Reconceptualising engagement: a relational practice with people experiencing communication disability after stroke
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‘Engagement’ is a term increasingly used in healthcare and has commonly been conceptualised as a patient behaviour and responsibility. However, an emerging body of research indicates that the practitioner can influence engagement through their ways of relating, communicating and working with the patient. This doctoral research sought to explore the concept of engagement in stroke rehabilitation, and to develop rich, nuanced understandings of how practitioners engage people experiencing communication disability in this context. A conceptual review explored how engagement was conceptualised in the healthcare literature, followed by two empirical qualitative studies utilising a Voice Centre Relational Approach. The first empirical study explored how people conceptualised engagement, by completing interviews with seven people experiencing communication disability and 14 rehabilitation practitioners. The second empirical observational study was a longitudinal exploration of how engagement was enacted in stroke rehabilitation services, observing 28 rehabilitation practitioners as they worked with three people experiencing communication disability. Together, these three studies helped develop in-depth understandings of engagement practices. This research identified engagement to be a process, something facilitated through the practitioner’s way of working, and as a patient state, evident in the patient’s actions. The findings of this doctoral work propose that engagement is a relational practice, an intentional and reflexive way of thinking, working and being on the part of the practitioner. When enacting engagement as a relational practice, practitioners prioritised getting to know the patient and their needs, and used this knowledge to determine how best to work with them. This could see them emphasise relational or technical, disciplinary-based work depending on the patient’ needs and priorities. Relational dialogue, an integrated approach to communication, was embedded throughout their interactions. Engagement as a relational practice involved weaving together relational work and communication, together with technical, disciplinary-based work, and rehabilitation tasks. Practice was surrounded by a relational frame, a philosophy of practice. There was consistency and coherence between how the practitioner thought about engagement and how they enacted it. Engagement appeared co-constructed; each party’s engagement was influenced by their perceptions of the other person’s engagement. Engagement as a relational practice appeared a skilled, sophisticated way of working. In explicating the recognisable elements of engagement practice, detailing communication patterns which appeared important for engagement, and demonstrating the need to consider practitioner (dis)engagement, this research makes significant contributions to knowledge. It challenges dominant understandings of which aspects of rehabilitation work and communication are legitimate and valuable when working to engage people experiencing communication disability in rehabilitation. This has implications for clinical practice, service development, and student education. These findings also serve as a base for on-going research into engagement. Re-conceptualising engagement as a relational practice may support practitioners to reflect on their understandings of engagement, their patient’s engagement, on their ways of working, and perhaps most fundamentally, the frames and philosophies which surround and influence their practice.