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Research Article

Rehabilitation: collective construction of a concept in a focus group

[version 1; peer review: 2 approved with reservations]
PUBLISHED 01 Feb 2023
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Abstract

Background: Human dimensions are transversal to the concepts of health rehabilitation, since they motivate care actions. The aim of this study was to understand rehabilitation from the collective discernment of a multidisciplinary group.
Methods: This was participatory research that used a qualitative approach combined with brainstorming and conceptual mapping techniques, in a focus group of a team of researchers from the Laboratory of Research, Teaching, Extension and Technology in Health, Nursing and Rehabilitation of a Federal University in Brazil, with data publication authorised by the participants. Participants were 92% women and 8% men aged between 25 and 62 and who were members of the research group. The thematic analysis occurred from the semantics of words and associated connectors.
Results: Actions in structured levels were found in the collective understanding of rehabilitation, which enabled the formation of a theoretical care design. The first level presented love, hope, respect, empathy, understanding, esteem, and self-determination. The second level included the pillars of the (re)habilitation process: praxis, intersubjectivity, and comfortable living as a product. The third level showed the dimensions of the person as a whole: spirituality, (re)signification of the meanings of life, functionality of biophysical structures, and biopsychosocial (re)construction — the environment where the dynamic constitution of identity is internalised. The fourth level was the environment where actors move and transform (becoming), where diversity is manifested and the uniqueness of the person is acknowledged.
Conclusions: Rehabilitation is a (co)constructed process based on human attributes that facilitate or may not facilitate transformation. It implies rebuilding of the process of living, with the diversity of each person. Its actions are based on love, solidarity, and respect for mutual rights. The concept of rehabilitation can support the operationalisation of research and interdisciplinary care in a multidisciplinary team.

Keywords

Rehabilitation, Reconstruction, Functionality, Person-Centred Assistance.

Introduction

The concept of rehabilitation inspires a debate on human dimensions at the centre of health, which focuses on the centrality of the person as an active being, protagonist of choices and decisions around their own lives. However, this debate is still dichotomous, deviating from rehabilitation care to reach human wholeness in the process of reconstruction.

A partial understanding of rehabilitation produces disconnections at different levels of care, which can range from interaction between professionals to the purpose of care, whose most common primary intention is the mobility of the dysfunctional organ/system, selecting it as the only object of care and distances itself from human wholeness.

Thinking about health in a fragmented way favours the perpetuation of an instrumentality that limits the reach of human dimensions. Rehabilitation implies identifying the necessary connections between dysfunctional aspects and meeting the global needs of the person, which demands complex care, engaged collaborative teams, and technologies. This requires interdisciplinary research and planning that includes the person, the family, and the support network, meeting rehabilitation demands.1,2

Rehabilitation requires person-centred assistance and a more comprehensive design, with actions aimed at rebuilding the quality of life and functional independence of the individual, minimising subsequent disabilities.3,4 On the other hand, ideas that reinforce fragments, especially ones that privilege unilateral specialised practices, may not reach the global purpose of human wholeness.

The definition of the appropriate terms that guide rehabilitation processes and their parameters of harmony, balance, connections, and disconnections between the constitutive, biopsychosocial and spiritual elements are controversial. They are not separated, except for didactic and/or research purposes, as advocated in evidence-based science.5 There are some questions regarding the meaning of the term. Definitions used to support rehabilitation specialties are claimed to be relevant to that specialty, but can hinder the actions aimed at individuals in the rehabilitation process.6 However, this is a relevant argument for the integration of health rehabilitation actions and interprofessional practices. The idea of interdisciplinary knowledge to understand a design facilitates rehabilitation actions by meeting professional expectations related to a connection around the universe of needs associated with person-centred care, which presupposes multidisciplinary teamwork and decision-making.

In this universe, it is proposed as an objective to understand the rehabilitation of the person in the conception of a multidisciplinary group, for a collective conceptualization.

Due to high-quality evidence on the strength of emerging needs in the process of rehabilitation, the World Health Organization (WHO) recommends that health systems around the world should have a multidisciplinary workforce to ensure the complete and wholesome care of the individual.7

Specific skills are necessary in collaborative work to contemplate the complexity of care requiring deep knowledge about the different dimensions of the person. Rehabilitation should be based on the assessment of global needs, which requires integrated training and a concept of the whole person. These questions are essential to guide deliberation in intervention teams about rehabilitation.

