Dr Viki Teggart, Clinical Neuropsychologist GMMH NHS Foundation Trust

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Presentation transcript:

Cognitive Rehabilitation for Everyone – Embedding Enhanced Learning Techniques in Practice Dr Viki Teggart, Clinical Neuropsychologist GMMH NHS Foundation Trust Dr Natalie Arran, Clinical Psychologist specialising in Neuropsychology Salford Royal NHS Foundation Trust

What is Rehabilitation? Rehabilitation is a process whereby people who have sustained insults to the brain are helped to achieve their optimum physical, emotional, psychological and vocational well being (McLellan, 1991) The focus of treatment is on improving aspects of everyday life; rehabilitation therefore needs to involve personally meaningful themes, activities, settings, and interactions (Ylvisaker & Feeney, 2000) What is Rehabilitation?

Ingredients for Effective Rehabilitation Winson, Wilson & Bateman, 2017 Therapeutic milieu Meaningful goals Shared understanding Psychological interventions Compensatory strategies and retraining Families and caregivers

Rehabilitation and Learning Effective rehabilitation involves: Learning by the patient Teaching by the professional Smits et al, 2010

What kinds of things do people need to learn or relearn after a stroke?

Some Examples of Things to Learn KNOWLEDGE MOVEMENT COMMUNICATION FUNCTION What a stroke is Bed mobility How to find words How to scan The effects of the stroke How to transfer (using aids) Using a communication book How to swallow Potential risks How to walk (using aids) Using gestures Using new equipment Options for future support Balance How to thicken drinks

Cognitive Deficits and Learning Ability to learn can be affected by deficits in: Processing speed Attention Comprehension Memory Self monitoring Self awareness

Your turn…. Think of a person you are working with and a specific skill you are working on with them. What are you trying to help your patient learn? What cognitive difficulties does your patient have that might affect learning? Write your answers down on the worksheet

Adapting Teaching Styles Ideally we would acquire a detailed assessment of cognitive functioning and gain an understanding of learning style / needs of each patient… But it is not always practical, possible or necessary… So we should assume that most patients will benefit from enhanced learning and embed enhanced learning in all teaching activities

Systematic Instruction (Ehlhardt, Sohlberg et al 2008) People with learning challenges benefit most from: Explicit modelling Minimisation of errors during initial acquisition Strategies to promote learner engagement Guided practice Systematic Instruction (Ehlhardt, Sohlberg et al 2008)

The person learns new skills by imitating another person who performs the behavior or action to be learned Explicit Modelling Show, don’t tell or Show and tell

Explicit Modelling Example – Object to Picture Matching Place picture on table in front of client and name it Pick up object and name it Place object on top of picture and name both

Your turn…. Back to the client you are working with… How have you used explicit modelling so far? Can you think of any other ways to include modelling? Write your answer down on the worksheet

Minimisation of Errors - Errorless Learning Break down information into small chunks Provide sufficient models before client is asked to perform Encourage avoidance of guessing Immediately correct errors Carefully fade prompts "to reduce substantially, if not eliminate, errors during the acquisition phase of learning" (Baddeley & Wilson, 1994) Minimisation of Errors - Errorless Learning

Errorless Learning for Teaching Information Break down information into small chunks What does the person need to know? Provide sufficient models before client is asked to perform Tell rather than ask Make sure information is given in a consistent way Errorless Learning for Teaching Information

Errorless Learning for Teaching Information Encourage avoidance of guessing - “If not sure, it’s okay to say don’t know” Immediately correct errors - “that’s not quite right, I said ….” Carefully fade prompts - don’t go too fast when removing help Errorless Learning for Teaching Information

An Errorless Learning Orientation Script Example orientation programme This is an errorless learning programme. We will be providing X with orientation information without asking him to recall or guess the answers for a few weeks to help his learning. During this time, please avoid asking X questions about what happened to him.

An Errorless Learning Orientation Script   Please update the orientation date board in X’s room everyday. When doing formal orientation work with X, please give information one sentence at a time. If using this information to answer questions at other times, pick the appropriate sentences to use

An Errorless Learning Orientation Script Date “Today’s date is ……” Also show X this written on the board Place “You are in X Hospital in X, “You have been here (insert number) weeks”  

An Errorless Learning Orientation Script  Situation “You are here because you have had a stroke” “A stroke is an illness that affects your brain”

An Errorless Learning Orientation Script  Insert key difficulties as appropriate for example: “At the moment, your legs aren’t strong enough to hold you up” (point to or touch legs). “Also your left arm doesn’t move very easily” (point to or touch left arm). “You are finding it difficult to remember things that have happened recently. You might feel confused about what is going on.”

An Errorless Learning Orientation Script “Your wife / husband / children know you are here and visit you very often” “We are working with you everyday to try and get you home safely as soon as possible” Repeat information as necessary.

Minimisation of Errors - Chaining “Each new step is individually taught and linked sequentially to the previous step. The learner moves on to a new step as soon as the current step is mastered.” Sohlberg, Ehlhardt, & Kennedy (2005) Conduct a task analysis to identify the key stages List the specific actions required at each stage Teach each stage action or step individually Carefully fade prompts Minimisation of Errors - Chaining

Chaining Task Analysis – Sit to Stand Shuffle bottom to edge of chair Lean weight forward Put feet back Put hand on arms of chair Put weight through legs Move forwards and up

Errorless Learning and Chaining Combined - Grooming Open wash bag and place comb, toothbrush, toothpaste and paper towel on the sink. Stand in front of the mirror and hold on to the grab rail saying ‘ stand in front of the mirror and hold on to the grab rail’ Take brush from sink and brush hair, say ‘brush your hair’. Place the brush back in the wash bag. Sit on a perching stool in front of the sink. Say, ‘sit in front of the sink and brush your teeth’

Your turn…. Back to the client you are working with… How can you break down the task you are teaching into small steps? How could you incorporate errorless learning into the task? Write your answer down on the worksheet

Promoting Learner Engagement “encouraging active processing during training increases learning” Sohlberg & Turkstra (2011) Promoting Learner Engagement Get the client to be active in the learning process Encourage self generated learning and elaboration Make learning meaningful and fun

Promoting Learner Engagement Ask client to describe the learned task in their own words Use visual imagery or video feedback Develop mnemonic strategies - rhymes, songs, stories Link tasks to meaningful goals or valued activities

Increasing independence when practising a task whilst still receiving enough support to Minimise errors and maintain consistency Develop a between session practice plan Model approach to other staff Involve family Provide sufficient written / visual prompts or reminders Guided Practice

Guided practice Write a plan for all staff to follow consistently and model to others Set reminders for practice or use calendars / notes / stickers Write steps down Draw pictures Make video for people to watch between sessions Involve family / carers

Your turn…. Back to the client you are working with… What techniques could you introduce to promote engagement in learning the task How can you support guided practice within and between sessions? Write your answers down on the worksheet

Thank you for your attention and participation