rehabilitation psychology case study

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• Published: 11 February 2021

Regaining A Sense Of Me: a single case study of SCI adjustment, applying the appraisal model and coping effectiveness training

• J. Duff 1 &
• B. Angell 1  

Spinal Cord Series and Cases volume  7 , Article number:  11 ( 2021 ) Cite this article

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• Patient education
• Quality of life

Introduction

Sustaining a spinal cord injury (SCI) has been shown to impose a significant physical and psychological challenge with threat to quality of life (QOL). Duff & Kennedy provide a SCI explanation of appraisals and the two-stage process of an individual’s primary assessment of their experience, and their secondary appraisal of their perceived coping resource being key facilitators of adjustment and fundamental to longer term adaptation. King & Kennedy designed a group coping effectiveness training (CET) intervention with a framework of coping strategy selection fit to reduce use of threat appraisals/avoidance coping, and to promote development of challenge appraisals with consequent stress reduction and adjustment.

Case presentation

This CET approach was applied within individual psychological therapy with a 74-year old woman who presented with symptoms of anxiety, reactivated PTSD, mood disturbance and difficulty adjusting after sustaining SCI. Psychological adjustment treatment enabled resolution of post-trauma symptoms, re-evaluation of appraisals and perceived loss of identity, and development of positive coping strategies, and promoted a new conceptualisation of independence.

Case studies of psychological treatment are rare within the SCI literature. This paper provides a detailed application of primary appraisals and coping strategy selection fit in individual therapy. Attention is drawn to the important impact appraisals have on long-term rehabilitation outcomes and the necessity of a multi-disciplinary team (MDT) approach to achieve optimal psychological and physical adjustment following SCI. Finally, the paper highlights the need for community education to reduce negative perceptions/taboo of disability.

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Sustaining a spinal cord injury (SCI) has been shown to impose significant physical and psychological consequences [ 1 ]. In some instances, research has evidenced a reduction in quality of life (QOL), with around 35% of patients experiencing depression [ 1 , 2 ], alongside a higher likelihood of anxiety and an increased risk of suicide [ 3 , 4 ].

Contemporary explanatory models of psychological adjustment following SCI were built on an understanding that successful coping and adjustment is a product of interactions between a person and their environment [ 5 ]. Over time, researchers have considered the role of coping strategies, applying Folkman and Lazarus’s Transactional Model of Stress and Coping [ 5 ], and developing more advanced adjustment models formulated on individual response [ 6 ]. This led to the evolution of coping models that focused on the individual’s preferential coping style and recognised bespoke personal adjustment.

Duff and Kennedy [ 7 ] provided an SCI-specific translation of the Transactional Model (Fig. 1 ), suggesting SCI-specific examples of threat, loss and challenge (primary appraisals) and perceived resources available for coping (secondary appraisals [ 5 ]). They recognise from general psychological research, the influence of pre-injury psychological factors (e.g., emotional history, social support, self-efficacy etc.) but make specific reference to disability beliefs about self-world schema adjustment from cognitive therapy, which can influence preferred coping styles. Folkman et al. suggested that problem-focused coping strategies find best fit with situations appraised to be ‘changeable’ and emotion-focused strategies to situations appraised to be ‘unchangeable’ [ 8 ]. Contemporary research has criticised the stringent categories of emotion and problem-focused coping, questioning their conceptual clarity [ 9 ]; Duff and Kennedy’s model therefore advances these suggesting that beliefs about ‘manageability’ develop from appraisal-coping strategy fit. ‘Manageability’ develops through use of approach strategies (e.g., thinking about how to cope and problem solve), or negatively develops an avoidance framework, with hypothesised detrimental adjustment outcome, from beliefs that SCI is ‘unmanageable’. This conceptualisation was developed further through coping effectiveness training (CET) [ 10 , 11 , 12 ], with Kennedy’s longitudinal research endorsing the association between avoidance, poorer adjustment and mood state [ 13 ].

SCI Appraisal Adjustment Model (based on transaction model of stress and coping [ 8 ]), Duff and Kennedy [ 7 ].

Additionally the SCI Adjustment Model [ 14 ], based on Duff and Kennedy, adds to research knowledge of the fluidity and non-linear process of adjustment within developing self-efficacy beliefs after SCI.

Appraisal-based models within SCI research have indicated associations and predictions between early coping strategies after injury and long-term coping [ 13 ]. Evidence also highlights negative appraisals as key predictors of mood [ 15 ] and shows their significant impact on coping [ 16 ]. The use of avoidance-focused coping strategies were found to be significant predictor of mood, stress and QOL at 12 weeks and 1 year post injury, and contributed significantly to the variance in these outcomes at 2 years post injury [ 17 ].

Although there is limited comparative research into psychological treatment, it is recognised that addressing psychological health and adjustment impacts on rehabilitation outcome [ 7 ]. Cognitive Behavioural Therapy (CBT) is an evidence-based structured intervention for anxiety and depression [ 18 , 19 ], however, SCI-specific applications of effectiveness are less conclusive [ 20 , 21 , 22 ]. Dorstyn et al. [ 23 ], in a meta-analysis of CBT efficacy for adults with SCI, suggested a significant positive impact on short-term psychological factors (mood); however, these benefits were not sustained 2 years after SCI and suggested the need for specific therapeutic interventions focusing on short, medium and long-term adjustment.

King and Kennedy designed the brief, structured group intervention, CET, to teach practical appraisal skills and a stress management toolkit within SCI rehabilitation [ 10 ]. A crucial component of CET is the re-evaluation of appraisal and coping strategy fit - whether the impact of a stressor was reduced. CET amalgamates psychological appraisal theory and CBT, providing a framework that individuals can utilise to reduce threat appraisals and development of avoidance coping strategies [ 24 ]. CET has been shown to reduce depression, anxiety and psychological distress [ 12 ], through providing a group space in which individuals can consider potential stressor reactions whilst focussing on practical problem-focussed strategies to promote wellbeing. By reducing perceived demand and consequent stress, the intervention aims to improve an individual’s actual and perceived control [ 25 ]. Components of the intervention include psychoeducation, goal directed action/goal planning [ 26 ], problem solving, reconnection with values and social support work [ 24 ].

This case report details the psychological adjustment intervention provided to an inpatient during SCI rehabilitation with psychological formulation from Duff and Kennedy [ 7 ]. CET was applied as direct individual treatment rather than in-group therapy, as previously published.

Theresa, a 74-year old woman, sustained a complete C5–C6 SCI, following a fall in March 2017. She was admitted to a local hospital where she underwent initial acute surgery and spinal stabilisation, and admitted to SCI rehabilitation 2 months after injury.

Theresa was referred to the clinical psychology team the day following admission with trauma symptoms, high levels of anxiety and difficulties coping. A comprehensive psychological assessment revealed Theresa experiencing symptoms of reactivated PTSD including anxiety at night and nightmares and difficulty coping without her family close. Routine psychological screening measures for mood and adjustment were completed: the short form of the Appraisals of DisAbility Primary and Secondary Scale (ADAPSSsf) [ 27 ], the Hospital Anxiety and Depression Scale (HADS) [ 28 ] and the Perceived Manageability Scale (PMnac) [ 29 ].

The ADAPSS is an SCI specific, 33 item self-report measure with demonstrated robust psychometric properties [ 27 ]. The short form is one of the quality indicators for psychological wellbeing on the NHS England SCI dashboard, assessing six appraisal subsets and providing a structure for a clinical interview about adjustment and areas for psychological treatment. Each subset has a normal, upper/lower and high/low distress range. The HADS [ 28 ] is a 14 item self-report measure of symptoms of anxiety and depression [ 30 ]. The PMnac [ 29 ] is a validated SCI-specific scale based on the theory of planned behaviour, and measures an individual’s beliefs about perceived control. It comprises five items measured via a four-point Likert scale. The scale is on the UK National dashboard as an outcome measure for psychological intervention and is used in QOL research [ 31 ].

