Implementing the ‘Rehabilitation is all about learning’ approach; a qualitative study providing insight into facilitators and barriers from both healthcare professionals’ and patients perspectives

Implementing the ‘Rehabilitation is all about learning’ approach; a qualitative study providing insight into facilitators and barriers from both healthcare professionals’ and patients perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Implementing the ‘Rehabilitation is all about learning’ approach; a qualitative study providing insight into facilitators and barriers from both healthcare professionals’ and patients perspectives Rick A.H. van de Ven, Marcel A.L. Hendriks, Roderick Wondergem, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6377146/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objective: To explore the facilitators and barriers of implementing the ‘Rehabilitation is all about Learning’ approach from both healthcare professionals’ and patients’ perspectives. Design: Phenomenological qualitative study using semi-structured interviews Subjects: Healthcare professionals and inpatient patients of Tolbrug Rehabilitation engaged in the ‘Rehabilitation is all about Learning’ approach Methods : The interview guide for healthcare professionals was based on the Theoretical Domains Framework, and for patients, on the Positive Health Model. Themes emerged after thematic analyses. Results : Three main themes emerged: competence, autonomy, and relatedness. Healthcare professionals experienced tensions between their medical expertise and coaching roles. Patients initially relied on guidance but later gaining confidence in self-directed rehabilitation. Interdisciplinary collaboration enhanced patient-centered care, although unclear role boundaries posed challenges in coordinating treatment. While empowerment motivated proactive patients, it raised concerns for those with cognitive impairments. Peer and organizational support were essential for healthcare professionals’ confidence, while patients valued communal spaces and peer support for increased motivation. Conclusion : A patient-centred, learning-based approach such as ‘Rehabilitation is all about Learning’, fosters autonomy, ownership, and participation. Successful implementation relies on healthcare professionals’ competence and confidence in their evolving roles as coaches, as well as their ability to collaborate effectively within interdisciplinary teams. Continuous feedback and on-the-job coaching are essential for improving implementation. Future research should explore how the RiL-approach can be adapted and implemented in diverse rehabilitation settings to enhance long-term patient autonomy and team collaboration. Humanities/Health humanities Humanities/Medical humanities autonomy interdisciplinary collaboration learning principles participation patient-centred self-management skills Introduction Each year, approximately 200,000 individuals in the Netherlands undergo rehabilitation to enhance their functional abilities, autonomy, and participation in daily life [ 1 ]. However, successful completion of rehabilitation programs does not necessarily lead to successful long-term participation [ 2 – 4 ]. Patients continue to face difficulties with information processing, mobility, social engagement, work, and finances [ 2 – 4 ]. Although many of these patients live with lifelong disabilities, their limited participation may also stem from inherent limitations within the rehabilitation system. Current rehabilitation programs are predominantly based on therapist-led, expert-driven interventions to enhance the patients’ functional capacity. The structured, evidence-based treatment protocols within these programs are designed to minimize mistakes and optimize recovery. However, while effective in restoring basic functional abilities, this approach may inadvertently hinder the development of crucial self-management skills, which can impair their ability to manage their health and wellbeing in the long term independently [ 5 , 6 ]. This lack of self-management skills poses challenges in daily life and contributes to increased secondary healthcare costs [ 2 , 7 ]. Recognizing these challenges, there is increasing advocacy for patient-centred rehabilitation approaches focusing on developing self-management skills [ 8 , 9 ]. Self-management is defined as an ongoing process of self-regulation wherein individuals assume responsibility for their health management [ 10 , 11 ]. To address this need, Tolbrug Rehabilitation implemented the "Rehabilitation is all about Learning" (RiL) approach in March 2020. This innovative patient-centred approach integrates learning principles into traditional rehabilitation programs, fostering problem-solving abilities and self-management skills to enhance the transition from rehabilitation to independent participation [ 12 ]. The RiL-approach prioritizes the patient's learning process to promote competence and autonomy [ 12 ]. By establishing a learning environment, it encourages patients to regain or maintain independence. However, this presents challenges, as it must be tailored to the evolving learning needs and contextual factors unique to each patient. A core element of the learning environment is the interdisciplinary collaboration within the rehabilitation team, where healthcare professionals extend beyond their traditional roles, acting as both expert and coach [ 13 ]. This flexibility allows patients to consult multiple healthcare professionals, including specialized experts, as many as needed. However, the specific adjustments required to create an effective learning environment are not predetermined. Implementing the RiL-approach can vary across organisations and healthcare professionals, further complicating the process [ 12 ]. At Tolbrug Rehabilitation, several modifications have optimized the learning environment. Patients are assigned a personal rehabilitation coach who helps set goals and oversee self-regulation. A structured, predefined planning system is replaced with a flexible, self-managed approach where patients schedule their therapy sessions with guidance of their rehabilitation coach. Group sessions are incorporated to provide peer support and shared learning experiences. Peer counsellors assist patients in processing and coping with their limitations. These adaptations aim to foster autonomy and active participation in rehabilitation. This new approach requires behavioural changes for both healthcare professionals and patients. Healthcare professionals must shift from being primarily experts to learning facilitators and have to develop skills in group dynamics to guide sessions effectively. Patients must take ownership of their rehabilitation process, actively engage in decision-making, and assume responsibility for self-regulation. However, the experiences of both groups with this new approach remain largely unexplored. This study aims to investigate the facilitators and barriers of implementing the RiL-approach from the perspectives of healthcare professionals and patients. Findings will offer valuable insights to refine implementation of the RiL-approach and support its broader application in rehabilitation settings. Methods Design This qualitative phenomenological study used semi-structured interviews, conducted between March 2021 and February 2022, to explore experiences of healthcare professionals and patients working with the RiL-approach. Participants Healthcare professionals and patients involved in Tolbrug Rehabilitation’s inpatient program and working according to the RiL-approach were eligible. Purposive sampling ensured diversity in age, gender, profession, experience, and diagnosis [ 14 ]. Participants were initially invited via email, including an information letter and consent form. Non-responders received a follow-up from the primary researcher (RV) after two weeks. Written informed consent was obtained before scheduling interviews. Data-collection Interviews were conducted face-to-face at Tolbrug Rehabilitation or at patients' homes. Demographic data were recorded: age, gender, profession, and work experience for healthcare professionals, and for patients: age, gender, diagnosis, rehabilitation duration, and family situation. Participants could ask questions before interviews began. Primary researchers (.. and ..) conducted all 60–90 minutes interviews, audio-recorded with consent. The healthcare professionals’ interview guide was based on the Capabilities, Opportunities, Motivation and Behaviour (COM-B) model and the Theoretical Domains Framework (TDF), addressing behavioural determinants for adopting the RiL-approach [ 15 – 16 ]. Patient interviews focused on autonomy and long-term participation, aligning with the Positive Health Model, which provides a holistic perspective on health and promotes patient autonomy [ 17 ]. The interview guide was structured around its key domains. Data were securely stored on Fontys University’s Research Drive. Data-analysis Audio recordings were transcribed in Microsoft Word, ensuring anonymity. Transcripts summaries were returned to participants for member checking. The interview data was analysed separately for healthcare professionals and patients. Thematic analysis identified patters in the data [ 18 ]. Open coding began with meaningful transcript