It took one determined woman, Dr Marjory Warren (1897–1960), to overcome the combined effects of low expectations, scarce resources and wartime privation on a west London hospital and its patients and by doing so, to demonstrate the effectiveness of rehabilitation services for older people (Evers 1993). Her influence was also felt in Australia and rehabilitation soon became established as a key component of newly created departments of geriatric medicine (Lefroy 2001). Despite these auspicious beginnings, rehabilitation units for older people, at least in the UK, have subsequently struggled to attract and retain the staff and resources that they need to provide a high-quality service. The development of such services was further impeded by geographical isolation and social stigma. Transfer from an acute care setting to a rehabilitation ward often involved leaving the main hospital site and being moved to a former workhouse building some distance away. Patients’ motivation was not promoted by the resentment engendered by a transfer to a ward perceived by relatives and the wider public as a second-rate survival from the grim era of the Poor Law. Nurses and other members of the rehabilitation team were required to wage a constant battle to overcome these prejudices and promote more positive attitudes. However, in the last few years, many rehabilitation units for older people in the UK have been relocated to main hospital sites and so, are directly comparable with their equivalents in the USA and Australasia.
Much debate has been generated in recent years by the perceived need to understand the personal meanings that people undergoing a rehabilitation process bring to their situation (Nolan & Nolan 1998). This can be seen as a reaction against the early philosophy of rehabilitation, which had its origins in a quasi-military environment where groups of patients carried out simultaneous exercises in a gymnasium. This approach emphasized physical needs above all others and was often based on the assumption that the rehabilitation goals of all patients sharing the same diagnosis were identical. While the philosophies embraced by nurses working in rehabilitation have recently come in for review, as they attempted to make their contribution more patient-centred, nurses have sometimes struggled to identify a distinctive role for themselves (Long et al. 2002). The literature in the field suggests a range of potential nursing roles are undertaken, including the maintenance of patients’ physical well-being, reinforcing the input of other staff and maintaining a 24-hour presence in the rehabilitation unit, but none of these constitute a unified philosophy of rehabilitation nursing (Nolan & Nolan 1998). A recent contribution to this debate from Finland has identified key components, which could underpin such a philosophy (Routasalo et al. 2004).
The situation in the UK has been further complicated by the emergence of the term ‘intermediate care’ to designate a range of services developed as a response to some of the common problems faced by older people in their encounters with health services. These can include inappropriate admission to acute hospital facilities, delayed discharge from hospital and a lack of support for independent living (DoH 2001). Services that have been developed include ‘rapid response’ community teams, day care, rehabilitation facilities located in care homes rather than hospitals and ‘hospital at home’ schemes. While this move away from a ‘one-size-fits-all’ model of rehabilitation service organization has been widely welcomed, evaluation is needed to assess the effectiveness and acceptability of such developments (Roe et al. 2003).
Despite the variety of modes of service delivery in rehabilitation, it is clearly essential that patients and their relatives have their information needs met effectively. Staff should provide timely and realistic information and that information strategy ought to be consistently applied by the different professional groups involved in the care of patients. Staff also need to deliver information in a positive manner, as their confidence helps reinforce patient motivation (Resnick 1996). In this paper, McKain et al. have made a useful contribution to the literature on patients’ views concerning the extent to which they believed that their information needs were met. Their findings indicate that patients recalled receiving very little information from either formal or informal sources. In place of definite information from health care professionals, the patients seem to have developed their own (largely positive) interpretations of the transfer to the rehabilitation unit. Therefore rehabilitation was seen as ‘a ticket out’ and ‘a step in the right direction’. The views expressed by patients in this paper appear more uniform and more positive than those reported in a recent UK paper (Maclean et al. 2000). This qualitative study divided respondents into those deemed by the staff to fall into high and low motivation groups. While the former group reported that information from staff helped them to understand their rehabilitation goals, those in the low motivation group tended to complain of a lack of information, and blamed it for their anxieties about the rehabilitation process.
Despite their differences, both these studies lend support to the view that the aim of developing a rehabilitation service which promotes person-centred care, minimizes regimentation and yet ensures that vital information is given to all patients in a consistent manner remains to be fulfilled. This will require a greater understanding of individual patients’ perceptions and priorities and it is likely that the concept of a rehabilitation ‘trajectory’ will prove to be a useful frame of reference (Burton 2000). The attitudes and behaviours of staff also require further study. While strong motivation and positive attitudes are likely to be helpful in the context of rehabilitation, little attention has so far been paid by researchers to the effects of failing to meet desired goals. Health care professionals have yet to develop consistent frames of reference for discussing possible outcomes from the rehabilitation process, and hence have been found to be ill-equipped to convey information about the ‘possibility of disappointment’ (Wiles et al. 2004).