Theresa scored above the recommended clinical threshold of 22 on the ADAPSSsf, and therefore, the full scale was completed. Her ADAPSSsf profile showed adjustment difficulties, with all three subscales in the high distress range for the loss/‘catastrophic negativity’ domain [ 27 ]. In terms of the ‘resilience’ domain, two subscales were in a positive direction. She was within the upper normal range for determined resolve and growth and resilience, but the low range for personal agency (Fig. 2 ). Theresa scored above clinical caseness (16) on HADS anxiety and borderline caseness (9) HADS depression. Her outcome measures reflected her clinical interview self-report, indicating that both her primary and secondary appraisals of her current situation made it feel ‘unmanageable’ (Table 1 ; PMnac) [ 7 ].

ADAPPS-sf admission (solid line) and discharge (dotted line).

Prior to sustaining an SCI, Theresa was an extremely active individual: hobbies were daily swimming, social connection with friends and family, reading, and attending church, and she took great pleasure in baking. Theresa provided care for her grandchildren and was considered to be the ‘matriarch’ and ‘go to’ person by her grown up children and family system, offering regular support. For Theresa, her SCI represented a catastrophic loss of this active contributing lifestyle, with her self-identity and perceived role within the family shifting dramatically. Theresa saw her identity move from a predominantly independent care provider to being dependent and cared for. Her family remained a strong support system, visiting the hospital regularly and providing active care. Theresa felt in great need and appreciative of such support, but recognised it compounded her perceived identity shift and psychological distress.

The NSIC Stoke Mandeville SCI Psychological Health and Wellbeing Matched Care Intervention Pathway (Table 2 ) outlines standard care to be psychological therapy every 2–3 weeks for mood/adjustment difficulties without presentation of active suicide risk [ 32 ]. Theresa attended psychological treatment aligned with this; the main intervention used was individualised CET, specifically the components of psychoeducation, problem solving, identity reconstruction and social support [ 24 , 25 ]. This collaborative intervention aimed to facilitate reappraisal and shift her perception towards one of ‘manageability’, activate approach-focused coping strategies and increase her sense of control.

Relevant medical history included a period of intubation in an intensive care unit (ICU) 20 years earlier in which Theresa recalled being unable to speak or cry but ‘inside was screaming’. These traumatic memories were reactivated following SCI surgery prior to rehabilitation and were appraised by Theresa as an ongoing threat and she requested the constant presence of a family member, predominantly her daughter, during SCI rehabilitation.

A key component of the initial psychological intervention was treatment of Theresa’s reactivated trauma symptoms and acute distress. This included reframing her traumatic memories to associate them as ‘past’ and for her to develop a current sense of safety and symptoms quickly resolved [ 33 ]. In relation to Theresa’s acute adjustment distress, intervention focused on discussion about challenges, with sessions enabling exploration of her perceptions of her ability to cope and a focus on primary appraisals, centreing on threat and loss such as, ‘I am not the same person as I used to be’ and ‘I can’t look after my grandchildren any more’. Theresa and her clinical psychologist established a strong therapeutic collaborative alliance from the initial assessment, possibly enhanced by the therapist first seeing her shortly after admission at a very vulnerable stage, whilst still on bed rest to discuss the reactivated trauma memories, and later in her rehabilitation maintaining therapeutic contact during brief ICU regressions. This therapeutic alliance enabled Theresa to be open about her greatest fears, be tearful at times, and provided space to explore her self-doubt whilst maintaining confidence in her therapist’s ability to receive and hold her strong emotion, without being overwhelmed by it, and to maintain a framework of unconditional positive regard which is central to therapeutic work. During sessions, sensitive exploration identified her values of being a good mother/grandmother/friend and discussed how to reconnect with this and regain a sense of ability. Through acknowledgement of her initial sense of perceived loss and graded CET approach, Theresa was able to connect with different aspects of the stressors, and develop small problem-solving coping actions to test out her negative beliefs, such as sending letters and cards to loved ones to maintain a social connection. This enabled re-evaluation of her appraisals and beliefs about ‘manageability’ and connected her with the value behind the action, even though the mechanism to achieve the outcome was different (e.g., through initially dictating letters to her daughter and then using voice-activated software). In time, she reconnected with other values, such as re-establishing the perceived lost role of collecting her grandchildren from school, and attending school concerts and family engagements. For a significant part of Theresa’s individual psychological treatment her daughter (her main support in hospital) was also provided with independent counselling support. In the latter stages of Theresa’s admission this became joint work with Theresa and her clinical psychologist and involved mutually-negotiated goal setting between Theresa and her daughter to enable her daughter to have time away from hospital. This involved explicit naming and recognition of the potential of carer strain and the importance of self-care. It served the dual purpose of supporting her daughter to emerge from the inpatient hospital phase and regain her own sense of personhood as well as increasing Theresa’s independence. It is a testament to the strength of Theresa, her daughter and her wider family structure that Theresa was able to have the sustained support she did and also that the system was flexible enough to cope with the changed relationship dynamics as she progressed towards discharge, and to facilitate her regaining her sense of self.

A central feature of CET is appraisal and coping strategy fit, so psychological treatment also focused on development of this and approach-focused coping strategy development. Regular mindfulness sessions were used to reduce anxiety symptoms [ 34 ], and therapy connected her behaviourally with skills of using a tablet to access mindfulness apps and develop a sense of self-care and compassion. Taught CBT mood-management strategies coupled with CET were continuously revisited throughout Theresa’s rehabilitation, aimed at increasing her perceived ability to cope. Behavioural activation (BA), commonly considered a third-wave therapy stemming from CBT, recognises the importance of changing behavioural patterns that may be positively reinforcing depression or anxiety [ 35 ]. For Theresa’s treatment, BA was used to integrate a sense of self e.g., looking like ‘old self’ (applying makeup, setting hair, wearing colourful clothes) and engaging in activity scheduling (setting aside ‘non hospital’ time to read books or watch films). Psychoeducation enabled her to identify how to use strategies to elevate her mood and reduce the impact of prolonged hospitalisation.

Promotion of Theresa’s independence and control was an ongoing theme throughout her psychological treatment sessions. Intervention included empowering her to feel comfortable and confident in expressing her needs through verbal instruction to the ward and therapy team. This piece of work included goal setting in sessions with Theresa and her daughter and then the inclusion of these within multi-disciplinary team (MDT) goal planning which in turn increased her sense of control enough for her to be alone, without her family, in hospital for a few hours and then a day. This fed into the collaborative work on identity shift, changing identification with the ‘dependent’ role adopted since injury and reclaiming behaviours and activities associated with her ‘old’ identity.

Overall, working flexibly by employing strategies from multiple psychological models and therapeutic approaches such as CET, CBT and BA enabled Theresa to adapt her self-world beliefs and thought processes (cognitions) around her injury, regain important elements of independence and control, reclaim activities in line with her values and identity, learn mood-management strategies to build resilience and maintain wellbeing, and develop a belief that SCI could be ‘manageable’ [ 7 ].

On discharge, following this regular psychological intervention, Theresa’s ADAPSSsf score had reduced to 14 (Fig. 2 ), with scores on fearful despondency and negative perceptions of disability scales decreasing. This indicated disengagement from cognitions around catastrophic negativity and loss and an increased sense of manageability (Table 1 ). Theresa’s HADS scores reduced to 6 (below clinical caseness for anxiety) and to 2 (normal range for depression).

