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The British Journal of Occupational Therapy logoLink to The British Journal of Occupational Therapy
. 2023 Nov 3;87(4):239–250. doi: 10.1177/03080226231206686

Occupational therapy practice to support executive function impairment after acquired brain injury: A UK clinical survey

Sarah de Charentenay 1,, Julie Whitney 2, Philippa A Logan 3
PMCID: PMC12033893  PMID: 40336584

Abstract

Introduction:

This study explored treatment of executive functioning impairment in adults after acquired brain injury (ABI), clinician’s confidence and support received, in a sample of occupational therapists in the United Kingdom.

Methods:

A 24-item online questionnaire was sent to 750 members of the Royal College of Occupational Therapists Specialist-Section in Neurological Practice. Data was collected at a nominal and ordinal level and included yes/no Likert-type scale and free field comments. Descriptive statistical analysis was completed.

Results:

Seventy-six occupational therapists working in a range of neurological settings completed the survey. Frequently used interventions included education (n = 57, 75%), task modification (n = 56, 73%), instrumental activities of daily living (ADL) (n = 54, 71%), personal ADL (n = 53, 70%) and goal setting (n = 53, 70%). Seventy-one percent used metacognitive strategies. Occupation-based metacognitive approaches were rarely used. Thirty-one (41%) participants reported being fairly confident and 28 (37%) were very confident. Support for clinical practice was accessed most frequently through joint clinical sessions (n = 30, 39%).

Findings:

Participants used various clinical interventions to treat service users with executive dysfunction after ABI. Meta-cognitive strategies were employed; however, occupation-based metacognitive approaches were infrequently utilised, suggesting uncertainty in adopting these in practice. The need for further training on evidence-based interventions and knowledge translation support was highlighted.

Keywords: Acquired brain injury, executive function, intervention, metacognitive strategy, occupation-based approaches, occupational therapy

Introduction

Impairments in higher level thinking also known as executive functioning skills frequently impact individuals after acquired brain injury (ABI); defined as a non-degenerative injury to the brain after birth including traumatic and non-traumatic brain injuries (Cramm et al., 2016; Goldman et al., 2022). Executive function is an umbrella term for several complex thinking processes required for successful goal-directed behaviour (Cicerone et al., 2000) and is a strong predictor of functional recovery (Shea-Shumsky et al., 2019). These functions are essential for successful activity performance (Cristofori et al., 2019) and incorporate the ability to plan, monitor, evaluate and change behaviour (Cicerone et al., 2006). Thus executive functioning impairment can result in task failure (Connor and Maeir, 2011) and impact day-to-day functioning (Spitz et al., 2012; Stolwyk, 2021) and societal participation (Erez et al., 2009; Skidmore et al., 2010). Addressing executive function impairment (EFI) post ABI has been identified as an important rehabilitation component (Cramm et al., 2016; Skidmore et al., 2023; Wolf, 2010).

Occupational therapists work with a range of adult service users including those experiencing executive functioning impairment after ABI and provide practical ways to support engagement in meaningful occupations (RCOT, 2020). Clinicians must be cognisant of current evidence (Cramm et al., 2013), and effectively translate and apply research into practice (Donnelly et al., 2016). Evidence to support the effectiveness of interventions for executive functioning impairment is developing, with systematic reviews (Cicerone et al., 2011, 2019; Kennedy et al., 2008) and guidelines (Jeffay et al., 2023; Royal College of Physicians, 2023) providing some practice recommendations based on research in this area.

Several studies have explored the clinical practice of occupational therapists working with individuals with neuro-cognitive impairment (Nott et al., 2020), stroke (Koh et al., 2009; Korner et al., 2011) and brain injury (Holmqvist et al., 2014). These studies identified that cognitive rehabilitation interventions used by clinicians were often generic, consisting mainly of functional retraining, with some use of compensatory (Holmqvist et al., 2014; Koh et al., 2009) and remedial (Holmqvist et al., 2014) cognitive approaches that can support areas of difficulty and optimise functional performance (Chung et al., 2013). The need to address executive functioning impairment after ABI has also been increasingly identified by occupational therapy clinicians (Holmqvist et al., 2014). More recently, a survey of occupational therapy cognitive rehabilitation practice in Australia identified use of specialist cognitive interventions in clinical practice for individuals with neurocognitive impairment, such as metacognitive strategy training (Nott et al., 2020).

