Title: Exploring and targeting the behavioural factors influencing patient participation in rehabilitation on critical care, to inform a theory-based behaviour change intervention.
Funder: Health Education England

Abstract: Background Improved survival following critical illness brings an increase in long-term complications including physical, psychological and cognitive morbidity. These can hinder and dictate the course of recovery, therefore, the delivery of physical rehabilitation to restore muscle strength and improve functional independence, is essential throughout the critical care continuum. Despite the development of guidelines, recommending the initiation of early rehabilitation, uptake and provision of rehabilitation on critical care units in the UK remains inconsistent. Existing literature focuses on organisational and healthcare professional-level barriers, and very little is known about the perceptions of patients and families and their reasons for non-engagement in rehabilitation in this setting. Applying behavioural theory could provide a useful structure to explore the factors influencing patient participation, understand the behaviour-change processes and inform the development of a targeted intervention. Aim The overarching aim of this proposed research is to develop a theoretically-informed behaviour change intervention to increase patient participation in early rehabilitation on critical care. This will be achieved by addressing the following research questions: What are the component behaviour change techniques (BCTs) used in existing critical care rehabilitation studies to increase patient participation in rehabilitation on critical care and how are they linked to effectiveness? What are the key perceived barriers and facilitators to participation in early rehabilitation on critical care from the perspective of patients, their family members, and healthcare professionals? To what extent do the components of existing interventions target the key barriers and facilitators? What are the missed opportunities for intervention design and refinement?Plan Multi-phased mixed methods study with three planned phases: Phase A: A systematic review of existing critical care rehabilitation literature and content analysis of existing interventions. This will aim to describe the content of existing interventions, in terms of the behaviours they target, their functions and component BCTs. Phase B: Qualitative semi-structured interviews with critical care patients, their relatives/carers and healthcare professionals. The theoretical domains framework (TDF) will inform the topic guide and analysis, to identify the barriers and facilitators to participation in rehabilitation on critical care. Phase C: Triangulation of findings from the interview studies, to identify key barriers and facilitators. The findings will be mapped, using established matrices, to explore whether existing interventions target identified barriers/facilitators and ascertain whether the inclusion of additional BCTs is required. The findings will be used to propose BCT intervention packages using a co-design panel. A group of patients, relatives, healthcare professionals and behavioural scientists will then be asked to rank the proposed intervention packages during a consensus setting exercise, using a nominal group technique. The intervention package ranked most highly will be ready to carry forward to pilot stage. Summary of potential benefitImprove the standard of care, by providing recommendations to support clinicians to identify and target key patient defined barriers/facilitators to participation in rehabilitation on critical care. In the longer term, following pilot testing and economic evaluation the targeted intervention package will potentially lead to greater patient participation in rehabilitation, hence improved physical and psychological function at Critical Care discharge.

Lay abstract: Background Research has shown that exercise and early movement can help patients to recover during their critical care stays (intensive and high dependency care). Therefore, physiotherapists often give patients exercises and help them to get out of bed as soon as possible. This is called 'rehabilitation' and it aims to help patients to regain their muscle strength and independence. Studies have shown that rehabilitation is safe and achievable for critical care patients. However, the number of patients taking part in rehabilitation on critical care wards remains inconsistent. There has been some research looking at the possible reasons for this, but it has mainly focused on the views of healthcare professionals and organisational issues, for example, limited resources. There is very little known about how patients and their relatives feel about participating in rehabilitation at this stage in their hospital stay and what influences' their decision on whether to take part. It is important to explore experiences of rehabilitation and understand what factors (e.g. motivation, support, fear) might help or limit patient participation on critical care. Aims To explore the rehabilitation experiences of patients, their relatives/carers and healthcare professionals and identify what influences a patient's decision whether to take part in rehabilitation on critical care. It is hoped that by recognising the influences, it might be possible to develop a behaviour change intervention to help healthcare professionals to encourage patients to participate in early rehabilitation on critical care. Methods This project proposes a number of studies over three phases: Phase A: The research team will review existing studies about rehabilitation on critical care. They will look at whether any behaviour change techniques (BCTs) have been used in those studies to encourage patients to take part in rehabilitation. Phase B: The research team will carry out in-depth interviews with adult patients from UK critical care units who have received or been offered rehabilitation, their relatives/carers, and healthcare professionals. The interviewers will ask people to talk about their recent experiences of rehabilitation. A framework, commonly used in health research to look at influences of behaviour will be used to guide the discussion. Using this framework will help the researchers to understand possible factors (known as the barriers and facilitators) that might contribute to a patient's decision on whether or not to take part in rehabilitation. Phase C: The research team will develop a list of possible BCT packages using an existing behaviour change guide. For example, if 'motivation' was identified in phase B as a 'barrier' to patient participation, the framework might suggest 'goal setting' as a possible BCT. A group of patients, relatives and professionals will then be asked to rank the suggested BCT packages and review them against a set of criteria. The BCT package ranked most highly will be put forward as a new intervention for further development and testing. Patient and Public Involvement A Project Advisory Panel of lay advisors (patients and relatives/carers) and clinicians will be involved throughout the research project. They will review and modify study information and help to develop accessible study resources. Additionally, they will support the research team by providing their comments on the interpretation of the data. Dissemination The results of the project will be submitted to journals for publication and presented at national and international conferences. The project advisory panel will help to share information with the wider public through relevant charities, specialist interest groups and social media.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: GENERIC HEALTH RELEVANCE