Although many studies analyse the effectiveness of theories and models across patient populations, this paper seeks to provide a rare in-depth exposition and application of an adjustment-specific model and its connected intervention. It outlines how a psychological model of appraisals and coping strategy fit can be applied within a physical health setting [ 7 , 11 , 24 , 25 ]. Application of core themes from the group CET intervention (stressors after SCI, the development of appraisal-coping fit and effective coping strategies to promote long-term health and wellbeing) are interpreted and applied to an individual’s psychological treatment with therapeutic exploration of identity. In a study analysing avoidance and approach-focused coping at 12 week and 21-year follow-up, Kennedy et al. found that positive reinterpretation of the injury 12 weeks post SCI predicted 37.2% of variance in depression at 21 plus years [ 13 ]. This demonstrates how early rehabilitation can be a predictor of long-term adjustment and the importance of early intervention. This case study also draws healthcare professionals’ attention to the potential of re-traumatisation years after ICU admission. In the current climate of the COVID-19 pandemic it is, now more than ever, paramount that we understand both the immediate psychological impact of ventilation/life support and the long-term effects this has on psychological adjustment following future hospital admissions. In a multi-centre study analysing the risk of developing mental health difficulties following discharge from ICU, Hatch et al. found that over half the participants reported significant symptoms of anxiety, depression or PTSD and that, when symptoms of such psychological disorders were present, there was a 65% chance that they would co-occur with one of the other two disorders [ 36 ]. Kennedy et al.’s findings suggested that psychological factors such as depression and coping ability may contribute to premature mortality after SCI [ 13 ]. In addition, during the COVID-19 pandemic, many inpatients have been denied access to loved ones. In Theresa’s case, her inability to have family present during her earlier hospital admission may have contributed to her symptoms of trauma, and activated her security for her family to be present continuously during her SCI rehabilitation. This highlights the impact that being denied social connectedness may have on a patient’s ability to cope and recover. An understanding of how this isolation may also influence a patient’s presentation or reactions to staff in rehabilitation settings is valuable. Gillet et al. offer insight into psychological implications of isolation within infection-control settings in SCI and the potential barriers to social connectedness [ 37 ]. Overall, the significance of acknowledging previous health episodes and maintaining awareness that previous experiences can impact on patient’s psychological adjustment is essential and may serve as an interesting topic for future research.

This case report emphasises the significance of recognising the influence that appraisals have on behaviour, mood, adjustment and, in turn, rehabilitation outcome. Theresa initially experienced a number of threat appraisals and perceived a significant loss, in her sense of control and identity, which led to avoidance-focused coping and development of low mood and anxiety. This presentation supports the findings of Kennedy et al. [ 38 ], who found use of avoidance-focused strategies to be associated with poor mental health, and Kennedy et al. [ 15 ], who conducted a multiple regression analysis showing appraisals to have the strongest association with adjustment, accounting for 12% variance in anxiety and 34% variance in depression. Being provided with a confidential psychological space to promote positive reinterpretation and alternative appraisals meant that Theresa was able to dynamically select a coping strategy using ‘best fit’ to meet her appraisal/stress demand in the individual situations she encountered. This promoted her sense of cognitive agency, increased her sense of control and resilience, supported and integrated her SCI with her self-concept and, in turn, facilitated her psychological adjustment.

Alongside this, a key point from this case, and significant consideration for future research, is the impact that negative perceptions and unconscious cognitive bias can have on adjustment after SCI. Negative perceptions of disability are commonplace in the non-injured population. Theresa’s presentation shows how these beliefs can have a significant negative effect on initial perception after injury, with assumptions being made about value, purpose and usefulness of one’s life based on these. Olver and Duff matched SCI individuals with non-SCI individuals and found that people without SCI consistently predicted lower quality, value and meaning of life for people with SCI compared to their own [ 39 ]. The implications of such negative perceptions and assumptions of disability are poignant and extremely relevant for people who are newly injured, their families, rehabilitation staff and wider society.

Providing education and awareness-raising within non-injured community members, including friends and relatives of people living with SCI, is a crucial and sometimes neglected element of rehabilitation, and one that peer mentors within SCIC rehabilitation can positively influence. Although most UK SCI Centres provide psychoeducational family days, there is more that can be done at a societal level to provide education around disability. Including books such as ‘The Adventures of Grandad Wheels’ as a part of mainstream reading education can be effective in reducing community taboo [ 40 ].

The case study demonstrates the complexity of SCI rehabilitation and the interconnected MDT approach to psychological treatment. Although application of the appraisal-based model and associated intervention was a part of structured psychological therapy, this was provided within a backdrop of complimentary intervention by others such as nursing teams, physiotherapy, occupational therapy, medical input and in Theresa’s case speech and language therapy with MDT goal planning connecting psychological goals [ 26 ] within overall BA and rehabilitation outcomes [ 41 ]. Theresa was supported in attending groups to aid communication, socialisation with other individuals with SCI and peer mentoring. Successful adjustment to SCI requires a collaborative MDT approach, with progress being interconnected with improvement in other therapies. During Theresa’s psychological treatment sessions, discussions were focused around verbal independence and goal setting however, the real-life application of this was only able to be behaviourally applied with support from the nursing and therapy team. This highlights the significance of collaborative across-team working in order to achieve optimal psychological and physical adjustment following SCI.

Martz E, Livneh H, Priebe M, Wuermser LA, Ottomanelli L. Predictors of psychosocial adaptation among people with spinal cord injury or disorder. Arch Phys Med Rehabilit. 2005;86:1182–92.

Article   Google Scholar  

Pollard C, Kennedy P. A longitudinal analysis of emotional impact, coping strategies, and post-traumatic, psychological growth following spinal cord injury: a 10-year review. Br J Health Psychol. 2007;12:347–62.

Kennedy P, Rogers BA. Anxiety and depression after spinal cord injury: a longitudinal analysis. Arch Phys Med Rehabilit. 2000;81:932–7.

Article   CAS   Google Scholar  

Fitchenbaum J, Kirshblum S. Psychologic adaptation to spinal cord injury. In: Kirshblum S, Campagnola DI, DeLisa JA, editors. Spinal cord medicine. Philadelphia: Lippensott, Williams and Wilkins; 2002.

Lazarus RS, Folkman S, editors. Stress, appraisal and coping. New York: Springer; 1984.

Buckelew SP, Frank RG, Elliott TR, Chaney J, Hewett J. Adjustment to spinal cord injury: stage theory revisited. Paraplegia. 1991;29:125–30.

CAS   PubMed   Google Scholar  

Duff J, Kennedy P. Spinal cord injury. In: Llewelyn S, Kennedy P, editors. Handbook of clinical health psychology. Chichester: John Wiley & Sons Ltd; 2003. p. 251–75.

Folkman S, Lazarus RS, Gruen R, DeLongis A. Appraisal, coping, health status and psychological symptoms. J Personal Soc Psychol. 1986;50:571–9.

Skinner E, Edge K, Altman J, Sherwood H. Searching for the structure of coping: a review and critique of category systems for classifying ways of coping. Psychol Bull. 2003;129:216–69.

King C, Kennedy P. Coping effectiveness training for people with spinal cord injury: preliminary results of a controlled trial. Br J Clin Psychol. 1999;38:5–14.

Chesney MA, Chambers DB, Taylor JM, Johnson LM, Folkman S. Coping effectiveness training for men living with HIV: results from a randomized clinical trial testing a group-based intervention. Psychosom Med. 2003;65:1038–46.

Kennedy P, Duff J, Evans M, Beedie A. Coping effectiveness training reduces depression and anxiety following traumatic spinal cord injuries. Br J Clin Psychol. 2003;42:1–52.

Kennedy P, Kilvert A, Hasson L. A 21-year longitudinal analysis of impact, coping, and appraisals following spinal cord injury. Rehabilit Psychol. 2016;61:92–101.

Middleton J, Craig C. Psychological challenges in treating persons with spinal cord injury. In Craig A, Tran Y (Eds.). Psychological dynamics associated with spinal cord injury rehabilitation: New directions and best evidence. New York: Nova Science Publishers, 2008.

Kennedy P, Evans M, Sandhu N. Psychological adjustment to spinal cord injury: the contribution of coping, hope and cognitive appraisals. Psychol Health Med. 2009;14:17–33.

Wineman NM, Durand EJ, Steiner RP. A comparative analysis of coping behaviors in persons with multiple sclerosis or a spinal cord injury. Res Nurs Health. 1994;17:185–94.

Kennedy P, Lude P, Elfström ML, Smithson E. Appraisals, coping and adjustment pre and post SCI rehabilitation a 2-year follow-up study. Spinal Cord. 2012;50:112–8.

NICE. Generalised anxiety disorder and panic disorder in adults: management. 2011. https://www.nice.org.uk/guidance/CG113/chapter/1-Guidance .

NICE. Depression in adults: recognition and management. 2016. https://www.nice.org.uk/guidance/CG90 .