Meta-cognitive strategies can be described as thinking tools and techniques to help individuals monitor, adapt and modify their behaviour and performance to optimise task efficiency and accuracy (Sohlberg et al., 2005). Preliminary research has identified that occupation-based approaches which utilise metacognitive strategy instruction (also known as occupation-based metacognitive approaches) can improve functional performance for individuals experiencing executive functioning impairment after traumatic brain injury (TBI) and stroke (Cicerone et al., 2019; Kennedy et al., 2008). These approaches use meaningful occupation and activities therapeutically to achieve client goals and outcomes (Che Daud et al., 2015), while applying a framework to support application of metacognitive strategy use (Toglia et al., 2020). However, the optimal treatment approach and intervention components including dose and timing for individuals with neurological cognitive impairment is unclear (Swanton et al., 2020), with more robust evidence required to establish intervention efficacy and guide practice (Chung et al., 2013; Skidmore et al., 2023)

The need for knowledge translation to implement evidence-based interventions into clinical practice has also been increasingly recommended (Downing et al., 2019; Nott et al., 2020). For example, Tang et al. (2017) completed qualitative interviews with primary and secondary care workers to establish views on support received by service users with memory difficulties after stroke. The authors identified that despite programmes such as the United Kingdom (UK) Sentinel Stroke National Audit Programme to audit and monitor stroke care; there was a lack of continuity between hospital and community services and care gaps were experienced by service users. Recommendations included creating post-stroke cognitive impairment care pathways and increasing provision of education for staff and service users in this area. McEwen et al. (2019) reviewed implementation of an occupation-based metacognitive approach, the Cognitive Orientation to Daily Occupational Performance (CO-OP) (Polatajko, 2012) in an inpatient neurological multidisciplinary team setting. Study results identified some changes in clinician practice after the approach was implemented; however, this was impacted by barriers including outdated clinical guidelines (McEwen et al., 2019).

There is growing international research on occupational therapy clinician practice for the treatment of cognition including executive functioning impairment, for individuals with ABI. The aim of this study is to expand on this body of evidence by exploring treatment for post ABI executive functioning impairment by occupational therapists in the UK. Additionally, the study will look at clinical support received and confidence in intervention provision. The information from the study will describe current practice and identify areas for future research.

Materials and methods

Aims

  1. To determine interventions utilised to treat executive functioning impairment after ABI from a sample of UK occupational therapists working across the continuum of care.

  2. Establish what support a sample of UK occupational therapists’ access to assist practice development in this area.

  3. Establish clinician’s confidence in the treatment of executive functioning impairment for service users with ABI.

Survey design

The questionnaire was developed from a literature review of occupational therapy practice for the management of EFI completed by the principal author. The author also contacted an author of a clinical survey undertaken in Australia in 2020 (Nott et al., 2020) who provided initial feedback on the selected survey questions. A questionnaire with 24 questions was then drafted and organised in three sections (see Supplemental File):

  • Section 1: Demographic questions including practice setting, years of experience, experience with individuals with EFI and confidence in delivering interventions.

  • Sections 2 and 3: Questions about interventions used to treat or support patients with ABI experiencing EFI, including treatment activities and delivery, metacognitive strategies/techniques, occupation-based metacognitive approaches and questions about training and development accessed to support practice in this area.

Operational definitions for key terms were identified and provided to participants.

To ensure the questionnaire reflected key concepts identified in the study aims (Gerrish, 2015) and survey questions enabled effective data collection (Scott et al., 2021), a small qualitative project using a cognitive interviewing technique (Drennan, 2003) was completed with six occupational therapists from the Royal College of Occupational Therapists Specialist Section in Neurological Practice (RCOTSS-NP). This forum promotes best practice in occupational therapy for people with neurological conditions in the UK (Royal College of Occupational Therapists, 2020).

Members were contacted by email and those expressing an interest and who consented to participate were invited to interview. This was conducted individually online using Microsoft Teams or telephone by the principal author using ‘think aloud’ methodology (Howlett et al., 2018). The interviewee received a copy of the survey questions and was asked to answer the questions out loud. Therapists were encouraged to express their perceptions, understanding and opinions on the survey questions, including order and response categories. After each interview, iterative changes were made to the survey questions. This process was completed until no changes were required. This occurred on the sixth interview. The final draft was checked and agreed by the research team.

Ethical approval

Ethical approval was received on 8th March 2021, from the Faculty of Medicine and Health Sciences Research Ethics Committee at Nottingham University Hospital UK, prior to survey commencement.

Participants

Survey recruitment and dissemination was completed through RCOTSS-NP in the UK.

Study regime

RCOTSS-NP members received an email inviting them to participate in the survey. A participant information sheet was attached outlining the research objectives and survey procedures. All participants were provided a link to the secure online survey software application Joint Information Systems Committee (JISC, 2020). Participants were required to provide electronic consent prior to commencing the survey. Survey completion time was approximately 25 minutes. The survey was open for a 7-week period (18th May 2021 to 30th June 2021). A reminder email was sent out 1 month after the survey opened to optimise participant recruitment.