segments, followed by a consensus meeting after the first interview to ensure coding consistency. After coding four interviews per dataset, open codes were categorized into axial codes, and the interview guides were evaluated. Data collection continued until no new axial codes emerged in two consecutive interviews, confirming data saturation. Axial codes were then grouped into themes separately for healthcare professionals and patients. Five research team meetings ensured analytical rigor. Final themes were synthesized into overarching categories. Ethical consideration The Medical Ethical Committee Brabant approved the study (protocol … ). The study follows the COREQ checklist [ 19 ]. The anonymised dataset is available upon reasonable request from the corresponding author. Results Participants This study included 20 participants; 10 healthcare professionals (9 females) and 10 patients (5 females). Healthcare professionals’ ages ranged from 29 to 59 years (mean 42.7 years), with work experiences spanning from 7 to 39 years (mean 20.5 years). Patients’ ages ranged from 48 to 72 years (mean 62.9 years), and their inpatient rehabilitation duration varied from 5 weeks to 6 months (mean 12 weeks). Data saturation was reached after 8 interviews in each group. The demographic characteristics of the participants are presented in table 1. Themes Three main themes emerged from the analysis: competence, autonomy, and relatedness, aligned with the self-determination theory [20]. Competence Healthcare professionals emphasized that their sense of competence was key to mastering the RiL-approach. They stressed the need for openness and adaptability. However, several factors were mentioned that led to doubts about the approach's suitability. These included the tension between their roles as medical experts and coaching professionals, the lack of empirical evidence supporting the approach's effectiveness, and challenges in establishing new routines. The RiL-approach pushed them beyond their comfort zones, which, while necessary for learning, also heightened concerns about their abilities in the coaching role. - Healthcare professional 8: “You have to step outside the comfort zone, which makes me worry beforehand whether I'm doing it right.” Patients also went through an adjustment period to align with the RiL-approach's behavioural competencies. Initially, many expected healthcare professionals to take control, believing recovery occurred by following expert instructions. They viewed healthcare professionals as the primary agents of control. Despite the RiL-approach being introduced early, many patients struggled to understand their role in actively participate in decision-making, leading to a passive approach to goal-setting. However, once they grasped the approach, they found it motivating, enabling them to set personal goals and engage in more meaningful rehabilitation activities. - Patient 4: “At first, I didn't know what was expected of me… … when I figured it out, I thought this way of treatment was ideal.” Autonomy Self-managing A significant shift in healthcare professionals’ work patterns was the move from a structured planning system to a more flexible, self-managed approach without predefined appointments. Many professionals saw this flexibility as an advantage, enabling them to quickly respond to patients' emerging needs. However, the lack of a structured, predefined plan posed challenges for some healthcare professionals in maintaining an overview of patient care. Due to the interdisciplinary nature of the RiL-approach, with undefined professional boundaries, some professionals struggled to implement the approach in daily practice. - Healthcare Professional 6: “The space I have in my schedule allows me to respond quickly to acute problems. This is a big advantage.” - Healthcare Professional 2: “I do see the potential, but I think it looks easier on paper than to put it in practice.” At the beginning of their rehabilitation, patients found goal-setting challenging and recognized times when healthcare professionals needed to take control. They believed that healthcare professionals, with their medical expertise, were better equipped to assess their abilities and guide them safely towards their goals. In early stages, this professional guidance helped reduce patients’ barriers to engaging in activities and boosted their self-confidence. - Patient 10: After falling twice I was afraid to walk. Finally, the therapist said I would be better off using a walker for walking longer distances. I wish I had known this earlier. As patients advanced in their rehabilitation, they gained confidence in making decisions and taking responsibility. They became more skilled at prioritizing personal goals and emphasized the importance of having time to control their rehabilitation process. This autonomy allowed them to learn from their mistakes, leading to a deeper understanding of the consequences of their choices. - Patient 9: It’s better to set your own goals than that somebody makes that choice for you. Mostly that is not what you really want.” Patients reported that the lack of a predetermined plan allowed them to engage in meaningful activities aligned with their life goals, such as cooking, cycling, and gardening. These activities boosted their motivation and sense of control, as they were no longer required to participate in irrelevant tasks. Most patients noted that they became more adept at incorporating meaningful activities into their daily routines. - Patient 10: “The fact that I did not had to practice something that I would never do in daily life made me feel in control” Empowerment Healthcare professionals described the RiL-approach as enhancing patient autonomy, especially for those proactive in setting goals and taking initiative. These self-motivated patients sought their own solutions to challenges. However, professionals expressed concerns about balancing patient empowerment with maintaining professional control. Some feared that prioritizing autonomy could compromise care quality, particularly for patients with severe cognitive impairments who struggle with decision-making. These professionals questioned whether patients could handle the autonomy granted to them, believing that expert-based goals should still be pursued alongside those identified by the patients. - Healthcare Professional 1: “If you rely purely on what people have their questions about, you fail them in letting them discover their possibilities.” The RiL-approach also fostered autonomy among healthcare professionals, enabling them to make decisions based on their clinical judgment, which many found increased job satisfaction. However, some professionals expressed concerns about the abrupt implementation of the approach, feeling that it was introduced without sufficient consultation or adequate time to adapt to the new working methods. - Healthcare Professional 5: “The steering group should contain healthcare professionals who work at the inpatient department... ...it frustrates me that people who do not work as healthcare professionals determine how we are going to implement the RiL-approach.” In the early stages of rehabilitation, patients saw the absence of healthcare professionals during evenings and weekends as a barrier, leading to fewer activities. However, as they took more responsibility for their rehabilitation, they began viewing this lack of supervision as an opportunity to organize their own activities, which helped them assess their capabilities and re-evaluate their goals. - Patient 1: “Why should I not do anything on the weekends? The more I train during the weekends, the sooner I will achieve my goals.” Relatedness Interdisciplinary collaboration Healthcare professionals saw increased team collaboration as key to the RiL-approach, believing that working interdisciplinary allowed them to fully leverage each other's expertise. However, they felt a need for more insight into each other's roles, as uncertainty about colleagues' tasks hindered the interdisciplinary approach to coordinate treatments effectively. They emphasized the importance of fostering a learning culture, where they feel comfortable asking and giving regular feedback, and believe that smaller teams are more conducive to creating a positive learning environment. - Healthcare Professional 7:” We can make much more use of each other’s talents... we need to get to know each other better… but the better you know someone, the easier it is to see each other and the better you understand each other.” Some healthcare professionals felt that their specific expertise was undervalued within the interdisciplinary team, leading them to actively advocate for the importance of their professional roles to avoid being overshadowed by others. This challenge made it difficult for them to integrate their expert role with their coaching responsibilities. They felt a personal obligation to maintain their position as experts throughout the patient’s rehabilitation process. On the other hand, some professionals believed that the lack of shared responsibility for the patient's overall rehabilitation stemmed from colleagues who were too focused on their own areas of expertise. - Healthcare Professional 2: “People often still think: this is my expertise and has priority for me, otherwise it may not be