Craig A, Hancock K, Dickson H, Chang E. Long-term psychological outcomes in spinal cord injured persons: results of a controlled trial using cognitive behavior therapy. Arch Phys Med Rehabilit. 1997;78:33–38.

Dorstyn DS, Mathias JL, Denson LA. Psychological intervention during spinal rehabilitation: a preliminary study. Spinal Cord. 2010;48:756–61.

Mehta S, et al. An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post-spinal cord injury. Rehabilit Psychol. 2011;56:15–25.

Dorstyn D, Mathias J, Denson L. Efficacy of cognitive behavior therapy for the management of psychological outcomes following spinal cord injury a meta-analysis. J Health Psychol. 2011;16:374–91.

Kennedy P. Coping effectively with spinal cord injuries; a group programme workbook. Treatments that work series. Oxford: Oxford University Press; 2009.

Craig A, Middleton J, Duff J. (accepted for publication). Spinal Cord Injuries, p X in vol X. In: Comprehensive Clinical Psychology. Elsevier Science Ltd.

Kennedy P, Henderson J, Gallagher S. Improving goal attainment with spinal cord injured patients. J Assoc Qual Healthc. 1996;3:145–5.

Google Scholar  

Dean RE, Kennedy P. Measuring appraisals following acquired spinal cord injury: a preliminary psychometric analysis of the appraisals of disability. Rehabilit Psychol. 2009;54:222–31.

Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–70.

Kennedy P, Scott-Wilson U, Sandhu N. The psychometric analysis of a brief and sensitive measure of perceived manageability. J Psychol Health Med. 2009;14:454–65.

Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale. Update Lit Rev J Psychosom Res. 2002;52:69–77.

Wolstenholme D, Downes T, Leaver J, Partridge R, Langley J. Improving self-efficacy in spinal cord injury patients through “design thinking” rehabilitation workshops. BMJ Qual Improv Rep. 2014;3:1–5.

Duff J. NSIC Stoke Mandeville SCI Psychological health and wellbeing matched care intervention pathway. UK Copyright Service Registration: 284734611 (2017).

NICE guideline. 2018. www.nice.org.uk/guidance/ng116 .

Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78:169–83.

Lewinsohn PM. The behavioral study and treatment of depression. In: Hersen M, Eisler RM, Miller PM, editors. Progress in behavioral modification. New York: Academic; 1975. p. 19–65.

Hatch R, Young D, Barber V, Griffiths J, Harrison DA, Watkinson P. Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study. Crit Care. 2018; 22.

Gillett JL, Duff J, Eaton R, Finlay K. Psychological outcomes of MRSA isolation in spinal cord injury rehabilitation. Spinal Cord Ser Cases. 2020;6:63–72.

Kennedy P, Lowe R, Grey N, Short E. Traumatic spinal cord injury and psychological impact: a cross-sectional analysis of coping strategies. Br J Clin Psychol. 1995;34:627–39.

Olver L, Duff J. Cited in: Duff J, Kennedy P. Spinal cord injury. In: Llewelyn S, Kennedy P (eds.). Handbook of clinical health psychology. Chichester: John Wiley & Sons Ltd; 2003. p. 251–75.

Abram B. The adventures of grandad wheels. United Kingdom: Independent Publishing Network; 2019.

Duff J. Rehabilitation and goal planning approaches following spinal cord injury: facilitating adjustment. In: Craig A, Tran Y, editors. Psychological aspects associated with spinal cord injury rehabilitation: new directions and best evidence. New York: Nova Science; 2008.

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Acknowledgements

The authors would also like to thank Theresa for permission to share her story and members of the MDT who provide a collaborative service offering individuals optimal rehabilitation.

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The authors would like it to be known that Theresa is a pseudonym used to maintain anonymity. Written consent was gained from the individual detailed for her case to be used in an ISCoS Scientific Meeting oral presentation (2019) and in this written publication (2020).

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Duff, J., Angell, B. Regaining A Sense Of Me: a single case study of SCI adjustment, applying the appraisal model and coping effectiveness training. Spinal Cord Ser Cases 7 , 11 (2021). https://doi.org/10.1038/s41394-020-00349-3

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Received : 01 September 2020

Revised : 09 October 2020

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Published : 11 February 2021

DOI : https://doi.org/10.1038/s41394-020-00349-3

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Case Studies in Neuropsychological Rehabilitation

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After a discussion of current theory and research findings relating to rehabilitation of brain injury, this book presents 20 case studies of adults with severe brain injuries sustained several years earlier. The causes of their brain damage include traumatic head injuries, encephalitis, stroke and hypoxia. Problems that follow such injuries including loss of self-care skills, memory impairment, language, reading, visuoperceptual and behavioural difficulities, are analysed in detail. The book describes the premorbid lifestyle of each of the 20 individuals, the onset of their brain damage, subsequent symptoms, neuropsychological assessment, rehabilitation, and long-term outcome. Most chapters include a report by the patient and/or family member, thus providing an extra dimension that helps to increase the reader's understanding of the predicaments faced by brain-injured individuals as they learn to cope with traumatic changes in lifestyle. Although improvement for most brain-injured people is slow and limited, all those described in this book made some progress after their admission to rehabilitation services. The exhaustive analysis of each case and step-by-step description of treatment will encourage professionals and other care-givers that much can be done for this severely injured group. For students of neuropsychology and rehabilitation, the book should serve as an inspiring and informative supplementary text.

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• About the Project
• Introduction to the ICF
• Introduction to the ICF Core Sets
• Introduction to ICF-based Documentation Tools and Rehab-Cycle
• 01 | Goal-Setting
• 02 | Independence
• 04 | Health Behaviour
• 05 | SCI in Older Persons
• 06 | Recovery After Traumatic SCI
• 07 | Return-to-Work
• 08 | Community Reintegration
• 09 | Sports in Rehabilitation
• 10 | Walking Recovery
• 11 | Care in Low and Middle-Resource Countries
• 12 | SCI and Environmental Accessibility
• 13 | SCI in Adolescence and Peer Relationships
• 14 | Bowel and Bladder Management
• 15 | Psychological Issues And SCI
• 16 | Time-Related Aspects
• 17 | Motivation And Rehabilitation
• 18 | Social Service Support In SCI Rehabilitation
• 19 | SCI And Chronic Pain Management
• 20 | Rights For Persons With Disability

Psychological Issues And SCI

Spinal cord injury (SCI) is an extreme and stressful life event that can leave individuals in a state of emotional instability. The person's overall psychological well-being can be influenced not only by the stress experienced during and after the trauma, but also by his or her personal resources and coping strategies.

General Introduction

Ingrid's Story

Ingrid had been living an independent and successful life when a mountain bike tour changed her life completely.

To develop a profile of Ingrid’s functioning state at the start of the Rehab-Cycle ® , her rehabilitation team conducted a comprehensive assessment. This first assessment encompassed a battery of discipline-specific evaluations (health professional perspective) and involved interviewing Ingrid to capture her perspective about her functioning and health status (patient perspective).

Goal-setting/Determination of Intervention Targets

As a guide for creating Ingrid's functioning profile, for setting goals and for determining intervention targets based on the first assessment of Ingrid's functioning, the rehabilitation team utilised the ICF Core Set for spinal cord injury (SCI) in the post-acute context.

Assignment and Intervention

In Ingrid's Rehab-Cycle ® , a psychologist was assigned to address her emotional and psychological needs, focusing primarily on Ingrid's cycle goal 4 ‘psychosocial well-being’.

After completing the intervention phase of the Rehab-Cycle ® Ingrid's functioning was re-evaluated to assess the extent to which the goals she and her rehabilitation team had set at the beginning of the Rehab-Cycle ® were achieved.

The major life changes and the stress that accompany a spinal cord injury (SCI) can contribute to increasing the risk of developing emotional and other psychosocial problems.