Sample size

A convenience sample of 750 members of RCOTSS-NP was utilised based on membership at the time of survey delivery. There is lack of consensus on what constitutes a good response rate (Badger and Werrett, 2005). However, response rates of 44% have been reported in online education surveys (Wu et al., 2022) with a lower rate (16.5%) identified in an online allied health public health survey (Kidd et al., 2019). Due to the limited survey opening time, a response rate of between 10 and 15% (N = 75–112) was anticipated.

Data analysis

Data was collected at a nominal and ordinal level. The majority of survey questions required a categorical response or use of Likert-type rating scales, allowing respondents to rate the degree to which they agree or disagreed with each question (Sullivan and Artino, 2013). Participants were invited to comment using free text on six questions exploring clinical intervention types, metacognitive strategies, techniques and approaches or programmes used in practice. All responses to free text questions were analysed and summarised by the main author using an inductive and deductive coding process. This included prior identification of possible categories and themes from the current literature (Linneberg and Korsgaard, 2019) before coding responses. Examples of codes identified included metacognitive strategies such as self-monitoring (Cicerone et al., 2011) and video and verbal feedback (Cicerone et al., 2019). Descriptive statistical analysis was performed calculating frequencies and percentages of responses to each categorical answer, or score on the Likert-type scale (O’Cathain and Thomas, 2004). All available responses for each question were included in the analysis. Lastly, as the survey was conducted during the Covid pandemic, on survey commencement, participants were requested to answer practice questions based on the health climate prior to the pandemic.

Results

Participant demographics

Seventy-six participants completed the survey, approximately 10% of RCOTSS-NP members. Participants were employed in a variety of settings including inpatient neurological rehabilitation units, community neuro teams, early supported discharge teams/reablement teams, and stroke units (including hyper acute stroke and acute stroke units). Participants worked mainly with service users with TBI, ABI other (e.g. hypoxia, encephalitis, brain tumour) and stroke. The most frequently answered experience categories were 16–20 years (n = 21, 28%) and 6–10 years (n = 20, 26%). The majority of participants (n = 68, 90%) were band 6 or above, described in Agenda for Change (NHS, 2020) as an occupational therapist with 2 years clinical experience or more. Over half (n = 41, 54%) were employed at band 7 or 8 (typically senior or clinical leadership roles) (see Table 1 for details).

Table 1.

Participant demographics (N = 76).

Characteristics n (%)
Current work setting:
 Inpatient neurological rehabilitation unit. For example, 1a, 1b, 2b and so on 21 (28)
 Community neuro (mixed) 20 (26)
 Early supported discharge/reablement 14 (18)
 Stroke unit (hyper acute stroke unit or acute stroke unit) 13 (17)
 Community TBI 13 (17)
 Acute, for example, A&E, neurosurgery, neuro-medical, neuro-outliers 12 (16)
 Community stroke 10 (13)
 Private practice – independent practitioner 9 (12)
 Vocational rehabilitation 8 (11)
 Private hospital or rehabilitation service 6 (8)
 Neuro outpatients 5 (7)
 University/teaching/academic 2 (3)
Service user groups currently working with:
 TBI 65 (86)
 ABI other (e.g. hypoxia, encephalitis, brain tumour etc.) 60 (79)
 Stroke 59 (78)
 Functional neurological disorders 38 (50)
 Dual diagnosis, for example, TBI and mental health, TBI and spinal injury 38 (50)
 Progressive neurological conditions 37 (49)
 Mild TBI or post concussion syndrome 31 (41)
 Transient ischaemic attack 25 (33)
 Other 8 (11)
Current grade:
 Band 7 or equivalent 36 (47)
 Band 6 or equivalent 27 (36)
 Band 8 or equivalent 5 (7)
 Band 5 or equivalent 4 (5)
 Other 4 (5)
Number of years’ experience working with individuals with ABI:
 16–20 years 21 (28)
 6–10 years 20 (26)
 11–15 years 13 (17)
 More than 26 years 10 (13)
 Less than 2 years 6 (8)
 2–5 years 4 (5)
 21–25 years 2 (3)

Please note that participants may work in multiple settings, and work with multiple service user groups.

ABI: acquired brain injury; TBI: traumatic brain injury; A&E: accident & emergency.

The majority of participants (n = 63, 83%) regularly undertook assessment of individuals with EFI, while 10 (13%) sometimes provided assessment. Sixty-six (87%) of participants regularly provided intervention for EFI, eight (11%) sometimes provided intervention and two (3%) did not provide any intervention.