discussed.” Patients reported that the interdisciplinary collaboration within the team of healthcare professionals was highly beneficial. They noticed that each professional, regardless of their discipline, was familiar with their personal goals, which fostered a sense of accessibility. Patients felt they could seek help from any team member and receive the appropriate treatment at the right time. As a result, patients became less dependent on specific healthcare professionals for particular tasks. For example, a patient needing help with walking no longer had to wait for the physiotherapist to be available, as other team members were equally equipped to provide support. - Patient 8: “The occupational therapist helped me with walking and the physiotherapist helped with reading.” Support Healthcare professionals noted that organizational support, as well as guidance from colleagues and trainers at the Rehab Academy, was essential for developing the competencies necessary to implement the RiL-approach. Trainers were regarded as experts and provided valuable support through brainstorming and on-the-job coaching, which played a crucial role in facilitating the integration of the approach. Additionally, healthcare professionals emphasized the need for continuous coaching and adequate time to adapt in order to prevent reverting to previous practices. - Healthcare Professional 3: “I thought the introduction meeting was very useful... …it's nice that we can spar regularly with colleagues or with the implementation coaches of Rehab Academy.” Patients identified the rehabilitation coach as a central figure in their rehabilitation process. They frequently reported a lack of clarity regarding the available options, and the rehabilitation coach played a crucial role in helping them identify potential achievements, thus facilitating the goal-setting process. This highlights the importance of healthcare professionals being well-acquainted with the competencies of their colleagues, ensuring that the full spectrum of expertise within the interdisciplinary team is effectively utilized. - Patient 1: By reaching my goals, I had fewer and fewer questions. However, by discussing this with the rehabilitation coach, I came up with new questions for help in other areas that I had not even thought of myself. Confidence Healthcare professionals highlighted the importance of peer support in adapting their coaching roles. Positive feedback from colleagues boosted their confidence in applying the RiL-approach. However, they expressed concerns about a divide between inpatient and outpatient teams, with inpatient professionals feeling that outpatient colleagues did not fully understand or support the approach. This led to negative feedback, which undermined confidence and, for some, prompted a return to previous practices. - Healthcare Professional 5: “Critical questions from colleagues and hardly receiving compliments or hearing what is going well makes me insecure.” Patients reported that peer support enhanced their self-confidence, encouraging greater participation in activities with fellow patients. Shared experiences within peer groups helped them to learn from each other and overcome challenges. Peer counsellors also played a key role in helping patients better understand their abilities. Furthermore, involving relatives in rehabilitation sessions facilitated a smoother transition to home, as family members were better prepared to offer support. - Patient 8: “My daughter -in-law, for example, joined a training session with the speech therapist. At home she knew how to help me to read those (training) cards.” Resources Healthcare professionals had mixed views on the rehabilitation centre’s resources. While they valued the communal living room for promoting patient interaction, they expressed concerns about the lack of additional resources, such as public transport cards or debit cards, which they saw as obstacles to fully implementing the RiL-approach. - Healthcare Professional 3: “I would like to have a public transport card and debit card available in the department that we can use, so that we, for example, can easily go grocery shopping with patients during their rehabilitation without having to pay in advance.” In contrast to healthcare professionals, patients reported no shortage of facilities. They found the environment well-suited to their needs, offering plenty opportunities for activities such as swimming, cycling, and golfing. Patients particularly appreciated the living room in the inpatient department, describing it as a space that encouraged social interaction and relaxation. This setting was seen as motivating and conducive to active participation in rehabilitation, fostering a sense of community and well-being. - Patient 7: “The living room made it possible to connect with everyone by just small talks and playing games. I always liked that. It gave me energy .” Discussion This qualitative study explored the facilitators and barriers to implementing the RiL-approach from the perspectives of healthcare professionals and patients. From the patients’ viewpoint, the RiL-approach successfully empowered them to engage in rehabilitation based on their personal needs and values. They felt a strong sense of control over their process, valuing the autonomy to participate in meaningful activities. However, many initially found the RiL-approach unclear and felt they lacked self-management skills. Peer collaboration helped them navigate and master their rehabilitation process. This concept of collaborative learning, commonly used in educational settings, provides social, psychological, and academic benefits, enabling patients to take an active role in their rehabilitation [ 21 ]. With appropriate support from peers and healthcare professionals, patients reported significant improvements over time in autonomous navigation of their rehabilitation process. This aligns with literature suggesting patients value autonomy and meaningful life over functional independence [ 22 – 26 ]. Studies on stroke survivors in self-management programs show that empowering patients to control their rehabilitation leads to better long-term outcomes [ 27 ]. While self-management programs emphasize collaboration with healthcare professionals, the RiL-approach focuses on independent learning, enabling long-term autonomy and participation without ongoing professional involvement [ 27 , 28 ]. Further research is needed to explore this advantage. The role of healthcare professionals in supporting patient autonomy is complex and may require a shift in traditional professional boundaries. In patient-centred programs that emphasize autonomy, all team members must align with shared goals, blurring disciplinary boundaries [ 13 ]. Some professionals in our study struggled to move beyond their expert roles, prioritizing their own professional needs over those of the patient [ 29 ]. This aligns with previous research on the challenges of interdisciplinary collaboration, particularly when trust and teamwork are not well-established [ 30 ]. Healthcare professionals expressed confusion about each other’s roles and competencies, hindering interdisciplinary team functioning. Insufficient understanding of colleagues' skills also undermined their confidence in the RiL-approach. Team effectiveness could improve through regular interdisciplinary meetings to better align members’ strengths. Our study highlights that healthcare professionals' mastery of the RiL-approach was influenced by factors such as autonomy, competence, and support. The approach promotes autonomy, allowing professionals to base decisions on their clinical judgment, while balancing the need to provide appropriate guidance and giving patients space to make their own decisions [ 31 ]. However, for those accustomed to more expert-driven, structured methods, balancing roles as training experts and learning coaches can be difficult [ 32 , 33 ]. Transitioning to the RiL-approach was particularly challenging and stressful for these individuals, with many emphasizing the need for scientific evidence to support it. Healthcare professionals who embraced the approach tended to be committed to continuous learning, which enhanced their job satisfaction and motivation. A key challenge identified by healthcare professionals in implementing the RiL-approach was their lack of confidence in coaching patients with severe cognitive impairments. They assumed these patients had limited self-management skills. In such cases, involving family members is crucial for improving outcomes [ 34 ]. Healthcare professionals noted the need for additional training to better support these patients. Without proper guidance, they may default to traditional, directive methods, potentially reducing patient autonomy and promoting passivity. On-the-job coaching could improve their skills and confidence [ 35 ]. This study identified organizational and peer support as crucial for adopting the RiL-approach. The absence of positive reinforcement and constructive feedback from peers led to insecurity among healthcare professionals and reduced their self-confidence in implementing the approach effectively. Previous research supports that positive social influences and support for new methods are vital for successful implementation [ 36 , 37 ]. Cultivating a