• Lazarus RS, Folkman S. Stress, appraisal and coping. New York, USA: Springer Publishing; 1984.
• Kennedy P, Evans M, Sandhu N. Psychological adjustment to spinal cord injury: The contribution of coping, hope and cognitive appraisals. Psych Health Med. 2009; 14(1): 17-33.
• Peter C, Rauch A, Cieza A, Geyh S. Stress, internal resources and functioning in a person with spinal cord disease. NeuroRehabilitation. 2012; 30(2): 119-130.
• Bickenbach J, Officer A, Shakespeare T, von Groote P. (eds.) International perspectives on spinal cord injury (IPSCI). Geneva, Switzerland: World Health Organization; 2013.
• Fichtenbaum J, Kirshblum S. Psychological impact of spinal cord injury. In: Kirshblum S, Campagnolo DI. (eds.) Spinal cord medicine. Philadelphia, Pennsylvania (USA): Lippincott Williams & Wilkins; 2011. p. 382-397.
• Galvin L, Godfrey H. The impact of coping on emotional adjustment to spinal cord injury (SCI): Review of the literature and application of a stress appraisal and coping formulation. Spinal Cord. 2001; 39: 615-627.
• Livneh H, Martz E. Coping strategies and resources as predictors of psychosocial adaptation among people with spinal cord injury. Rehabil Psychol. 2014; 59(3): 329-339.
• Mohta M, Sethi AK, Tyagi A, Mohta A. Psychological care in trauma patients. Injury, Int J Care Injured. 2003; 34: 17-25.
• North NT. The psychological effects of spinal cord injury: A review. Spinal Cord. 1999; 37: 671-679.
• Harper LA, Coleman JA, Perrin PB, Olivera SL, Perdomo JL, Arango JA, Arango-Lasprilla JC. Comparison of mental health between individuals with spinal cord injury and able-bodied controls in Neiva, Colombia. J Rehabil Res Dev. 2014; 51(1): 127-136.
• Lequerica AH, Forschheimer M, Tate DG, Roller S, Toussaint L. Ways of coping and perceived stress in women with spinal cord injury. J Health Psych. 2008; 13(3): 348-354.
• Folkman S. The case for positive emotions in the stress process. Anxiety, Stress, & Coping. 2008; 21(1): 3-14.
• Pollard C, Kennedy P. A longitudinal analysis of emotional impact, coping strategies and post-traumatic psychological growth following spinal cord injury: A 10-year review. Br J Health Psychol. 2007, 12: 347-362.
• Kennedy P, Kilvert A, Hasson L. A 21-year longitudinal analysis of impact, coping, and appraisal following spinal cord injury. Rehabil Psychol. 2016; 61(1): 92-101.
• Elfström ML, Kennedy P, Lude P, Taylor N. Condition-related coping strategies in persons with spinal cord lesion: A cross-national validation of the Spinal Cord Lesion-related Coping Strategies Questionnaire in four community samples. Spinal Cord. 2007; 45: 420-428.
• Elfström ML, Rydén A, Kreuter M, Persson LO, Sullivan M. Linkages between coping and psychological outcome in the spinal cord lesioned: Development of SCL-related measures. Spinal Cord. 2002; 40: 23-29.
• Dryden DM, Saunders LD, Rowe BH, May LA, Yiannakoulias N, Svenson LW, Schopflocher DP, Voaklander DC. Depression following spinal cord injury. Neuroepid. 2005; 25(2): 55-61.
• Orenczuk S, Mehta S, Slivinski J, Teasell RW. Depression following spinal cord injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A. Eds. Spinal Cord Injury Rehabilitation Evidence (SCIRE) Version 5.0. 2014. p. 1-33.
• Post MWM, van Leeuwen CMC. Psychosocial issues in spinal cord injury: A review. Spinal Cord. 2012; 50: 382-389.
• World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland: World Health Organization; 2001.
• Kirchberger I, Cieza A, Biering-Sørensen F, Baumberger M, Charlifue S, Post MW, Campbell R, Kovindha A, Ring H, Sinnott A, Kostanjsek N, Stucki G. ICF Core Sets for individuals with spinal cord injury in the early post-acute context. Spinal Cord. 2010; 48(4): 297-304.
• Grazebook K, Garland A. What is CBT? (PDF on the British Association For Behavioural and Cognitive Psychotherapies (BABCP) website). [Internet] June 2005. Available from: http://www.babcp.com/Public/What-is-CBT.aspx. Accessed May 2016.
• Hillier S and Worley A. The effectiveness of the Feldenkrais Method: A systematic review of the evidence. Evid Based Complement Alternat Med. 2015; 2015 (Article ID 752160): 1-12.
• Elfström ML, Rydén A, Kreuter M, Taft C, Sullivan M. Relations between coping strategies and health-related quality of life in patients with spinal cord lesions. J Rehabil Med. 2005; 37: 9-16.

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A case study of a strategic initiative in pediatric rehabilitation transition services: An insiders' perspective on team principles and practices

Gillian king.

1 Bloorview Research Institute and Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada

Laura R. Bowman

2 Holland Bloorview Kids Rehabilitation Hospital and Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada

C. J. Curran

3 Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada

Laura Thompson

Carolyn mcdougall, dolly menna-dack, laura howson-strong, associated data.

The original contributions presented in the study are included in the article/supplementary materials. Further inquiries can be directed to the corresponding author/s.

The aim was to describe an innovative initiative that took place in a pediatric rehabilitation hospital. The goal of this organization-wide strategic initiative, called the Transition Strategy, was to improve service delivery to children/youth with disabilities and their families at times of life transition. The research question was: What are the key elements that have contributed to the success of the Strategy, from the perspective of team members? The objectives were to describe: (a) the guiding principles underlying team functioning and team practices, (b) key enablers of positive team functioning, (c) the nature of effective team practices, and (d) lessons learned.

A holistic descriptive case study was conducted, utilizing historical documents, tracked outcome data, and the experiences and insights of multidisciplinary team members (the authors). Reflecting an insiders' perspective, the impressions of team members were key sources of data. The perspectives of team members were used to generate key teamwork principles, enablers of team functioning, team practices, and key learnings.

Findings and Discussion

Team members identified four guiding humanistic principles (respect, support, partnership, and open communication). These principles underpinned three novel practices that contributed to team effectiveness in the eyes of team members: supportive relational practices, human-centered co-design, and solution-focused communication. Key enablers were the relational style of leadership, and a team climate of innovation, autonomy, and trust, supported by the organizational vision. This team climate fostered a sense of psychological safety, thereby encouraging both experimentation and learning from failure.

Conclusions

This article provides information for other healthcare organizations interested in understanding the Strategy's value and its implementation. It provides a practical example of how to adopt a humanistic approach to health care, leading to both innovative service development and thriving among team members.

Introduction

“ Fallen through the cracks ”, “ left stranded ”, and “ lost in the system ”: These metaphors describe the demoralizing state of affairs experienced by many youth with disabilities as they transition to adulthood ( 1 – 3 ). They also indicate the widespread need for an initiative or approach to address the shortcomings of the healthcare system, as it often fails to address the needs and aspirations of children and youth with disabilities, particularly at times of transition such as from post-secondary education to adult roles ( 4 ).

Transition is a complex and multifaceted process requiring partnerships among young people, their families, service providers, and healthcare organizations and systems ( 5 ). Since transitions are often challenging for youth with disabilities and their families, innovative organizational initiatives are needed to address issues arising during transitions to adult roles and adult healthcare systems. Accordingly, this article describes the principles and practices of an organization-wide strategy (the Transition Strategy), which was designed to provide evidence-informed services to support children and youth with disabilities at times of transition and to foster meaningful experiences and meaningful lives ( 6 ). In this descriptive case study, eight members of the Transition Strategy reflected on their experiences and, guided by Mathieu et al.'s model of factors influencing team effectiveness ( 7 ), identified the key team principles and practices that supported the Strategy's functioning, achievements, and outputs.

The Transition Strategy

The context for this work was a Canadian pediatric rehabilitation hospital that is also an academic health science centre, meaning that it promotes the integration of research, clinical, and educational activities to achieve evidence-informed decision making and optimal client care ( 8 ). The Transition Strategy was a five-year, donor-funded initiative that aimed to explore, understand, and take action to promote participation and well-being for young people with disabilities. The Strategy adopted an innovative focus on the process of transition, addressing the psychosocial aspects of growing into adulthood through the design of youth and family interventions informed by a humanistic approach and life course perspective ( 6 , 9 , 10 ). Beyond the impact on children, youth, and families, the Strategy aimed to have an impact on the pediatric rehabilitation healthcare system by changing engrained practices.