Confidence levels

Thirty-one (41%) participants were fairly confident treating individuals with EFI, 28 (37%) participants were very confident and 13 (17%) were somewhat confident. The lowest confidence level was slightly confident, reported by four (5%) participants.

Clinical interventions and support

Theoretical approaches

Participants reported being aware of cognitive rehabilitation intervention categories including adaptive approaches (n = 75, 99%), remedial (or restorative) approaches (n = 67, 88%) and metacognitive approaches (N = 71, 93%).

Interventions

Participants used an average of eight different interventions. The most frequently used, that is, with the greatest number of participants using them always or often, were education (n = 57, 75%), task modification (n = 56, 73%), instrumental activities of daily living (ADL) retraining (n = 54, 71%), personal ADL retraining (n = 53, 70%) and goal setting (n = 53, 70%). Interventions used by the greatest number of participants often or sometimes included compensatory training (n = 56, 75%), risk management (n = 49, 64%), leisure, avocational or vocational training (n = 45, 59%). The least frequently used, that is, with the least number of participants using them always, often or sometimes, were group work and computer interventions (see Table 2).

Table 2.

Activities used in occupational therapy practice to treat service users with ABI experiencing EFI (N = 76).

Treatment activity Always
2–4 × weekly
n (%)
Often weekly
n (%)
Sometimes 2–3 × month
n (%)
Rarely
<1 month
n (%)
Never or not currently
n (%)
ADL retraining or practice 25 (33) 28 (37) 14 (18) 7 (9) 2 (3)
Education or training (service user or carer) 23 (30) 34 (45) 15 (20) 3 (4) 1 (1)
Task modification or adaption 23 (30) 33 (43) 14 (18) 6 (8) 0 (0)
Instrumental ADL retraining or practice 22 (29) 32 (42) 15 (20) 6 (8) 1 (1)
Goal setting or review 17 (23) 36 (48) 18 (24) 3 (4) 1 (1)
Compensatory training to support performance 13 (17) 33 (43) 23 (30) 7 (9) 0 (0)
Leisure, avocational or vocational activities 8 (11) 21 (28) 24 (32) 16 (21) 7 (9)
Sessions focusing on risk management 6 (8) 19 (25) 30 (39) 16 (21) 5 (7)
Computer – functional tasks 4 (5) 14 (18) 31 (41) 17 (22) 10 (13)
Computer-remedial training 3 (4) 9 (12) 13 (17) 24 (32) 27 (36)
Group work impairment based 3 (4) 4 (5) 5 (7) 13 (17) 51 (67)
Group work function based 3 (4) 3 (4) 7 (9) 12 (16) 51 (67)

ADL: activities of daily living; ABI: acquired brain injury; TBI: traumatic brain injury; EFI: executive function impairment.

Metacognitive strategies or techniques to support EFI

Participants were provided with a list of metacognitive strategy options or techniques from the current literature, for example (Engel et al., 2019; Nott et al., 2020). Participants reported being aware of visual or written prompts (n = 76, 100%), video/verbal feedback (n = 75, 99%), graded verbal prompts or instructions (systematic instruction techniques) (n = 70, 92%), performance prediction and review (n = 69, 91%) and self-cueing strategies (n = 57, 75%). Fifty four participants (71%) reported using meta-cognitive strategies.

Participants were asked to specify using free text which specific metacognitive strategies or techniques they used in their practice. Fifty-seven (75%) responded. Manual coding of responses indicated the most frequently used were visual or written prompts (n = 39) and performance predication and review (n = 31) (see Table 3).

Table 3.

Metacognitive strategies or techniques used in practice to support individuals with ABI experiencing EFI.

Metacognitive strategies or techniques (most frequently utilised) Frequency
(Total N = 57)
Visual or written prompts 39
Performance prediction and review 31
Graded prompts or cues (systematic instruction techniques) 29
Feedback interventions, e.g., video/verbal feedback 24
Self-cueing strategies 18
Use of specific cognitive tools 17
Feedback (general) 12
Prompts (general) 6
Self-rating scales 6
Self-monitoring 5

Please note categories were generated from open-text questions allowing for multiple responses.

ABI: acquired brain injury; EFI: executive function impairment.

Approaches, models, programmes or intervention to support EFI

Most participants reported being aware of occupation-based metacognitive approaches. Examples included video/verbal feedback (n = 47, 62%), for example (Schmidt et al., 2013); occupational and goal setting approaches (n = 45, 59%), for example (Doig et al., 2014); mental imagery (n = 40, 53%), for example (Liu et al., 2009); cognitive strategy use (n = 25, 33%), for example (Skidmore, 2011); the multicontext approach (n = 21, 28%), for example (Toglia, 1991) and the CO-OP approach (n = 23, 30%), for example (Polatajko and Mandich, 2004).