Methods

This research used a qualitative approach combined with brainstorming and conceptual mapping techniques, with a focus group method for data collection. Data were collected by the researcher at meetings of the Laboratory of Research, Teaching, Extension, and Technology on Health, Nursing, and Rehabilitation — (RE)HABILITAR, of the Federal University of Santa Catarina, Brazil, with the objective of analysing the collective understanding of (re)habilitation. The focus group discussion meeting was conducted in Portuguese and the analysis translated for this manuscript.

Strategies

The perceptions on the proposed topic emerged from brainstorming techniques, with the elaboration of a conceptual map in focus group workshops. The data were registered in a diary29 that was later interpreted by thematic analysis and resulted in the collective conception.

The methodological course was based on the related literature: 1) Brainstorming promoted the collection of ideas and perceptions through insights about the topic and enabled cognitive associations and interpretations by the group with the help of a mediator. Its principles and rules reinforce the group’s ideas as complementary8; 2) The concept map developed by Novak9 from the Learning Theory by David Ausubel10 aimed at expressing the representation of the existing associations that formed the cognitive propositions, such as the connectives between one or more constructs of semantic units. The proposition was to explain the formation and association of meanings at the participants’ cognitive level11 and; 3) As a non-directive technique, the focus group provided semi-structured discussion practice to obtain information about cognitive meanings, enabling an in-depth discussion of ideas.12

Participants and reflexivity

The study included 13 researchers from several regions of Brazil, from multidisciplinary areas related to health sciences, such as nursing, physiotherapy, pedagogy, psychology, and social work, and members of the teaching and research laboratory. The participants were selected and invited because they were specialists in the area, and they were all researchers from the rehabilitation laboratory. 92% of participants were of female sex and 8% were of male sex, and they were aged between 25–62 years. Of these, 15.38% were at the postdoctoral level, 7.7% at the doctoral level, 30.77% had a master’s degree, 30.77% were graduates, and 15.38% were at the undergraduate level. Notably, 84.62% were professionals in addition to participating in the research group. The authors of this manuscript represent 76.93% of the workshop participants. The other participants were specialists in the field, have experience in rehabilitation studies and/or practices. There is no relevance in relation to the sex and/or gender of the participating individuals.

The group was led by a facilitator who is one of the authors of this study. He has a master’s degree in health and work management, is a doctoral student in nursing and health, and has experience in training and developing work teams. The facilitator and the participants are from the same research laboratory and declared interest in the collective construction of the concept of rehabilitation, accepting to participate in the group.

Data collection

The data were collected in three synchronous meetings, in May 2021, totalling 12 hours, in the Google Meet platform meeting room due to the COVID 19 pandemic. The meetings took place exclusively with the participants, and were supported by PowerPoint with manually annotated observations, conducted by the facilitator author. The first was attended by the 13 participants and provided, respectively: 1) brainstorming experience and 2) concept map development. It aimed at expressing the understanding of cognitive associations discussed over the years regarding the term. The experience of brainstorming was obtained as a product. Subsequently, a conceptual map of the knowledge on the subject was created, which was used as a methodological tool and didactic strategy to problematise and synthesise epistemological and scientific thoughts.13

The second meeting also had exclusively 13 participants, and involved the following activities: 3) associations around the propositional focal question; 4) discussion of concepts and propositions; The third meeting was for 5) synthesis and validation of ideas for cognitive and collective conceptualisation. For the synthesis, the participants were invited to provide statements that they considered adequate and meaningful to the concept of rehabilitation. Thus, they formed phrases and/or sentences connecting the expressed words.

Administration of the methods

The first meeting included (1) a brainstorming experience; after an informal course, the participants saw a slide with empty balloons and the word (RE)HABILITATION in the centre. Subsequently, they suggested words associated with the exposed content as they came to mind, regardless of order. The words and content were arranged in a cloud in the shape of a heart (Figure 1).