feedback-driven learning culture, where continuous learning is encouraged, could help address these challenges. Both positive and constructive feedback are essential for fostering such a culture [ 38 ]. This study had both strengths and limitations. A key strength is that it provides valuable insights into the experiences of those directly involved in a new approach that integrates patient-centred care, interdisciplinary collaboration, self-management promotion, and potentially value-based care. While these individual elements are supported by evidence, research on their combined implementation, as in the RiL-approach, is lacking. Addressing the identified barriers could improve adoption and implementation. Another strength is the achievement of data saturation, ensuring comprehensive findings. Although the small sample size limits exploration of how demographic factors influence adoption, participants' personal learning styles likely play a more significant role in successful implementation. Additionally, the study’s design, involving multiple researchers in data collection and analysis, enhanced its validity. Thorough transcription and member checking minimized information bias. A limitation is that the interviews were conducted at a single point in time, and participants' views may evolve as they gain more experience with the RiL-approach. A longitudinal study could provide deeper insights into how perceptions and experiences change over time. Since the RiL-approach was only implemented at Tolbrug Rehabilitation during the study, the findings may not be directly applicable to other contexts or rehabilitation centres. In conclusion, this study identifies key facilitators and barriers to implementing the RiL-approach in rehabilitation. Shifting from traditional care models to a patient-centred, learning-based approach empowers patients by increasing autonomy and participation. However, successful implementation depends on healthcare professionals' competence and confidence in their coaching roles, as well as effective interdisciplinary collaboration. To optimize adoption, clear expectations should be established early, and a culture of continuous learning should be promoted through regular feedback and coaching, especially for guiding cognitively impaired patients. Future research should evaluate the long-term effectiveness and broader applicability of the RiL-approach across various rehabilitation settings. Declarations Acknowledgments We kindly thank all participants of the study and the founders of Rehab Academy for providing insight in the concept of the ‘Rehabilitation is all about Learning’ approach. Declaration of funding statement The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Declaration of interest statement The authors have no relevant financial or non-financial interests to disclose. Declaration of authors contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by … and …. All authors discussed analysis till consensus was reached. The first draft of the manuscript was written by … and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Declaration of Ethical Approval This study was approved by the Medical Ethical Committee Brabant (Protocol number: NW2021-22) on February 22, 2021. The research was conducted in accordance with the Declaration of Helsinki and local regulations concerning medical research involving human subjects. Declaration of Informed Consent All participants received both written and oral information about the study and gave their written informed consent prior to participation. The consent procedure was approved by the Medical Ethical Committee Brabant. Declaration data availability The anonymised dataset is available upon reasonable request from the corresponding author. References Revalidatie Nederland. Brancherapport Revalidatie 2020. 2022. Revalidatie Nederland. Hilberink SR, van der Slot WM, Klem M. Health and participation problems in older adults with long-term disability. Disability and Health Journal . 2017;10(2):361-6. Törnbom K, Lundälv J, Sunnerhagen KS. Long-term participation 7-8 years after stroke: Experiences of people in working-age . PloS one . 2019;14(3):e0213447. Boerboom W, Heijenbrok-Kal MH, Van Kooten F, Khajeh L, Ribbers GM. Unmet needs, community integration and employment status four years after subarachnoid haemorrhage. Journal of rehabilitation medicine . 2016;48(6):529-34. Levack WM, Dean SG, Siegert RJ, McPherson KM. Navigating patient-centered goal setting in inpatient stroke rehabilitation: how clinicians control the process to meet perceived professional responsibilities. Patient education and counseling . 2011;85(2):206-13. Mudge S, Kayes N, McPherson K. Who is in control? Clinicians’ view on their role in self-management approaches: a qualitative metasynthesis. BMJ open . 2015;5(5):e007413. Meulenkamp T, Van der Hoek L, Cardol M. Deelname aan de samenleving van mensen met een beperking, ouderen en de algemene bevolking . Utrecht: NIVEL Figuur A. 2015;1. Langford AT, Sawyer DR, Gioimo S, Brownson CA, O'Toole ML. Patient-Centered. The Diabetes Educator . 2007;33(S6):139S-44S. van der Eijk M, Nijhuis FA, Faber MJ, Bloem BR. Moving from physician-centered care towards patient-centered care for Parkinson's disease patients. Parkinsonism & related disorders . 2013;19(11):923-7. J. Barlow, C. Wright, J. Sheasby, A. Turner, J. Hainsworth, Selfmanagement approaches for people with chronic conditions: a review, Patient Educ. Couns .48 (2002) 177–187. K.R. Lorig, H. Holman, Self-management education: history, definition, outcomes, and mechanisms, Ann. Behav. Med . 26 (2003) 1–7. Vuijk I. Revalideren is Leren . 2nd ed. Amsterdam: Studio HB; 2019. 264 p Choi BCK, Pak AWP. Multidisciplinarity, interdisciplinarity and transdis_ciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med. 2006 Dec;29(6):351–64. Patton MQ. Qualitative evaluation and research methods : SAGE Publications, inc; 1990. Keyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Acceptability, reliability, and validity of a brief measure of capabilities, opportunities, and motivations (“COM‐B”). British journal of health psychology . 2020;25(3):474-501. Michie S, Atkins L, West R. The behaviour change wheel. A guide to designing interventions . 1st ed Great Britain: Silverback Publishing. 2014:1003-10. Huber M, van Vliet M, Giezenberg M, et al. Towards a ‘patient-centred’ operationalisation of the new dynamic concept of health: a mixed methods study. BMJ Open 2016;5:e010091 Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology . 2006;3(2):77-101. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups . Int J Qual Health Care . 2007;19(6):349-357. Deci EL, Ryan RM. (2012). Motivation, personality, and development within embedded social contexts: An overview of self-determination theory. In Ryan RM, editors. The Oxford handbook of human motivation . Oxford: Oxford University Press; 2012. 85–107. Laal M, Ghodsi SM. Benefits of collaborative learning . Procedia-social and behavioral sciences. 2012;31:486-90. Peters M. Does constructivist epistemology have a place in nurse education? J Nurs Educ . 2000 Apr;39(4)(166–72). Fens M, Beusmans G, Limburg M, van Hoef L, van Haastregt J, Metsemakers J, et al. A process evaluation of a stroke-specific follow-up care model for stroke patients and caregivers; a longitudinal study. BMC Nurs . 2015 Jan 16;14(1):1. Graff MJL, Vernooij-Dassen MJM, Thijssen M, Dekker J, Hoefnagels WHL, Olderikkert MGM. Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: A randomized controlled trial. Journals Gerontol - Ser A Biol Sci Med Sci. 2007 Sep 1;62(9):1002–9. Cameron JI, Gignac MAM. “Timing It Right”: A conceptual framework for addressing the support needs of family caregivers to stroke survivors from the hospital to the home. Vol. 70, Patient Education and Counseling. 2008. p. 305–14. Vloothuis JDM, Mulder M, Nijland RHM, Goedhart QS, Konijnenbelt M, Mulder H, et al. Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): A randomized controlled trial. PLoS One . 2019 Apr 1;14(4). McKenna S, Martin S, Jones F, Gracey J, Lennon S. The Bridges Stroke Self-Management program for Stroke Survivors in the Community: Stroke, Carer and HealthProfessional Participants’ Perspectives. Physical Medicine and Rehabilitation-International . 2015;2(1):1030-6. Lorig KR, Holman HR. Self-management education: history, definition, outcomes, and mechanisms. Annals of behavioral medicine . 2003;26(1):1-7. Steenbeek R, Schellart AJ, Mulders H, Anema JR, Kroneman H, Besseling J. The development of instruments to measure the work disability assessment behaviour of insurance physicians. 2011. D’Amour, D., Ferrada-Videla, M., San Martin Rodriguez, L., Beaulieu, M.D., 2005. The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. J. Interprof. Care 19 (Suppl. 1), 116–131 George P, Reis S, Nothnagle M. Using a learning coach to teach residents evidence-based medicine. Family Medicine -Kansas City. 2012;44(5):351. Young HM, Apps LD, Harrison SL, Johnson-Warrington VL, Hudson N, Singh SJ. Important, misunderstood, and challenging: a qualitative study of nurses’ and allied health professionals’ perceptions of implementing self-management for patients with COPD. International journal of chronic obstructive pulmonary disease . 