Dr Kate Threapleton

Background

After a stroke, patients may have new and significant levels of impairment on discharge from hospital (Whitehead et al., 2014)

Pre-discharge home assessment visits are part of routine occupational therapy practice after stroke (Chibnall, 2011)

Background

After a stroke, patients may have new and significant levels of impairment on discharge from hospital (Whitehead et al., 2014)

Pre-discharge home assessment visits are part of routine occupational therapy practice after stroke (Chibnall, 2011)

However, this process can vary greatly across stroke services due to differing policies and resources (Drummond et al., 2012; Whitehead et al., 2014)

Is there scope for other methods to be used as part of discharge planning to support current practice?

Could virtual environments be an appropriate alternative tool?

Virtual Environments

Virtual environments are computer simulations of real world or strategically designed settings

User can explore and interact with the environments via an avatar – a digital representation of themselves

Used widely in health education and increasing application within stroke rehabilitation

Potential for pre-discharge planning?

Research Aims

To explore the potential of a virtual environment designed to simulate a generic layout of a home with issues relevant to patients after stroke

Initial qualitative study to explore both therapist and patient perspectives of this concept

Potential to support ward-based discussions regarding discharge with patients and carers

The Virtual Environment

The virtual environment was created using OpenSimulator software to simulate a generic layout of a bungalow

All on one level with four rooms: a kitchen, living room, bathroom and a bedroom

Users were able to navigate and explore the virtual home

Included standard furniture and household items

Contained 50 safety risks

Safety risks:

Trip hazards

Out of date food in the kitchen

Overloaded plug sockets

Faulty oven ignition

Iron with frayed cable

Method

Individual semi-structured interviews were conducted with three groups:

Occupational therapists from two Stroke Units

In-patients diagnosed with a stroke

Stroke survivors from a community setting

Interviews explored:

Perceptions of the virtual home for clinical use

Acceptability and perceived barriers

Participants were shown the virtual home at the start of the interview and given the opportunity to try the software

Results

• Occupational Therapists (N=13) were recruited

6 from acute stroke wards; 7 from stroke rehabilitation wards

• Patients (N=8) were recruited

2 male: 6 female; Mean age = 68 years (range 23-93 years; SD 23.73) 6 had no previous use of computers

• Stroke survivors (N=4) were recruited

Stroke onset ranged from 1999 to 2011 2 male: 2 female; Mean age = 70 years (range 65-78 years; SD 9.18) 1 had no previous use of computers

Interview Findings

Data was analysed thematically (Braun & Clarke, 2006)

1. Perceived clinical uses

a) Patient and carer education

b) Tool to screen and assess patient insight into safety risks

2. Barriers and limitations

3. Identified modifications

1. A. Patient & Carer Education

Therapists thought it could be used as a educational package to help patients and carers prepare for discharge

Visual way to facilitate discussions

Prompts about own home and any changes required

Increase awareness of safety risks

“It could definitely be used as an educational tool, and more of a prompt for our initial interview that we do with the family. Just to make sure we are not missing anything, because it is amazing what families forget to tell us.” (OT9)

Patient & Carer Education

Patients and stroke survivors also viewed it as a appropriate tool to facilitate discussions

“You can look at and say ‘Well, how would you cope with that? How are you going to cope with heating?

How are you going to cope with getting to the loo?’ or whatever. So it is something, it is always a good idea to

have a picture. A picture paints a thousand words” (Stroke Survivor 1)

Patient & Carer Education

• Thought useful to help visualise equipment needed at home

Grab rails, toilet frames, hospital beds, perch stools, and the logistics of fitting, moving and storing

“I always think that the family don’t really understand the amount of space that things might require.” (OT1)

1. B. Patient Assessment

Therapists felt would be improved if it could be more interactive

Could then be used to screen and assess patient insight into different safety risks and scenarios

“They could look around and find hazards, and it would give you a talking point to discuss what they

had seen and what they’d not seen.” (OT7)

Patient Assessment

Patients and stroke survivors were able to make comparisons to their own home and could identify relevant safety risks within the virtual home

“Well, it has made me be aware. Yes more aware, because I wasn’t even thinking about the safety

aspect at all really” (Patient 5)

2. Barriers & Limitations

Limited use for those with significant cognitive or visual impairments

"I think if you got patients that have got a marked visual impairment, they might struggle with it, and patients that are probably too cognitively impaired

really to sort of grab the concept really.” (OT1)

“I think for certain patients, it could be a bit confusing if it’s not their home.” (OT2)

Barriers & Limitations

Therapists cautious about it being used to fully replace home visit assessments

“The reason we are doing home visits is to replicate them in their home environment, so the virtual

environment won’t do that.” (OT12)

“I don’t know how this would represent the complex things that we often see on home

visits and that we don’t anticipate” (OT9)

Barriers & Limitations

Age and computer literacy viewed as a potential barrier

Therapists felt that it was more suited to ‘younger patients’

“The majority of patients we have are elderly, and technical things like these just totally frighten

them. So I think the concept of this would work perhaps better with younger patients.” (OT10)

Barriers & Limitations

However, this was felt more so by therapists and stroke survivors than patients

Even though the majority of patient interviewees had never owned a computer, they were able to engage with it

“I think it is brilliant because it can be shown to people, even people that don’t understand

computers. You could go through that couldn’t you, even not understanding computers” (Patient 2)

3. Identified Modifications

More content needed

General household items - ‘clutter’; more furniture; steps/stairs; door thresholds; equipment – hospital beds, grab rails etc

Improving the usability of the software

Easier navigation controls; view of the avatar; bigger font sizes; patterns and colours used

Conclusion

The research demonstrated potential for the wider use of virtual technologies within stroke rehabilitation

Further development of the virtual home is warranted

Number of modifications were identified to develop the virtual home appropriately for clinical use

These are currently being addressed in the next phase of the research

The Research Team

University of Nottingham

Prof Avril Drummond - Professor of Healthcare Research Prof Penny Standen - Professor of Health Psychology & Learning

Disabilities Dr Niki Sprigg – Associate Professor of Stroke Medicine Emily Birks – Researcher

University of Derby

Greg Sutton – Software Developer Karen Newberry – OT Lecturer Pauline Rowe - OT Lecturer

With thanks to our funders