The vision of the Strategy was to create a sustainable systems-wide model that “re-thinks rehabilitation” by moving from a deficit-oriented to strengths-based approach to transition programming ( 11 – 13 ). From this perspective, “successful transitions” refer to outcomes such as self-efficacy, self-determination, adaptation, and resiliency ( 14 ), rather than just a successful medical handover from pediatric to adult services. The Strategy's strategic goals were to improve existing transition services, and design new evidence-informed programs in partnership with children/youth, families, and community organizations, thereby building child, family, and organizational capacity. The objectives were to co-create a common Strategy vision and ensure every client has access to personalized services as well as a transition plan. Given the hospital's status as an academic health science centre, the Strategy had both research and clinical goals. These joint goals reflected an integrated knowledge translation strategy, where program design and delivery are research-informed, and research findings and recommendations are readily translated into clinical practice ( 8 , 15 ).

Our thinking about the Transition Strategy was guided by complex adaptive systems theory ( 16 ), which has been applied to healthcare organizations and systems. Key features of complex adaptive systems include multiple intersecting parts, an evolving, self-organizing nature, and simple rules that encourage creativity and innovation ( 17 , 18 ).

In the following section, we briefly review current literature on an organizational team model that specifies mechanisms of team functioning, shared leadership, and thriving at work. These key concepts emerged from and informed team members' discussions and reflections on their experiences in the Transition Strategy.

Background literature on effective team functioning

Models of team functioning.

There is a vast literature on effective team functioning and models of teamwork in various fields, including organizational management and health care. Our case study was guided by Mathieu et al.'s ( 7 ) model of organizational teams. This model views teams as dynamic, multilevel, complex systems, which aligns with our view of the Strategy as a complex adaptive system. Mathieu et al.'s review of the last decade of research on team effectiveness used an input-mechanism-output model, emphasizing compositional features of teams (i.e., the combination of members' characteristics), structural features (e.g., task scope and complexity, team interdependence), and mediating mechanisms.

Our interest was primarily in mediating mechanisms, defined as team members' affect, behavior, and cognitions ( 19 ). Mediating mechanisms include team processes, which refer to the interdependent activities that organize task work to achieve collective goals ( 7 , 20 ). Other mediating mechanisms are considered to be emergent states, including team cohesion, trust, and team climate (e.g., innovation climate and psychological safety climate). Mathieu et al. ( 7 ) have called for more research on teams as fluid entities operating in dynamic situations, and for more research on emergent states.

Shared leadership

In Mathieu et al.'s ( 7 ) model, shared leadership is both a structural team feature and a mediating mechanism. Shared leadership is a dynamic and emergent phenomenon, where team members share leadership roles and influence ( 21 ). Meta-analyses have shown a positive relationship between shared leadership and team performance ( 21 ). Relational leadership is one form of shared leadership, referring to a leadership model emphasizing social processes of co-construction, through which team collaboration and change emerge ( 22 ). From this perspective, leadership is a relational practice involving co-creation and co-production ( 23 , 24 ), where there is a focus on communication, caring, and thriving in the workplace. Relational leadership is considered to be essential for dealing with complex issues, such as the design of transition services, where sustainability is a desired outcome along with individual well-being, organizational flourishing, and social change ( 23 ).

Thriving at work

As discussed by Mathieu et al. ( 7 ), effective teams produce tangible outputs/products and provide team members with valuable experience and new learning ( 7 ), which can contribute to a sense of thriving in the workplace. “Thriving” refers to feeling energized, valued, and productive through dynamic connections with others in the workplace ( 25 ), and is associated with supportive coworker and leadership behavior, and perceived organizational support ( 26 ). As well, perceptions of trust, autonomy, meaning, and a positive work environment have been found to be associated with team performance, team members' confidence, work engagement, innovation, and the sustainability of an innovation ( 27 ). Positive workplace practices such as respect, support, and a sense of meaning are associated with a positive team climate and a climate of innovation ( 28 ). Thus, to summarize, thriving in the workplace is related to the relationships that exist among team members, as well as the support of leadership and a team climate of innovation.

Article aim and objectives

Our research question was: From the perspective of team members, what are the key elements that have contributed to the success of the Strategy? The specific objectives were to describe: (a) guiding principles underlying team functioning and team practices, (b) key enablers of positive team functioning, (c) the nature of effective team practices, and (d) lessons learned. These teamwork principles, enablers, team practices, and lessons learned can provide direction for others on how to co-design a successful innovation and encourage a sense of thriving among team members.

Case study design

The case under study was the Transition Strategy. We adopted Yin's ( 29 ) definition of a case study as an investigation of a contemporary phenomenon within its real life context. Case studies are appropriate when there is an interest in understanding how a complex real-life phenomenon occurs ( 29 – 31 ), particularly when the phenomenon and important contextual variables are not well understood ( 32 ), which is the case for the Transition Strategy. We adopted a descriptive case study approach, which involves describing the case, the sources and methods of data collection, and the findings ( 29 ). Ethical approval was not required for this study, as it was seen as a quality assessment.

Case study protocols capture the study design, objectives, data sources, and data analysis procedures ( 29 ). As shown in our protocol ( Figure 1 ), we took a holistic descriptive case study approach ( 29 ), using a single case to describe a unique phenomenon as a unit in a real-life context. As well, the case study was intrinsic—selected on its own merits, given the uniqueness of the Strategy ( 31 ). Similar to Di Pelino and colleagues ( 33 ), the perspectives of team members constituted the units of analysis ( 34 ), and the data consisted of their own direct first-hand experience in implementing the Strategy, as well as feedback they had received from other stakeholders and end users, including parents and youth who were receiving transition services.. Thus, the impressions of team members (the authors of this paper), who had clinical and research roles, were key sources of data ( 31 ). The perspective taken was that of the “insider”—an “emic” perspective that reflects an ethnographic approach ( 35 ).

Case study protocol.

Data collection

As shown in the study protocol ( Figure 1 ), the experiences and insights of team members were captured in minutes and meeting notes. Team members discussed team functioning, core practices, and lessons learned at retreats, monthly clinical-research team meetings, and at the end of project implementation, when the idea arose about writing an article to share our experiences and insights with others. Team members’ understanding of the implementation of the Transition Strategy was also informed by feedback they received from other clinicians implementing the Strategy, parents and youth receiving the services and engaged in advisory roles, and other organizational colleagues and upper management. This feedback came to the team from various discussions, through email, and from quality assurance surveys evaluating new programs.

Case studies routinely use multiple sources of data ( 29 ). As shown in Figure 1 , although the experiences and insights of the team members were the primary sources of data, we also utilized historical documents (strategic planning documents, operational plans, meeting minutes, and other organizational documents) and tracked output information (from annual accountability reports, the organizational decision support system, and as collected by Strategy research personnel).

Data analysis

The data analysis involved team discussion, critical reflection, and consensus regarding principles, practices, and enablers of the Strategy, as well as lessons learned. We began with a reflective stance, taking an inductive approach to our process. In addition, published literature on team functioning, including Mathieu's model of factors influencing team effectiveness ( 7 ), was also used to reflect on enablers and outcomes.

First, the perspectives of team members were used to generate key teamwork principles, enablers of team functioning, team practices, and key learnings. The first author, who is a researcher, developed the initial principles and practices based on key themes that arose repeatedly in discussions held at retreats, team meetings, and meetings held to draft this paper. Other authors wrote sections of text describing features and insights gained from the Strategy stream in which they were most involved. Consensus on key insights was achieved through discussion and reflection over monthly meetings held over a 6-month period, as the article was drafted. As the team generated ideas about thriving and relational leadership, research team members brought relevant literature to the full team for discussion. There were multiple check-ins, as team members read drafts of the article, to ensure the written representation fit their understanding of events and experiences.

Thus, team members critically reflected on their experiences over a period of prolonged engagement, which contributes to the trustworthiness of case study research ( 30 ). Triangulation among team and the use of multiple sources of data also serve to enhance credibility ( 36 ). Team members can be considered key informants, as they had been involved with the Strategy since its inception, and were able to report on clinical, client/family, and organizational perspectives.