2015:1043-52. Satink T, Cup EH, de Swart BJ, Nijhuis-van der Sanden MW. Self-management: challenges for allied healthcare professionals in stroke rehabilitation–a focus group study. Disability and rehabilitation . 2015;37(19):1745-52. Norman SL, Taha AA. Delirium knowledge, self-confidence, and attitude in pediatric intensive care nurses. J Pediatr Nurs . 2019 May 1;46:6–11. Satink T, Josephsson S, Zajec J, Cup EHC, Swart BJM, Nijhuis-van der Sanden MWG. Self-management develops through doing of everyday activities—a longitudinal qualitative study of stroke survivors during two years post-stroke. BMC Neurology . 2016:16(221) Fishbein MA, Ajzen I. Belief, attitude, intention and behaviour: An introduction to theory and research. Reading, MA: Addison-Wesley; 1975. Ajzen I, Fishbein M . Understanding attitudes and predicting social behavior . Englewood Cliffs, N.J.: Prentice-Hall; 1980. The Association for Talent Development. Building a culture of learning. The foundation of a successful organization . Alexandria, Virginia: ATD Research; 2016. Table Table 1: demographic data of the interviewed healthcare professionals and patients - Healthcare professionals - Occupational therapist - Nurse - Social worker - Physiotherapist - Speech and language therapist - Healthcare assisstent - Patients - Cerebrovascular Accident (CVA) - Covid-19 - Benign brain tumor surgery - Muscle disease and CVA - CVA and Covid-19 N=10 - N=3 - N=2 - N=2 - N=1 - N=1 - N=1 N=10 - N=4 - N=3 - N=1 - N=1 - N=1 Gender (Male/Female) - Healthcare professionals - Patients 1/9 5/5 Age (years) - Healthcare professionals - Patients Mean: 42.7 (29-59) Mean: 62.9 (48-72) Patients’ duration of rehabilitation (weeks) Mean: 12 weeks (5-26) Work experience healthcare professionals - Total (years) - At Tolbrug (years) Mean 20.5 (7-39) Mean 10.7 (1-24) Home situation patients - Single - Partner - Partner with children N=3 N=6 N=1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Apr, 2026 Reviewers agreed at journal 01 Apr, 2026 Reviews received at journal 01 Apr, 2026 Reviewers agreed at journal 29 Mar, 2026 Reviews received at journal 05 Sep, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor invited by journal 18 Apr, 2025 Editor assigned by journal 18 Apr, 2025 Submission checks completed at journal 18 Apr, 2025 First submitted to journal 04 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6377146","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":500557560,"identity":"690cb9d9-b86b-4995-8e7a-877ba88155d8","order_by":0,"name":"Rick A.H. van de Ven","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIie3RsQrCMBCA4ZNAuxx0PUF8hojQCvVh6mKWUgouAXed3LP5KpGCLkUcO1ZcHfoIRiroYo2bSP4hkJCPEA7A5frF2HPt1QCTpD3O7QjjGuhBuN1bHlmRaM1qhhADP2z2y0ZSFilxYnkHGRQeN0QAL4/zSpe0GFRpzlQHIXO/p6CAvkrDareimaI0YWhFttcwtybQGBIQhtASoT8Qj+uGCwwwHVNp/kJ4haKTBMW5TmQ89Pxy1Eg5zcgX5wvK9+SeNlPAlz2akX6ZX38rXC6X67+7AVkuQPWAkOv1AAAAAElFTkSuQmCC","orcid":"","institution":"Tolbrug Rehabilitation/ Jeroen Bosch Hospital ’s-Hertogenbosch","correspondingAuthor":true,"prefix":"","firstName":"Rick","middleName":"A.H. van","lastName":"de Ven","suffix":""},{"id":500557561,"identity":"6e14110f-c11f-4b7b-bc45-3fea5a5d624c","order_by":1,"name":"Marcel A.L. Hendriks","email":"","orcid":"","institution":"Fontys University of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Marcel","middleName":"A.L.","lastName":"Hendriks","suffix":""},{"id":500557562,"identity":"6c7291d0-be66-4913-b323-ba8d7828ec0c","order_by":2,"name":"Roderick Wondergem","email":"","orcid":"","institution":"Fontys University of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Roderick","middleName":"","lastName":"Wondergem","suffix":""},{"id":500557563,"identity":"c5c5ca3c-4125-412f-bfc5-ab8f0afe920c","order_by":3,"name":"Lieke M.A. Dekkers","email":"","orcid":"","institution":"HAN University of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Lieke","middleName":"M.A.","lastName":"Dekkers","suffix":""},{"id":500557564,"identity":"241a1b7d-cf94-4f00-95e4-3930bf198037","order_by":4,"name":"Martijn F. Pisters","email":"","orcid":"","institution":"Fontys University of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Martijn","middleName":"F.","lastName":"Pisters","suffix":""},{"id":500557565,"identity":"07e0f3d9-0789-4b41-83bc-fcb5ab60e4f9","order_by":5,"name":"Annette A. van Kuijk","email":"","orcid":"","institution":"Tolbrug Rehabilitation/ Jeroen Bosch Hospital ’s-Hertogenbosch","correspondingAuthor":false,"prefix":"","firstName":"Annette","middleName":"A. van","lastName":"Kuijk","suffix":""}],"badges":[],"createdAt":"2025-04-04 14:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6377146/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6377146/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89584497,"identity":"593d9420-7e81-42c8-b29d-8db0885d7146","added_by":"auto","created_at":"2025-08-21 14:52:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":594186,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6377146/v1/df78ea51-5d17-4616-a793-34a9363d57aa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing the ‘Rehabilitation is all about learning’ approach; a qualitative study providing insight into facilitators and barriers from both healthcare professionals’ and patients perspectives","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEach year, approximately 200,000 individuals in the Netherlands undergo rehabilitation to enhance their functional abilities, autonomy, and participation in daily life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, successful completion of rehabilitation programs does not necessarily lead to successful long-term participation [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Patients continue to face difficulties with information processing, mobility, social engagement, work, and finances [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although many of these patients live with lifelong disabilities, their limited participation may also stem from inherent limitations within the rehabilitation system. Current rehabilitation programs are predominantly based on therapist-led, expert-driven interventions to enhance the patients\u0026rsquo; functional capacity. The structured, evidence-based treatment protocols within these programs are designed to minimize mistakes and optimize recovery. However, while effective in restoring basic functional abilities, this approach may inadvertently hinder the development of crucial self-management skills, which can impair their ability to manage their health and wellbeing in the long term independently [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This lack of self-management skills poses challenges in daily life and contributes to increased secondary healthcare costs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecognizing these challenges, there is increasing advocacy for patient-centred rehabilitation approaches focusing on developing self-management skills [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Self-management is defined as an ongoing process of self-regulation wherein individuals assume responsibility for their health management [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To address this need, Tolbrug Rehabilitation implemented the \"Rehabilitation is all about Learning\" (RiL) approach in March 2020. This innovative \u003cem\u003epatient-centred\u003c/em\u003e approach integrates \u003cem\u003elearning principles\u003c/em\u003e into traditional rehabilitation programs, fostering problem-solving abilities and \u003cem\u003eself-management skills\u003c/em\u003e to enhance the transition from rehabilitation to independent participation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe RiL-approach prioritizes the patient's learning process to promote competence and autonomy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. By establishing a learning environment, it encourages patients to regain or maintain independence. However, this presents challenges, as it must be tailored to the evolving learning needs and contextual factors unique to each patient. A core element of the learning environment is the \u003cem\u003einterdisciplinary collaboration\u003c/em\u003e within the rehabilitation team, where healthcare professionals extend beyond their traditional roles, acting as both expert and coach [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This flexibility allows patients to consult multiple healthcare professionals, including specialized experts, as many as needed. However, the specific adjustments required to create an effective learning environment are not predetermined. Implementing the RiL-approach can vary across organisations and healthcare professionals, further complicating the process [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt Tolbrug Rehabilitation, several modifications have optimized the learning environment. Patients are assigned a personal rehabilitation coach who helps set goals and oversee self-regulation. A structured, predefined planning system is replaced with a flexible, self-managed approach where patients schedule their therapy sessions with guidance of their rehabilitation coach. Group sessions are incorporated to provide peer support and shared learning experiences. Peer counsellors assist patients in processing and coping with their limitations. These adaptations aim to foster autonomy and active participation in rehabilitation.