagnosed with disorders that we considered
would affect motivation (for example, depression)a sizeable
proportion of stroke patients.16
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What is already known on this topic
Rehabilitation professionals have long held that patient motivation affects outcome, but little research has been conducted into the nature of motivation Clinical rehabilitation literature has relied on unsupported models of motivation as a character trait of the individual patient If motivation affects outcome, its nature and determinants ought to be better understood What this study addsPatients with stroke identified as having high motivation for rehabilitation were found to align themselves more closely to the aims and methods of rehabilitation professionals, and were more likely to understand the nature and purpose of their rehabilitation, than those identified as having low motivation Information about rehabilitation, favourable comparisons with other stroke patients, and the desire to leave hospital were positive determinants of motivation; overprotection from family members and professionals, lack of information and the provision of mixed messages about rehabilitation to patients, and unfavourable comparisons with other patients were negative determinants of motivation Rehabilitation professionals and carers ought to be aware of the ways in which their behaviour affects motivation |
Clinical implications
If motivation is linked to understanding rehabilitation (especially understanding the role expected of the patient by rehabilitation professionals), and if this understanding is related to
the possession of information about rehabilitation, then motivation might be increased through the provision of more extensive and more
efficiently communicated information. When we carried out this study
there was no formal provision of information about rehabilitation to
patients on the stroke unit. Provision of information to patients could
conceivably diminish the negative effects of overprotection,
unfavourable comparisons with other patients, and the encouragement of
a role at odds with the one prescribed by rehabilitation. In addition,
information about setting goals and involving the
patient in the process of setting these goals have previously been
proposed as positive determinants of
motivation.
17 18
It might be especially important
for nursing staff to avoid giving out "mixed messages" about what
is expected of rehabilitation patients. The constant contact nurses
have with patients gives them an important input in
rehabilitation.
16 19
Implications for further research
Further research into the determinants of motivation is required.
Ethnographic research into how patients are treated by rehabilitation
professionals on the basis of labels such as "motivated" and
"unmotivated," and the effects this might have on motivation, seems
warranted. Research into how patients themselves categorise motivation
might also be useful. All such research might help in maintaining
motivation among rehabilitation patients, a task often taken to be
"the most important, yet the most difficult part of the work of the
therapeutic professions."22
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Acknowledgments |
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We thank the professionals on the stroke unit, the family members, and most of all the patients who agreed to be interviewed. We also thank Dr Ajay Bhalla.
Contributors: NM refined the study design, performed a literature search, conducted and analysed the interviews, wrote the paper, and is guarantor. PP, CW, and AR were involved in the original study design, refining the study design, and drafting the paper.
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Footnotes |
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Conflict of interest: None declared.
Funding: The Stroke Association.
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References |
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Top
Abstract
Introduction
Methods
Results
Discussion
References
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| 1. | Gubrium JF, Buckholdt DR. Describing care: images and practice in rehabilitation. Cambridge, MA: Oelgeschlager, Gunn and Hain, 1982. |
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| 14. | Weber R. Basic content analysis. London: Sage, 1990. |
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| 16. | Anderson R. The aftermath of stroke. Cambridge: Cambridge University Press, 1992. |
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| 20. | Hoffman JE. Care of the unwanted: stroke patients in a Canadian hospital. In: Coburn D, D'Arcy C, New P, Torrance G, eds. Health and Canadian Society. Markham, ON: Fitzhenry and Whiteside, 1981. |
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| 22. | O'Gorman G. Anti-motivation. Physiotherapy 1975; 61: 176-179[Medline]. |
(Accepted 3 August 2000)
© BMJ 2000
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