Case description

Here we consider the structure and outputs of the Transition Strategy. It is important to provide evidence of successful clinical and research outputs to justify the assertion that the Strategy was indeed an effective innovation.

The Transition Strategy was overseen by a steering committee co-led by a director and a family leader (a parent of a child with a disability). This committee included Strategy team members, family leaders and youth leaders, executive sponsors, community partners from the adult sector, and physicians. Team members were seconded from other roles in the organization based on their expertise, attitudes, drive, and passion, as well as their ability to build community partnerships, collaborate in interprofessional teams, and function as systems-level change agents.

An initial planning retreat led to the formation of five strategy streams for the development of evidence-informed services and the co-discovery of knowledge: Bridging to Adulthood (which builds innovative services and strong community partnerships to support youth transitioning to adult roles and settings), Employment Participation (services designed to promote participation in a range of typical early employment experiences), Starting Early (providing services, information sharing, and connections to support families and their young children in their first and early life transitions), Youth Engagement (providing leadership development and paid employment opportunities for youth with disabilities), and Solution-focused Coaching (a cross-cutting stream informing all the others). A co-design approach, reflecting relational leadership ( 22 ), was taken to identify this set of service streams.

The Strategy's annual goals are presented in Figure 2 . These goals built upon the knowledge, connections, and practices developed in the preceding years to establish, implement, embed, and then sustain the learning achieved over time. The first year focused on establishing and grounding the Strategy to set the Strategy streams up for success. Years two and three focused on the development of new services built on transition best practices, along with the standardization of tools and procedures to facilitate transitions and evaluate the Strategy's success and impact. The final two years focused on spreading the established practices across and beyond the organization and finding ways to sustain these changes by embedding them in existing systems or proposing new teams, processes, or systems.

Yearly goals for the Transition Strategy.

Outputs from the Strategy's activities are summarized in Table 1 . Partnership/ collaboration activities led to the development of 32 new partnerships with external organizations, along with 23 new capacity building efforts developed in partnership with these organizations. More than 2,325 clients received clinical services, and 18 new or expanded programs were offered, along with 17 types of transition pop-up events (described later). Over 1,800 staff (internal and external) received training in solution-focused coaching and principles of solution-focused communication, and 23 student placements were offered, in addition to workshops and interprofessional education sessions. To date, research and program evaluation outputs included 49 conference presentations and 9 peer-reviewed journal publications. For example, a recent publication concerned pathways to employment for youth with disabilities ( 37 ).

Summary of key outputs from activities of the Transitions Strategy a .

Findings and discussion

Objective 1: guiding principles underlying team functioning and team practices.

Figure 3 visually represents the Strategy's principles, key enablers of positive team functioning, and the team practices considered crucial to team functioning. As shown in this figure, the guiding humanistic principles were respect, support, partnership, and open communication. Team members valued genuine partnerships and collaboration, as well as an environment characterized by trust and respect. These humanistic values align with humanocracy theory, which highlights the importance of human values and principles in the workplace (e.g., the satisfaction of human needs through respect, and having control, support, and the opportunity to engage in challenging work in a safe environment) ( 38 ). Humanocracy theory emphasizes that management can be people-centered ( 38 ), reflecting the widely adopted philosophy of client/family-centered care in pediatric rehabilitation ( 39 ). This correspondence between how one is treated by colleagues and leadership, and how one works with others clinically, has been called “parallel processes” ( 40 ).

Guiding principles underlying team functioning and team practices in the Transition Strategy.

Parallel processes refer to features that are common to effective relationships both among managers and staff, and between service providers and clients ( 40 ). The common features of all forms of effective relationships include engagement through listening and attending, good communication, empowerment, and strength-building ( 40 ). Thus, both client-practitioner and practitioner-organization relationships play a fundamental role in supporting effective service provision ( 11 ). The idea of parallel organizational management and clinical processes serves to connect the ideas of team thriving and transformation of services: teams thrive when humanistic principles are adopted, and their thriving contributes to the development of innovative services and offerings.

Objective 2: Enablers of positive team functioning

The team identified two main enablers of positive team functioning, with the first being the relational leadership style of the Strategy director. The director displayed a shared leadership approach, in which leadership roles are shared both formally assigned and informally adopted and encouraged ( 41 ). Kurucz et al. ( 42 ) has described leadership as a process of social engagement and the formal leader as someone who helps others collectively redefine what is seen as valuable, in light of various challenges. Leader inclusiveness promotes psychological safety and sets the stage for organizational learning ( 43 ).

Second, a team climate of innovation, autonomy, and trust, reflecting the broader organizational culture, was viewed as a key enabler of the Strategy's success, as it allowed team members to experience a sense of psychological safety. High quality relationships in the workplace foster psychological safety, which, in turn, is related to learning behaviors in organizations ( 44 ). Having shared goals, shared knowledge, and mutual respect foster psychological safety and enable team members to engage in learning from failure ( 45 ). Seeing failure as a chance to learn reflects the Strategy's humanistic and strengths-based perspective, and the effective practices adopted by the team.

Objective 3: Nature of effective team practices

Here we consider supportive relational practices, human-centered co-design, and solution-focused communication, as shown in Figure 3 . Each of these practices reflects a relational leadership model ( 23 ) and a team climate characterized by innovation and psychological safety ( 44 ). Table 2 provides examples of Transition Strategy models and programs that illustrate each of these practices, along with evidence of their impact.

Illustrations of effective team practices.

Supportive relational practices

The hospital has a culture of innovation, which is exemplified and promoted by the senior leadership. Ideas are welcomed, space and time are allowed for the exploration of ideas, and guidance is provided at key moments. In this regard, members of the Strategy experienced many challenges together, such as developing programs that were considered to be unfeasible by the steering committee and other key stakeholders. Some of these instances were viewed, in hindsight, as positive learning experiences.

Team members felt able to engage in lively debate on various issues. Despite opposing views, there was a team atmosphere of respect and a safe working environment in which team members could actively engage through “transparent and respectful conversation”. Free exploration of ideas promoted ongoing innovation. For example, prompted by the COVID-19 pandemic, virtual programming was adopted but, as the pandemic wore on, it became apparent that families felt “virtual fatigue”. Team members adjusted their approach by offering hybrid services (a combined virtual and face-to-face approach), offering workshops on an individual basis, embedding workshop knowledge in other hospital initiatives (e.g., parent support networks, webinars), and sharing content through YouTube videos for families. This example illustrates the ability of team members to identify issues, brainstorm, and innovate in a supportive team environment, and to quickly move from what does not work to better solutions.

Another example, dealing with Project SEARCH, is presented in Table 2 . Project SEARCH is an example of an innovative program aligned with the team's mandate. This project is an internationally adopted “best practice” transition-to-work model for students with developmental disabilities, which provides supported work experiences, life skills training, and employment planning ( 46 ). Inter-agency collaboration is a key ingredient of the model ( 47 ). Annually, up to 75% of Project SEARCH graduates transition to employment ( 46 , 48 ).

Human-centered co-design practices

Human-Centered Design (HCD) refers to principles and methods that aim to create innovative solutions tailored to the needs and preferences of the end user ( 49 ). HCD has been employed in business organizations to collaboratively solve complex problems and drive service innovation, and has been implemented in a variety of healthcare settings, including disease management and health education ( 50 ). To date, HCD has been used to co-design transition support services concerning hospital discharge/transfer of care and to create standardized products/tools ( 51 , 52 ), but not to design innovative procedures or strategies.

The team embraced HCD principles from IDEO.org (“design thinking”) as a foundation for program development and refinement, as these principles reflected the team's humanistic perspective and relational leadership approach. They used a five-stage HCD process developed by the Stanford d.school (a design thinking institute based at Stanford University): (1) empathizing with and understanding the needs of the users (empathy); (2) constructing a point of view based on the needs and insights of the users (define); (3) brainstorming ideas and generating creative solutions (idea); (4) building a physical representation of the ideas (prototype); and (5) testing ideas for feedback and iteration (test).