\u003c/p\u003e\u003cp\u003eThis new approach requires behavioural changes for both healthcare professionals and patients. Healthcare professionals must shift from being primarily experts to learning facilitators and have to develop skills in group dynamics to guide sessions effectively. Patients must take ownership of their rehabilitation process, actively engage in decision-making, and assume responsibility for self-regulation. However, the experiences of both groups with this new approach remain largely unexplored. This study aims to investigate the facilitators and barriers of implementing the RiL-approach from the perspectives of healthcare professionals and patients. Findings will offer valuable insights to refine implementation of the RiL-approach and support its broader application in rehabilitation settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003eThis qualitative phenomenological study used semi-structured interviews, conducted between March 2021 and February 2022, to explore experiences of healthcare professionals and patients working with the RiL-approach.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eHealthcare professionals and patients involved in Tolbrug Rehabilitation\u0026rsquo;s inpatient program and working according to the RiL-approach were eligible. Purposive sampling ensured diversity in age, gender, profession, experience, and diagnosis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Participants were initially invited via email, including an information letter and consent form. Non-responders received a follow-up from the primary researcher (RV) after two weeks. Written informed consent was obtained before scheduling interviews.\u003c/p\u003e\n\u003ch3\u003eData-collection\u003c/h3\u003e\n\u003cp\u003eInterviews were conducted face-to-face at Tolbrug Rehabilitation or at patients' homes. Demographic data were recorded: age, gender, profession, and work experience for healthcare professionals, and for patients: age, gender, diagnosis, rehabilitation duration, and family situation. Participants could ask questions before interviews began.\u003c/p\u003e\u003cp\u003ePrimary researchers (.. and ..) conducted all 60\u0026ndash;90 minutes interviews, audio-recorded with consent. The healthcare professionals\u0026rsquo; interview guide was based on the Capabilities, Opportunities, Motivation and Behaviour (COM-B) model and the Theoretical Domains Framework (TDF), addressing behavioural determinants for adopting the RiL-approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatient interviews focused on autonomy and long-term participation, aligning with the Positive Health Model, which provides a holistic perspective on health and promotes patient autonomy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The interview guide was structured around its key domains. Data were securely stored on Fontys University\u0026rsquo;s Research Drive.\u003c/p\u003e\n\u003ch3\u003eData-analysis\u003c/h3\u003e\n\u003cp\u003eAudio recordings were transcribed in Microsoft Word, ensuring anonymity. Transcripts summaries were returned to participants for member checking. The interview data was analysed separately for healthcare professionals and patients. Thematic analysis identified patters in the data [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Open coding began with meaningful transcript segments, followed by a consensus meeting after the first interview to ensure coding consistency. After coding four interviews per dataset, open codes were categorized into axial codes, and the interview guides were evaluated. Data collection continued until no new axial codes emerged in two consecutive interviews, confirming data saturation. Axial codes were then grouped into themes separately for healthcare professionals and patients. Five research team meetings ensured analytical rigor. Final themes were synthesized into overarching categories.\u003c/p\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003e The Medical Ethical Committee Brabant approved the study (protocol \u0026hellip; ). The study follows the COREQ checklist [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The anonymised dataset is available upon reasonable request from the corresponding author.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003e\u003cu\u003eParticipants\u003c/u\u003e\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThis study included 20 participants; 10 healthcare professionals (9 females) and 10 patients (5 females). Healthcare professionals\u0026rsquo; ages ranged from 29 to 59 years (mean 42.7 years), with work experiences spanning from 7 to 39 years (mean 20.5 years). Patients\u0026rsquo; ages ranged from 48 to 72 years (mean 62.9 years), and their inpatient rehabilitation duration varied from 5 weeks to 6 months (mean 12 weeks). Data saturation was reached after 8 interviews in each group. The demographic characteristics of the participants are presented in table 1.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eThemes\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree main themes emerged from the analysis: competence, autonomy, and relatedness, aligned with the self-determination theory [20].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompetence\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals emphasized that their sense of competence was key to mastering the RiL-approach. They stressed the need for openness and adaptability. However, several factors were mentioned that led to doubts about the approach\u0026apos;s suitability. These included the tension between their roles as medical experts and coaching professionals, the lack of empirical evidence supporting the approach\u0026apos;s effectiveness, and challenges in establishing new routines. The RiL-approach pushed them beyond their comfort zones, which, while necessary for learning, also heightened concerns about their abilities in the coaching role.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare professional 8: \u0026ldquo;You have to step outside the comfort zone, which makes me worry beforehand whether I\u0026apos;m doing it right.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients also went through an adjustment period to align with the RiL-approach\u0026apos;s behavioural competencies. Initially, many expected healthcare professionals to take control, believing recovery occurred by following expert instructions. They viewed healthcare professionals as the primary agents of control. Despite the RiL-approach being introduced early, many patients struggled to understand their role in actively participate in decision-making, leading to a passive approach to goal-setting. However, once they grasped the approach, they found it motivating, enabling them to set personal goals and engage in more meaningful rehabilitation activities.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 4: \u0026ldquo;At\u003c/em\u003e\u003cem\u003e first, I didn\u0026apos;t know what was expected of me\u0026hellip; \u0026hellip; when I figured it out, I thought this way of treatment was ideal.\u0026rdquo; \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAutonomy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eSelf-managing\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA significant shift in healthcare professionals\u0026rsquo; work patterns was the move from a structured planning system to a more flexible, self-managed approach without predefined appointments. Many professionals saw this flexibility as an advantage, enabling them to quickly respond to patients\u0026apos; emerging needs. However, the lack of a structured, predefined plan posed challenges for some healthcare professionals in maintaining an overview of patient care. Due to the interdisciplinary nature of the RiL-approach, with undefined professional boundaries, some professionals struggled to implement the approach in daily practice.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 6: \u0026ldquo;The space I have in my schedule allows me to respond quickly to acute problems. This is a big advantage.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 2: \u0026ldquo;I do see the potential, but I think it looks easier on paper than to put it in practice.\u0026rdquo; \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the beginning of their rehabilitation, patients found goal-setting challenging and recognized times when healthcare professionals needed to take control. They believed that healthcare professionals, with their medical expertise, were better equipped to assess their abilities and guide them safely towards their goals. In early stages, this professional guidance helped reduce patients\u0026rsquo; barriers to engaging in activities and boosted their self-confidence.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 10: After falling twice I was afraid to walk. Finally, the therapist said I would be better off using a walker for walking longer distances. I wish I had known this earlier. \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs patients advanced in their rehabilitation, they gained confidence in making decisions and taking responsibility. They became more skilled at prioritizing personal goals and emphasized the importance of having time to control their rehabilitation process. This autonomy allowed them to learn from their mistakes, leading to a deeper understanding of the consequences of their choices.