When asked if they used any particular interventions, approaches, models or programmes to treat or support service users, 45 (59%) participants reported yes, while one-third (n = 24, 32%) did not use any, and 7 (9%) were unsure. When asked which were used, 42 (55%) of participants responded using free text. The most frequently cited were goal setting (n = 9), Brain Tree Training resources (2020) (n = 8) and video feedback (n = 5). A small number of participants reported using occupation-based metacognitive approaches including the CO-OP approach (n = 3), Perceive Recall Plan and Perform (PRPP), for example (Nott and Chapparo, 2008) (n = 3), the multicontext approach (n = 3) and mental imagery (n = 2) (see Table 4).

Table 4.

Specific approaches, models, programmes or interventions used to support service users with ABI experiencing EFI.

Specific approaches, models or programme (most frequently utilised) Frequency (total N = 42)
Goal setting 9
Brain tree training 8
Video feedback 5
Brainwaves-R (Brain Tree Training, 2020) 4
CO-OP approach 3
PRPP 3
Multicontext approach 3
Metacognitive/cognitive strategies 3
Problem-solving approaches 3
Feedback (general) 3
Insight/awareness building 3
Mental imagery 2
Multiple Errands Task (Shallice and Burgess, 1991) 2
GAS goal setting (Kiresuk and Sherman, 1968) 2
Self-monitoring 2
Errorless learning/backward chaining 2
Brain injury workbook 2

Please note categories were generated from open-text questions allowing for multiple responses.

ABI: acquired brain injury; EFI: executive function impairment; PRPP: Perceive Recall Plan and Perform; CO-OP: Cognitive Orientation to Daily Occupational Performance; GAS: Goal Attainment Scale.

Intervention delivery

The most frequently used treatment delivery methods, that is, always or several times a week to often, that is, weekly, were one-to-one treatment sessions with an occupational therapist (n = 70, 92%), therapy sessions completed by support staff (such as rehabilitation assistants or support workers) under guidance from an occupational therapist (n = 52, 69%), independent practice or self-management (n = 49, 65%), and joint therapy sessions, for example, with another professional, for example, occupational therapist and speech and language therapists (n = 38, 50%). The least frequently used interventions, that is, with the least number of participants using them, were group work and computer interventions.

All participants (n = 76, 100%) reported working with staff, disciplines or others to treat or support service users with ABI experiencing executive functioning impairment. This occurred frequently (n = 39, 51%), often (n = 21, 28%), sometimes (n = 15, 20%) and rarely (n = 1, 1%). Participants worked mostly with speech and language therapists (n = 67, 88%), families and significant others (n = 66, 87%), physiotherapists (n = 66, 87%), neuropsychologists (n = 63, 83%) and rehabilitation assistants (n = 56, 74%) (see Supplemental File, Figure 1).

Practice support and training

Joint clinical sessions were the most frequent form of support for clinical practice development with (n = 30, 39%) reporting using it weekly or several times a month. Common support practices undertaken at least once every few months (sometimes, often or always) were supervision or mentoring (n = 61, 80%), self-directed learning (n = 63, 83%), peer-group support (n = 54, 71%), professional organisation support (n = 59, 78%) and education in the workplace (n = 52, 68%). Support using social media and education outside the workplace was less frequent (see Supplemental File, Table 5).

Participants identified a further need for access to education outside the workplace (n = 69, 91%), information regarding current research and effectiveness of approaches (n = 66, 87%), funding for education or CPD (n = 62, 82%), knowledge translation support (n = 62, 82%); additional therapy time to address cognitive rehabilitation (n = 58, 76%) and opportunities to access education inside the workplace (n = 57, 75%).

Lastly, as this questionnaire occurred during the Covid pandemic, participants were asked if they had experienced changes in practice to which three-quarters (n = 55, 72%) reported in the affirmative. Participants reported changes experienced were due to pandemic restrictions including increased use of online therapy, and reduced face-to-face sessions and community access.

Discussion

Seventy-six occupational therapists (10% of those approached) responded to the survey. The response rate was lower than other studies on cognitive rehabilitation. In Nott et al.’s (2020) study, 192 participants responded from a sample size of 19,516 therapists, which was a larger sample size but lower (1%) response rate. However, several factors may have influenced the response rate of this study. Firstly, due to the limited time available to complete the project, the survey dissemination was open for a 7-week period to RCOTSS-NP members only, reducing opportunity to participate. Additionally, response rates to online surveys can be low (Timmins et al., 2023); an effect possibly compounded by the study being undertaken during the Covid pandemic, which impacted engagement in education and research activities due to shifts in work place practices (Ward, 2020).