Over 100 individuals participated in the co-design process, including stakeholders, service providers, adult sector partners, and youth and families with lived experience. The following HCD principles were adopted: (a) assuming a beginner's mindset (a stance of curiosity), (b) approaching interactions with empathy, (c) co-creating ideas and prototypes (i.e., valuing lived experience and adopting a participatory stance), and (d) engaging in an iterative process, based on recognition that plans need to be flexible with respect to implementation ( 49 ). Co-creation is non-linear, iterative, and exciting; it is associated with the belief that solutions are emergent, and that it is alright to “not know”. One specific example, dealing with the creation of a new “Transition Pop-Ups” service delivery model, is presented in Table 2 .

Solution-focused (SF) communication practices

SF communication refers to a set of practices based on humanistic principles, where listening and communication are considered central to client-provider and team member relationships, client/family-centered care ( 39 ), and effective service delivery ( 53 – 55 ). As a result of the Strategy, training in SF communication took place across the hospital. This training facilitated knowledge and confidence in using SF coaching techniques, and provided a common framework for collaborative solution-finding among teams across the organization ( 56 , 57 ). A research study indicated that the training led to greater use of strengths-based language in clinical documentation, strengths-based initial assessments and intake interviews, and strengths-based activities in programs for both youth and family members ( 56 , 57 ). Table 2 provides an example of the use of SF communication in the design of workshops in the Starting Early stream.

Objective 4: Lessons learned

Here we discuss two key learnings that reflect the Strategy's humanistic principles and practices. The first was recognizing the value of embracing the inherent messiness of the process involved in designing new services, as well as the inherent messiness of transitions themselves. Embracing this messiness and uncertainty was seen as a key ingredient for healthy and “real” transitions, which, by their very nature, are stressful and highly individual. Given the widespread use of transition guides and skills checklists that are intended to make things “easier” for the healthcare system, it can be argued that the system paradoxically oversimplifies and overcomplicates transitions by not specifically adopting a client-centered perspective, even though this is often espoused. A client-centered perspective requires understanding the highly personal nature of a given youth's transition needs, resources, and supports. The Strategy team struck a balance between systematizing (for equity) and individualizing (for client-centeredness and humanism) by recognizing the real-world messiness of transitions and by listening to clients mindfully and authentically ( 58 ), in ways that validate their experiences and foster hope and resiliency.

The second key learning was the value of the Strategy for the organization, clients and families, and team members themselves. On an organizational level, the complement of clinical programs increased due to the efforts of the Strategy. New initiatives were developed in partnership with other service organizations or were adopted in other parts of the hospital, indicating the integration and sustainability of the offered services. One noteworthy example of sustainability and spread is the Solution-focused Coaching stream, which is now embedded hospital-wide and is part of the foundational training for all new staff members. Another example is Project SEARCH, which launched as a transition initiative but is now recognized as a key element of the organization's human resources function.

The value of the Strategy for clients/families can be seen in the “best practice” of supporting families from their first contact with the hospital and throughout their journey to adult systems and adult roles. Transition-related skills are seen as life-long capacities that develop over time within the family and real-world environment ( 6 ). Trained family leaders are now available at the hospital to provide information and support regarding strategies, resources, and connections to peer mentors and community agencies, in order to ease the transition journey.

Last, the value for team members was demonstrated by their commitment and ongoing engagement. They had rich learning experiences contributing to their personal and professional growth and sense of thriving in the workplace. By being open to the needs and hopes of clients/families, team members felt they were guided and led by families in essential ways, reflecting the notion of client/family-centered care. Through the integrated knowledge translation approach adopted in the Strategy, team members came to value research more highly and were in an ideal situation to integrate findings into practice in immediate ways.

Overall discussion

This article adopted an insider perspective to conduct a case study of the Transition Strategy, a five-year donor funded initiative that viewed transitions from a strength-oriented, systems perspective. The aim was to uncover and describe the key elements contributing to the success of the Strategy in the eyes of team members, who were the authors. Guiding principles underlying the functioning of the team were considered to be respect, support, partnership, and open communication, which align with principles identified in the literature on client/family-centered care ( 39 ). Key enablers were the Director's relational leadership style and the team climate, which contributed to a sense of psychological safety, trust, and thriving in the workplace. Several innovative team practices were identified, including supportive relational practices, human-centered co-design, and solution-focused communication. These practices reflect standardized processes generated by the team to enhance their effectiveness. Two key lessons learned were the inherent messiness of the transition process, which therefore requires an individualized approach, and the value of the Strategy for the many stakeholder groups involved with the initiative. Thus, this article provided an in-depth description of the variables that, in the eyes of team members, were responsible for team outputs and service transformation (attesting to the effectiveness of the Strategy), and members' sense of thriving in the workplace.

Limitations

This article has several limitations. Foremost, aside from personal anecdotes, we do not know the wider impact of the Strategy on clients and families. We did not conduct formal interviews with key informants; rather, we adopted an “insider” perspective where key informants were authors who collaboratively contributed their experiences and insights to this paper. Nonetheless, this article provides other organizations with a vision, starting point (key principles, enablers, and practices), and initial evidence for the utility of an organization-wide strategy with a focus on transforming services for young people with disabilities and their families, which has had the concomitant benefit of facilitating team members' sense of thriving in the workplace. There are important teamwork and leadership implications for others interested in implementing a similar initiative in health care, whether it be about transitions or another important gap concerning needs or issues in service delivery.

Implications

This article has implications for both public and private healthcare organizations. The principles, enablers, team practices, and lessons learned can be informative for others seeking to develop a strategic initiative that relies on the effective functioning of a team. In addition, interested organizations can use the Strategy's operational plans for guidance in how to set milestones for an organizational initiative. The annual operational goals were to establish the streams of the Strategy, to implement and evaluate new services and standardize tools and procedures, to spread established practices within the organization and beyond, and to sustain these changes by embedding them in existing or newly created processes or systems. This general process of establish, implement and evaluate, embed , and then sustain can be used by other organizations to develop milestones for similar initiatives that aim to improve service design and delivery on a system-wide level.

From a leadership perspective, one key take-away message is that a coordinated and directed initiative, operating in accordance with a humanistic philosophy, can develop innovative programs and facilitate learning among team members. Health care can be potentially humanized through strategic initiatives that build strong, flexible, interprofessional teams involving multiple stakeholders and partners. A team that thrives interpersonally, psychosocially, and practically can provide an ideal environment for the design of services that provide optimal client care. It should also be noted that the Strategy took place in a relatively ideal organizational situation, with ample funding and positive, ongoing relationships with partnering organizations. From the start, team members had many practical foundations in place, including expertise and established working relationships. As well, they were receptive to a relational model of leadership, and had a strong commitment to the Strategy. Thus, the present findings may not directly translate into other publicly funded organizational environments.

This case study of a workplace team brought together to design, deliver, and evaluate a suite of evidence-informed, transitions-oriented services has shown the value of humanistic principles and relational leadership, as well as supportive relational practices, human-centered co-design practices, and solution-focused communication practices. Our hope is that others can learn from and be inspired by the guiding principles and team practices that embodied the learning experiences of team members and contributed to their sense of thriving in the workplace.

Acknowledgments

We express our gratitude to all members of the Transition Strategy team, the Holland Bloorview Foundation (including Sandra Hawken, President and CEO), the generous individuals who funded the initiative, Holland Bloorview Kids Rehabilitation Hospital (including Julia Hanigsberg, President and CEO, and Diane Savage, Vice-President of Experience and Transformation), and the Transition Strategy steering committee. We also extend thanks to the Ministry of Health and Long Term Care's Business Innovation Office, for their input around human-centered design, and the Rotman NeXus Consulting Group. Many thanks to the clients and families who shared their perspectives and input on needs and services.

Gillian King holds the Canada Research Chair in Optimal Care for Children with Disabilities, funded by the Canadian Institutes of Health Research. This chair is supported by matching funds from the Kimel Family Opportunities Fund through the Holland Bloorview Kids Rehabilitation Hospital Foundation.

Data availability statement

Author contributions.

The first author led the conceptualization and writing of the article. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

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