Consequently (2), we proceeded to the elaboration of a conceptual map (Figure 2), where we queried about the meaning of (RE)HABILITATION as a focal theme, using the cloud to reorganise ideas and make connections. Therefore, it was necessary to understand the semantic units presented by each member and their association with the contextual universe (Table 1). Thus, the expressions suggested in column one were presented to the participants and they were asked to provide the semantic units in column two for each expression. The units in column two are all the expressions suggested as more adequate to the participants’ understanding of the research topic (RE)HABILITATION.

The subsequent processes (3 and 4) were used to answer the proposed question about the conception of the meaning of (RE)HABILITATION. The discussion led to the semantic evolution in which the words gained meanings that were expanded, valued, derived, and allocated according to the mental unit that visualised the object of rehabilitation care, i.e., the wholeness of the person. Afterwards (5), there was a synthesis and validation by the participants. They structured sentences from the provided connectives about rehabilitation, according to their understanding. Next, the material produced in the three meetings was read so that they could be confirmed/validated by the group participants.

Ethics and consent

This study aimed to explore the meanings attributed to a specific topic in the health area, configuring a public opinion that, according to Resolution 510/2016, Article 1, does not require registration and evaluation by the National Research Ethics Commission (CONEP), waiving ethical approval. The analysis was based on the perception of the participants and this analysis does not identify and does not offer physical or moral risks. Even so, all participants signed consent forms authorizing the publication of their data.

Analysis

The analysis begins with notes, searching for meanings, ideas and coding schemes. After familiarization with the data, brainstorming was used to generate the initial codes (themes) that emerged from the main research theme – (RE)HABILITATION. Afterwards, the levels of approximation to the larger theme were verified through the connectives arranged in the conceptual map, as a thematic map of analysis.14 The themes were presented in column one of Table 1 and associated and discussed in their semantic relationships expressed in column two.

Derived from the research theme – (RE)HABILITATION – 13 codes (themes) were precisely identified, mentioned by the participants and justified in their speech during the group meeting with simultaneous notes in the PowerPoint schemes and field diary. The description of the conceptual map used for decoding is shown in Figure 2. The data were manually managed in loco, without the use of software.

After producing the map and discussing its contents, the participants who were not authors left the group, and the participating authors proceeded with (5): a synthesis of the data collected in the meetings (3), (4) to form the concept of the term rehabilitation through thematic analysis.14 The relationship between the words displayed on the map was established according to its degree of functionality, meaning and action in a rehabilitation process aimed at a whole person, as discussed with group participants. Therefore, it was essential to validate with the participants to analyse specific connectives (associations between the terms found associated with the larger theme – Rehabilitation) and provide cohesion to phrasal relationships and conceptual production. Above all, it was necessary for capturing the expression of the experience produced by the group of researchers in the concept and in the connections and disconnections of the constructive process of collective conception and confirm the statements.

Results

From the (RE)HABILITATION theme, which was pre-defined with the objective of understanding the perceptions of the participants, subcategories of words emerged from the brainstorming task. These were then analyzed in their proximity and synonymy (semantics), and the participants then proceeded with the synthesis of the concept.

Brainstorming — exploring the group’s understanding

Thinking about a term that encompasses as many meanings as rehabilitation is a task that requires us to delve deeper into the subject to reach common certainties and uncertainties that can be discussed and elaborated in a group. Thus, the idea of having a brainstorming session to create a conceptual map seemed applicable to this group. The objective of all the participants was to conceptualise rehabilitation as a health practice common to all professionals in the area. At first, several disconnected words were attributed to the term.

Field notes from the discussion were used to build a word cloud. In Figure 1, a word cloud in the shape of a heart shows the expression of the words that appeared in the brainstorming with their frequency and intensity (participants’ emphasis): intersubjectivity, well-living, praxis, reconstruction, resignification, becoming, empathy, diversity, identity, respect, esteem, love, and self-determination.

9fe85eaf-be1c-425e-8c70-ea8754e63c9d_figure1.gif

Figure 1. (RE)HABILITATE group brainstorming experience (own source).

Semantic sense of expressions

The proximity and synonymy of the ideas represented by different words, typically used in each specialty, indicated the need for deeper articulation to connect ideas and make a cohesive construction of collective thinking that could elucidate the concept of rehabilitation in the conception of the interdisciplinary group, which led to an overall view of the actions.

An analysis of the meaning through which each word was associated with the main term: (RE)HABILITATION was conducted. At that moment, semantic units appeared with their correspondents. The discussion consisted of finding the associated terms most appropriate to the context, as shown in Table 1.