The majority of participants treated individuals with EFI post ABI. Most had over 6 years’ experience working predominantly in inpatient (acute and rehabilitation) and community settings with two or more service user groups including TBI and stroke. However, given the small sample size, it is difficult to establish if participant experience and practice patterns were representative of occupational therapists’ working practices nationally. Recruiting from a wider group of clinicians from a range of organisations across the UK would allow for a larger cohort and sample size.

Theoretical approaches

Most participants were aware of theoretical cognitive rehabilitation approaches to support EFI. This includes adaptive approaches which aim to increase independence using techniques and equipment to support areas of difficulty, and restorative (or remedial) approaches which aim to address underlying impairments to assist function (Chung et al., 2013). Participants also reported being aware of metacognitive approaches which utilise metacognitive strategies and techniques to support performance (Cicerone et al., 2005).

Interventions

The most frequently cited activities to treat EFI post ABI were client or carer education followed by functional retraining, task modification and goal setting. Use of education as a treatment activity has been cited in clinical studies on multidisciplinary cognitive rehabilitation (Downing et al., 2019; Nowell et al., 2020). However, despite evidence supporting its use in areas including carer and family psychosocial functioning (Royal College of Physicians, 2023), more research is needed to guide how educational interventions are best delivered to individuals with mild to moderate as well as severe cognitive impairments (D’Cruz et al., 2021).

Use of functional training, task modification and compensatory training identified by participants to treat EFI are deemed traditional practice approaches used in cognitive rehabilitation, and consistent with clinical practice in previous surveys (Koh et al., 2009; Korner et al., 2011; Nott et al., 2020). In comparison, this study also identified use of goal setting which is less cited in literature exploring occupational therapy practice in cognitive rehabilitation, with the exception of recent multidisciplinary studies (Downing et al., 2019; Nowell et al., 2020). Goal setting has been increasingly identified as an essential ingredient in rehabilitation for service users experiencing cognitive impairment after stroke (Royal College of Physicians, 2023), and TBI (Doig et al., 2009), including individuals with impaired self-awareness (Prescott et al., 2019). However, the context in which goal setting was used by participants was not clear, for example if it was used informally (Prescott et al., 2015), as an outcome measure, for example, Canadian Occupational Performance Measure (Law, 1998) and Goal Attainment Scale (Rockwood et al., 1997), or within a treatment programme, for example, Goal Management Training (Stamenova and Levine, 2019). Further exploration of occupational therapists’ use of goal setting for individuals with EFI is recommended to identify further training requirements in this area.

While less frequently cited, participants also supported EFI post ABI using risk management, leisure and vocational activities. Use of risk management as a cognitive rehabilitation activity has not been identified in previous occupational therapy clinical practice surveys. However, the need to embrace positive risk has been recognised in order to optimise service users’ autonomy, participation and reduce barriers (Royal College of Occupational Therapists, 2018). The concept of risk is particularly relevant to individuals with ABI due to the impact of EFI and self-awareness difficulties on risk-taking behaviours (Amanzio et al., 2020). In addition, engagement in meaningful leisure activities that promote psychological well-being, and community engagement is recommended post ABI, particularly for individuals with more severe cognitive impairments who may be unable to return to preinjury occupations such as work (Tate et al., 2020). Vocational rehabilitation is also an important focus for many individuals and presents particular challenges for those experiencing EFI (Hart et al., 2019; Mani et al., 2017; Mitrushina and Tomaszewski, 2019). However, further research to establish the longer-term effects of leisure therapy (Dorstyn et al., 2014) and return to work interventions for individuals with EFI is needed (Wolf, 2010).

Metacognitive strategies and techniques to support EFI

Participants were aware of several metacognitive strategies in line with current guidelines on the treatment of EFI after TBI (Jeffay et al., 2023) including performance prediction, video/verbal feedback, metacognitive instruction such as self-monitoring; and post stroke (Royal College of Physicians, 2023) including use of internal or external strategies and structured feedback. Over two-thirds reported using metacognitive strategies or techniques in their clinical practice. This suggests UK occupational therapists have some awareness of current evidence-based practice in this area. However, participants also reported use of systematic instructional techniques which are not necessarily metacognitive strategies. Possible reasons for this could be respondents being influenced by a preceding closed question in the survey that listed these as a technique.

Approaches, models, programmes or interventions to support EFI

Half the participants reported using specific interventions, approaches, models, or programmes to support EFI. This included utilisation of goal setting, feedback interventions, metacognitive strategies and online training programmes or resources. However, further exploration is needed to establish how these were used and applied in clinical practice, including the evidence base around some of these for individuals experiencing EFI post ABI. In addition, lack of clear terminology may have impacted participants responses due to lack of a unifying definition and concepts of EFI (Cramm et al., 2013), it’s measures and interventions (Skidmore et al., 2023).