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 9: It\u0026rsquo;s better to set your own goals than that somebody makes that choice for you. Mostly that is not what you really want.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients reported that the lack of a predetermined plan allowed them to engage in meaningful activities aligned with their life goals, such as cooking, cycling, and gardening. These activities boosted their motivation and sense of control, as they were no longer required to participate in irrelevant tasks. Most patients noted that they became more adept at incorporating meaningful activities into their daily routines.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 10: \u0026ldquo;The fact that I did not had to practice something that I would never do in daily life made me feel in control\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eEmpowerment\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals described the RiL-approach as enhancing patient autonomy, especially for those proactive in setting goals and taking initiative. These self-motivated patients sought their own solutions to challenges. However, professionals expressed concerns about balancing patient empowerment with maintaining professional control. Some feared that prioritizing autonomy could compromise care quality, particularly for patients with severe cognitive impairments who struggle with decision-making. These professionals questioned whether patients could handle the autonomy granted to them, believing that expert-based goals should still be pursued alongside those identified by the patients.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 1: \u0026ldquo;If you rely purely on what people have their questions about, you fail them in letting them discover their possibilities.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe RiL-approach also fostered autonomy among healthcare professionals, enabling them to make decisions based on their clinical judgment, which many found increased job satisfaction. However, some professionals expressed concerns about the abrupt implementation of the approach, feeling that it was introduced without sufficient consultation or adequate time to adapt to the new working methods.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 5: \u0026ldquo;The steering group should contain healthcare professionals who work at the inpatient department... ...it frustrates me that people who do not work as healthcare professionals determine how we are going to implement the RiL-approach.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the early stages of rehabilitation, patients saw the absence of healthcare professionals during evenings and weekends as a barrier, leading to fewer activities. However, as they took more responsibility for their rehabilitation, they began viewing this lack of supervision as an opportunity to organize their own activities, which helped them assess their capabilities and re-evaluate their goals.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 1: \u0026ldquo;Why should I not do anything on the weekends? The more I train during the weekends, the sooner I will achieve my goals.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRelatedness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eInterdisciplinary collaboration\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals saw increased team collaboration as key to the RiL-approach, believing that working interdisciplinary allowed them to fully leverage each other\u0026apos;s expertise. However, they felt a need for more insight into each other\u0026apos;s roles, as uncertainty about colleagues\u0026apos; tasks hindered the interdisciplinary approach to coordinate treatments effectively. They emphasized the importance of fostering a learning culture, where they feel comfortable asking and giving regular feedback, and believe that smaller teams are more conducive to creating a positive learning environment. \u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 7:\u0026rdquo;\u003c/em\u003e \u003cem\u003eWe can make much more use of each other\u0026rsquo;s talents... we need to get to know each other better\u0026hellip; but the better you know someone, the easier it is to see each other and the better you understand each other.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome healthcare professionals felt that their specific expertise was undervalued within the interdisciplinary team, leading them to actively advocate for the importance of their professional roles to avoid being overshadowed by others. This challenge made it difficult for them to integrate their expert role with their coaching responsibilities. They felt a personal obligation to maintain their position as experts throughout the patient\u0026rsquo;s rehabilitation process. On the other hand, some professionals believed that the lack of shared responsibility for the patient\u0026apos;s overall rehabilitation stemmed from colleagues who were too focused on their own areas of expertise.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 2: \u0026ldquo;People often still think: this is my expertise and has priority for me, otherwise it may not be discussed.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients reported that the interdisciplinary collaboration within the team of healthcare professionals was highly beneficial. They noticed that each professional, regardless of their discipline, was familiar with their personal goals, which fostered a sense of accessibility. Patients felt they could seek help from any team member and receive the appropriate treatment at the right time. As a result, patients became less dependent on specific healthcare professionals for particular tasks. For example, a patient needing help with walking no longer had to wait for the physiotherapist to be available, as other team members were equally equipped to provide support.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 8: \u0026ldquo;The occupational therapist helped me with walking and the physiotherapist helped with reading.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eSupport\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals noted that organizational support, as well as guidance from colleagues and trainers at the Rehab Academy, was essential for developing the competencies necessary to implement the RiL-approach. Trainers were regarded as experts and provided valuable support through brainstorming and on-the-job coaching, which played a crucial role in facilitating the integration of the approach. Additionally, healthcare professionals emphasized the need for continuous coaching and adequate time to adapt in order to prevent reverting to previous practices.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 3: \u0026ldquo;I thought the introduction meeting was very useful... \u0026hellip;it\u0026apos;s nice that we can spar regularly with colleagues or with the implementation coaches of Rehab Academy.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients identified the rehabilitation coach as a central figure in their rehabilitation process. They frequently reported a lack of clarity regarding the available options, and the rehabilitation coach played a crucial role in helping them identify potential achievements, thus facilitating the goal-setting process. This highlights the importance of healthcare professionals being well-acquainted with the competencies of their colleagues, ensuring that the full spectrum of expertise within the interdisciplinary team is effectively utilized.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 1: By reaching my goals, I had fewer and fewer questions. However, by discussing this with the rehabilitation coach, I came up with new questions for help in other areas that I had not even thought of myself.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eConfidence\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals highlighted the importance of peer support in adapting their coaching roles. Positive feedback from colleagues boosted their confidence in applying the RiL-approach. However, they expressed concerns about a divide between inpatient and outpatient teams, with inpatient professionals feeling that outpatient colleagues did not fully understand or support the approach. This led to negative feedback, which undermined confidence and, for some, prompted a return to previous practices.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 5: \u0026ldquo;Critical questions from colleagues and hardly receiving compliments or hearing what is going well makes me insecure.\u0026rdquo; \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients reported that peer support enhanced their self-confidence, encouraging greater participation in activities with fellow patients. Shared experiences within peer groups helped them to learn from each other and overcome challenges. Peer counsellors also played a key role in helping patients better understand their abilities. Furthermore, involving relatives in rehabilitation sessions facilitated a smoother transition to home, as family members were better prepared to offer support.