Table 1. Semantics of expressions associated with the term (RE)HABILITATION.

Brainstorming expressions (THEMES)Semantics
IntersubjectivityCommunication, reciprocity, sharing of meanings, experiences between
Well-livingEmancipatory life process, requiring hope, hoping
PraxisTransformative actions, working, acting, movement
ReconstructionReorganisation, restructuring, reconstitution, assistance, treatment
ResignificationNew meaning, redefinition, transformation
BecomingBecoming, transforming, coming to be
EmpathyBrotherhood, fraternity, bonding, understanding, solidarity
DiversityDifference
IdentityPersonal characteristics, personal attributes, personal distinction
RespectConsecration, tribute, right
EsteemAffection, consideration, appreciation
LoveSelf-appreciation, fraternity, well-being, well-wishing
Self-determinationLiberation, independence, autonomy, emancipation

Connectives between ideas

Once the semantic units of the words that appeared associated with the concept of (RE)HABILITATION were discussed and understood, connectives were suggested and arranged between several linguistic elements to generate assertions to validate a meaning for the group in the universe of the person undergoing rehabilitation. The conceptual map (Figure 2) expresses the main ideas that generated the concept of rehabilitation conceptualised by the (RE)HABILITATE group. The connection of ideas through semantics and connectives allowed the articulation and cohesion of a sequence of expressions to construct a collective conception that gave rise to the basic concept of rehabilitation actions for the group.

The themes were reorganized in a circular fashion according to the participants’ understanding of the importance and proximity in the rehabilitation process, defining the levels of the process, and not organised as a hierarchy.

9fe85eaf-be1c-425e-8c70-ea8754e63c9d_figure2.gif

Figure 2. (RE)HABILITATE group conceptual map (own source).

Discussion

The map (Figure 2) was analysed from the association with the term (RE)HABILITATION, represented from base to surface, in a circular way, in levels of processes, to express the intersubjectivity experienced by the authors involved in a rehabilitation process. A theoretical design that works on conceptual levels is obtained from deepening the conceptualisation of the terms, improving rehabilitation care.

In the group’s perception, the first level represents attributes for recognising the person in rehabilitation that permeates the relationship with care. At this level, close relationships of trust are built between the professional and the person undergoing rehabilitation. The premise of Honneth’s Recognition Theory15 is that the absence of intersubjective and social recognition causes conflicts and that the subject is built through relationships. Thus, potentiality needs to be recognised, so that the subject can develop and harmonise with the society in which they live. These attributes involved in care facilitate rehabilitation as an inclusive process.16

At the second level are the pillars of the (re)habilitation process: praxis, intersubjectivity, and well-living as a product. Praxis starts from the reflection between theory and practice, promoting the transformation (becoming) of the person being cared for and of their world.17,18 Intersubjective recognition relationships start from the professional’s and patient’s individualities, producing a relationship that is fundamental to maintain self-determination and well-being.19,20 Reciprocity leads to mutual recognition between those involved in the relationship. Human coexistence is based on experiences between people and on the processes arising from it: individuation and socialisation; that is, existing presupposed interaction and communication with others who are equal.21 Thus, praxis promotes the adaptation of intersubjectivity between the professional and the patient with the aim of promoting well-living.

At the third level, we found the dimensions of the wholeness of the person: spirituality in a more abstract plane, (re)signification of the meanings of life, functionality of biophysical structures, and biopsychosocial (re)construction in an environment where the dynamic constitution of identity is internalised, reconstructed from the rehabilitation process. The WHO and the World Psychiatric Association recognises spirituality in the area of health, contributing to the well-being of an individual.2224

(Re)signification, as a form of attribution to personal senses, aims to support the new context of life and provide internal security from support received in the external environment.25 The (re)signification is the cognitive correspondent and a behavioral motivator, not only from a biomedical point of view, considering the potential of each person, focusing on transformations and restoration possibilities aimed at well-living.26 Reconstruction involves the process of rehabilitation, encompassing the aforementioned dimensions with unique dynamics that emerge from relationships between the actors interacting as a labour movement with the aim of rehabilitation.