Only a small number of participants reported using occupation-based metacognitive approaches in clinical practice. Examples included the CO-OP approach (Dawson et al., 2009), the Multicontext approach (Toglia et al., 2010), PRPP (Nott et al., 2008) and mental imagery (Liu and Chan, 2014). This suggests several factors may impact on the clinical implementation of these approaches including limited clinician awareness and knowledge of approaches, in addition to inconclusive evidence in this area. Further exploration of these factors may be beneficial.

Intervention delivery

The most frequently used treatment delivery methods were one-to-one treatment sessions (either by an occupational therapist, or support staff such as rehabilitation assistants under guidance from an occupational therapist), independent practice or self-management and joint therapy sessions with another professional. However, while there is some evidence for the utilisation of support staff to assist therapy delivery and contribute to patient outcomes (Snowdon et al., 2020), more research is needed to establish how this staff group can best assist or complement allied health intervention (Lizarondo et al., 2010).

Self-management aims to support individuals to manage aspects of their condition (Parke et al., 2015) and optimise autonomy and participation (McClure and Leah, 2021). However, for self-management post stroke, guidelines are variable and require further universal consensus (Henry et al., 2022). For individuals with TBI, self-management may be feasible with further research recommended (Mäkelä et al., 2019). In addition, EFI can impact an individual’s ability to self-manage areas of difficulty including use of compensatory techniques to support performance (Lewis et al., 2011). Consequently, there is further need for self-management interventions to be adapted or modified to ensure suitability for individuals with cognitive impairment (Jones et al., 2016).

Moreover, EFI is a complex construct (Cramm et al., 2016; Skidmore et al., 2023), and allied-health clinicians have found this cognitive domain challenging to treat (Downing et al., 2019; Nowell et al., 2020). Consequently, the use of collaborative team-working including shared communication, identification of client goals and shared or complementary working practices (Körner, 2010) that focus on client centred functional outcomes (Waldron-Perrine et al., 2022) may be particularly relevant for treating individuals with EFI after ABI. This can include use of joint clinical sessions (Suddick and De Souza, 2007) incorporating clinical disciplines working within their individual specialisations and scope (Waldron-Perrine et al., 2022), in addition to family and carer involvement in the rehabilitation process (Lannin et al., 2021). The use of collaborative team-working has similarly been identified in other multidisciplinary clinical practice surveys on cognitive rehabilitation after TBI (Downing et al., 2019; Pagan et al., 2015; Nowell et al., 2020).

Practice support and training

Utilisation of joint clinical sessions with other health professionals was also frequently used by participants to support clinical practice in addition to other support activities such as supervision, self-directed learning and professional organisation support. Study results therefore identified collaborative team-working was used for intervention delivery as well as for clinical practice support. This theme would benefit from further exploration. Participants also identified the need for further access to education, increased information on current research, increased access to CPD funding and additional therapy time for cognitive rehabilitation. This is of interest as the need for occupational therapists to access suitable education and training to support knowledge acquisition in order to effectively support individuals with EFI has been highlighted (Cramm et al., 2016). Lastly, the need for knowledge translation support to assist implementation of evidence-based practice was also identified. This is consistent with findings from other occupational therapy cognitive rehabilitation clinical practice studies (Holmqvist et al., 2014; Nott et al., 2020).

Confidence

The majority of respondents reported being fairly to very confident in supporting service users with EFI. However, it is unclear if this is derived from mostly lengthy clinical experience or from knowledge and application of evidence-based practice. Thus, while confidence is assumed to generally increase with length of practice, studies have identified that occupational therapist’s confidence to utilise evidence-based practice can change over time (Klaic et al., 2019). In order to analyse clinician’s skills and competency levels and how these impact on confidence and use of evidence-based practice, further research may be of benefit using case vignettes (Korner et al., 2011). Use of case vignettes can allow for exploration of clinicians’ attitudes, perceptions and beliefs (Hughes and Huby, 2002), and provide a more in-depth understanding of clinicians’ lived experiences (Tremblay et al., 2022).

Limitations

There were several limitations to this study. Firstly, the sample size was small. However, the study participants are likely to be a suitable population given their engagement in a specialist interest group and length of clinical experience. More experienced practitioners may be more readily able to answer questions on EFI which can be challenging to treat, particularly if an individual has impaired self-awareness or insight (Downing et al., 2019). Nevertheless, the survey results may not be representative of less experienced therapists who may not be routinely involved in treatment of EFI or less confident to participate in research.