The fourth level presents diversity and becoming in the process of life. Becoming, as a movement, makes continuity or discontinuity possible, favouring transformations that emerge from actions and practices, assuming new identity positions.27 The ones involved in the universe of rehabilitation have peculiar, multifaceted characteristics that suggest the diversity and subsidises exchanges that favour transformations.

As a result of the cognitive exercise of critical thinking and in the complexity of the process, it was understood that praxis makes up the rehabilitation experience. The exercise of theoretical-practical studies and of conceptualisation contributed to the development of basic constructs used in a study organised by the research group in 2021.28

The understanding of rehabilitation permeates the holistic idea as a phenomenon carried out throughout the life cycle until the process of finitude, as in continuity in time and space, when pursuing the purpose of becoming, of maintaining emancipatory functionality with longevity and quality. This process is complete when integrated by connections of knowledge of interdisciplinary essence, of the linked specialties and, above all, of the subjects involved. It is a process governed by philosophical bases and biopsychosocial and spiritual conceptual designations, which move the actions. This will only make sense with the recognition of the person for their emancipation.

Strengths and limitations

This study is strengthened by bringing together several mutually dependent facets of rehabilitative care, which aim at human integrality rather than dichotomous conceptions. It denotes the conception of a multidisciplinary group specializing in rehabilitation that works on research in this area. It shows how comprehensive person-centered rehabilitation practices can be strengthened.

This research extensively explored the conceptions of the participants, through the discussion of each term that appeared in the formation of the concept.

However, there are limitations to the generalization of the concept, since other teams have not been tested, even due to the lack of joint work with the sole purpose of rehabilitation. Thus, further studies with multidisciplinary teams are suggested. The strengths and limitations of this study indicate the need to continue research in understanding the conception of care teams, since motivations influence rehabilitative care.

Conclusion

The concept of rehabilitation that recognises the person as a whole qualifies as care and is more likely to achieve its inclusive goals, as rehabilitation is a process based on the aegis of human attributes, facilitators or not of the process of transformation and (co)-construction of the person. This process must favour and authenticate singular recognition considering love, solidarity, and mutual respect. The rights defined in this scenario should aim at wholeness and, consequently, promote public policies, especially in health.

Scientific research in rehabilitation must presuppose person-centredness. Therefore, it should consider the interdisciplinary theoretical bases that underlie collaborative health practices due to the biopsychosocial and spiritual dimensions that encompass human wholeness.

In clinical practice, it is fundamental to unveil the rehabilitation process and consider the understanding of the involved factors, since the constructs generate actions, relationships, direct professional decision-making, and the role of the patient through expertise. Thus, evidence assumes the abstract field of subjectivation.

Financial support

The first author of this work is supported by the Coordination for the Improvement of Higher Education Personnel - Academic Excellence Program CAPES/PROEX, Brazil.

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Cunha TEdO, Schoeller SD, Martins MMFPdS et al. Rehabilitation: collective construction of a concept in a focus group [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:120 (https://doi.org/10.12688/f1000research.129073.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Reviewer Report 29 Dec 2023
Mette Ryssel Bystrup, Aalborg Universitet, Copenhagen, Denmark;  Regional Hospital Hammel Neurocenter (Ringgold ID: 91933), Hammel, Central Denmark Region, Denmark 
Approved with Reservations
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In short:
The manuscript concerns the exploration of health rehabilitation with a focus on interdisciplinary and huminitic dimensions. Various methodological approaches were used as well as various researchers participated in creating a collective and theoretical understanding of the concept ... Continue reading
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Ryssel Bystrup M. Reviewer Report For: Rehabilitation: collective construction of a concept in a focus group [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:120 (https://doi.org/10.5256/f1000research.141729.r225151)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 27 Feb 2023
Erico Gurgel Amorim, Universidade Federal do Rio Grande do Norte, Natal, Brazil 
Approved with Reservations
VIEWS 24
The study brings a contribution to the understanding of rehabilitation and invites the transformation of orthodox practices into inclusive ones. Its relevance is translated into the interdisciplinarity that mediated the construction process of the research and the data that emerged ... Continue reading
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HOW TO CITE THIS REPORT
Amorim EG. Reviewer Report For: Rehabilitation: collective construction of a concept in a focus group [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:120 (https://doi.org/10.5256/f1000research.141729.r162193)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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