The study also did not explore why and when particular interventions, strategies or approaches were chosen by participants, the dose and application of metacognitive strategies, how occupation-based metacognitive approaches were used in practice, and barriers to implementing these in practice. Further exploration of these areas, including the type and quality of training received and identification of ongoing learning needs is recommended.

Lastly, as the survey data collection method required the participant to self-report perceptions of clinical practice on EFI post ABI, there is the possibility of response or recall bias. This can include data being affected by bias caused by social desirability or approval, or participants’ perception and recall of information (Althubaiti, 2016). Participants were also asked to identify clinical practice prior to the Covid pandemic which may have resulted in recall bias. However, attempts to minimise this were made by validating the questionnaire before dissemination and providing participants with information on selected concepts and definitions. Additional measures to assess actual practice including file audit (Nowell et al., 2020) could be a consideration in future studies.

Conclusion

This study presented results from a clinical practice survey of a sample of Occupational Therapists working across a range of neurological settings in the UK. Participants regularly treated service users with EFI after ABI utilising clinical interventions that incorporated functional retraining, task modification and compensatory training in keeping with other clinical practice studies on cognitive rehabilitation, in addition to goal setting and educational approaches. The use of collaborative working practices was also utilised to deliver intervention and support practice in this area. Clinicians reported utilising metacognitive strategies; however, use of occupation-based metacognitive approaches were less reported. Reasons for this may be limited clinician awareness and knowledge of these approaches, and lack of conclusive evidence in this area.

Several interventions and activities used by participants require further research to establish their effectiveness for individuals with executive functioning impairment, including educational and self-management interventions, leisure and work activities and the role of support staff. Most participants reported being fairly or very confident when supporting service users with executive functioning impairment. The need for further education and training in evidence-based approaches, access to CPD funding and implementation approaches to translate evidence into practice was also highlighted.

Key findings.

  • Participants used a range of activities to treat individuals with EFI after ABI. Frequently used activities were education, task modification, functional retraining and goal setting.

  • Meta-cognitive strategies were frequently utilised; however, these were often generic, and use of occupation-based metacognitive approaches was less reported.

  • Further exploration of several interventions, as well as the type and quality of current training received, and identification of ongoing learning requirements is recommended.

What the study has added

  • This study adds to the evidence in exploring UK-based occupational therapists’ clinical practices in treatment of EFI after ABI.

  • Occupational therapists regularly treat and support service users with EFI using a range of clinical interventions, in addition to use of metacognitive strategies. This is in keeping with themes present in international occupational therapy clinical practice studies on cognitive rehabilitation for adults with ABI.

Supplemental Material

sj-docx-1-bjo-10.1177_03080226231206686 – Supplemental material for Occupational therapy practice to support executive function impairment after acquired brain injury: A UK clinical survey

Supplemental material, sj-docx-1-bjo-10.1177_03080226231206686 for Occupational therapy practice to support executive function impairment after acquired brain injury: A UK clinical survey by Sarah de Charentenay, Julie Whitney and Philippa A Logan in British Journal of Occupational Therapy

Footnotes

Research ethics: Ethical approval was received from the Research Ethics Committee, Faculty of Medicine and Health Sciences, University of Nottingham Ethics Committee (FMHS 167-0121) on 8th March 2021, prior to survey commencement.

Consent: Participants were required to provide written electronic consent prior to participating in the study.

Patient and public involvement: During the development, progress and reporting of the submitted research, Patient and Public Involvement in the research was not included at any stage of the research.

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The first author is currently a trainee instructor on the Perceive Recall, Plan and Perform assessment course.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Sarah de Charentenay, Pre-doctoral Clinical Academic Fellow, NIHR300334, was funded by the National Institute for Health Research (NIHR) for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, National Health Service (NHS) or the United Kingdom Department of Health and Social Care.

Contributorship: SdC researched literature, conceived the study, and completed participant recruitment. SdC and PAL completed protocol development and gained ethical approval. SdC and JW completed data analysis. SdC and JW wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

ORCID iD: Sarah de Charentenay Inline graphic https://orcid.org/0000-0001-9085-8999

Supplemental material: Supplemental material for this article is available online.

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Supplementary Materials

sj-docx-1-bjo-10.1177_03080226231206686 – Supplemental material for Occupational therapy practice to support executive function impairment after acquired brain injury: A UK clinical survey

Supplemental material, sj-docx-1-bjo-10.1177_03080226231206686 for Occupational therapy practice to support executive function impairment after acquired brain injury: A UK clinical survey by Sarah de Charentenay, Julie Whitney and Philippa A Logan in British Journal of Occupational Therapy


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