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 8: \u0026ldquo;My daughter -in-law, for example, joined a training session with the speech therapist. At home she knew how to help me to read those (training) cards.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eResources\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare professionals had mixed views on the rehabilitation centre\u0026rsquo;s resources. While they valued the communal living room for promoting patient interaction, they expressed concerns about the lack of additional resources, such as public transport cards or debit cards, which they saw as obstacles to fully implementing the RiL-approach.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003eHealthcare Professional 3: \u0026ldquo;I would like to have a public transport card and debit card available in the department that we can use, so that we, for example, can easily go grocery shopping with patients during their rehabilitation without having to pay in advance.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast to healthcare professionals, patients reported no shortage of facilities. They found the environment well-suited to their needs, offering plenty opportunities for activities such as swimming, cycling, and golfing. Patients particularly appreciated the living room in the inpatient department, describing it as a space that encouraged social interaction and relaxation. This setting was seen as motivating and conducive to active participation in rehabilitation, fostering a sense of community and well-being.\u003c/p\u003e\n\u003cp\u003e- \u003cem\u003ePatient 7: \u0026ldquo;The living room made it possible to connect with everyone by just small talks and playing games. I always liked that. It gave me energy\u003c/em\u003e\u003cem\u003e.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study explored the facilitators and barriers to implementing the RiL-approach from the perspectives of healthcare professionals and patients. From the patients\u0026rsquo; viewpoint, the RiL-approach successfully empowered them to engage in rehabilitation based on their personal needs and values. They felt a strong sense of control over their process, valuing the autonomy to participate in meaningful activities. However, many initially found the RiL-approach unclear and felt they lacked self-management skills. Peer collaboration helped them navigate and master their rehabilitation process. This concept of collaborative learning, commonly used in educational settings, provides social, psychological, and academic benefits, enabling patients to take an active role in their rehabilitation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith appropriate support from peers and healthcare professionals, patients reported significant improvements over time in autonomous navigation of their rehabilitation process. This aligns with literature suggesting patients value autonomy and meaningful life over functional independence [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Studies on stroke survivors in self-management programs show that empowering patients to control their rehabilitation leads to better long-term outcomes [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. While self-management programs emphasize collaboration with healthcare professionals, the RiL-approach focuses on independent learning, enabling long-term autonomy and participation without ongoing professional involvement [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Further research is needed to explore this advantage.\u003c/p\u003e\u003cp\u003eThe role of healthcare professionals in supporting patient autonomy is complex and may require a shift in traditional professional boundaries. In patient-centred programs that emphasize autonomy, all team members must align with shared goals, blurring disciplinary boundaries [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Some professionals in our study struggled to move beyond their expert roles, prioritizing their own professional needs over those of the patient [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This aligns with previous research on the challenges of interdisciplinary collaboration, particularly when trust and teamwork are not well-established [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Healthcare professionals expressed confusion about each other\u0026rsquo;s roles and competencies, hindering interdisciplinary team functioning. Insufficient understanding of colleagues' skills also undermined their confidence in the RiL-approach. Team effectiveness could improve through regular interdisciplinary meetings to better align members\u0026rsquo; strengths.\u003c/p\u003e\u003cp\u003eOur study highlights that healthcare professionals' mastery of the RiL-approach was influenced by factors such as autonomy, competence, and support. The approach promotes autonomy, allowing professionals to base decisions on their clinical judgment, while balancing the need to provide appropriate guidance and giving patients space to make their own decisions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, for those accustomed to more expert-driven, structured methods, balancing roles as training experts and learning coaches can be difficult [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Transitioning to the RiL-approach was particularly challenging and stressful for these individuals, with many emphasizing the need for scientific evidence to support it. Healthcare professionals who embraced the approach tended to be committed to continuous learning, which enhanced their job satisfaction and motivation.\u003c/p\u003e\u003cp\u003eA key challenge identified by healthcare professionals in implementing the RiL-approach was their lack of confidence in coaching patients with severe cognitive impairments. They assumed these patients had limited self-management skills. In such cases, involving family members is crucial for improving outcomes [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Healthcare professionals noted the need for additional training to better support these patients. Without proper guidance, they may default to traditional, directive methods, potentially reducing patient autonomy and promoting passivity. On-the-job coaching could improve their skills and confidence [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study identified organizational and peer support as crucial for adopting the RiL-approach. The absence of positive reinforcement and constructive feedback from peers led to insecurity among healthcare professionals and reduced their self-confidence in implementing the approach effectively. Previous research supports that positive social influences and support for new methods are vital for successful implementation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Cultivating a feedback-driven learning culture, where continuous learning is encouraged, could help address these challenges. Both positive and constructive feedback are essential for fostering such a culture [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study had both strengths and limitations. A key strength is that it provides valuable insights into the experiences of those directly involved in a new approach that integrates patient-centred care, interdisciplinary collaboration, self-management promotion, and potentially value-based care. While these individual elements are supported by evidence, research on their combined implementation, as in the RiL-approach, is lacking. Addressing the identified barriers could improve adoption and implementation. Another strength is the achievement of data saturation, ensuring comprehensive findings. Although the small sample size limits exploration of how demographic factors influence adoption, participants' personal learning styles likely play a more significant role in successful implementation. Additionally, the study\u0026rsquo;s design, involving multiple researchers in data collection and analysis, enhanced its validity. Thorough transcription and member checking minimized information bias.\u003c/p\u003e\u003cp\u003eA limitation is that the interviews were conducted at a single point in time, and participants' views may evolve as they gain more experience with the RiL-approach. A longitudinal study could provide deeper insights into how perceptions and experiences change over time. Since the RiL-approach was only implemented at Tolbrug Rehabilitation during the study, the findings may not be directly applicable to other contexts or rehabilitation centres.\u003c/p\u003e\u003cp\u003eIn conclusion, this study identifies key facilitators and barriers to implementing the RiL-approach in rehabilitation. Shifting from traditional care models to a patient-centred, learning-based approach empowers patients by increasing autonomy and participation. However, successful implementation depends on healthcare professionals' competence and confidence in their coaching roles, as well as effective interdisciplinary collaboration. To optimize adoption, clear expectations should be established early, and a culture of continuous learning should be promoted through regular feedback and coaching, especially for guiding cognitively impaired patients. Future research should evaluate the long-term effectiveness and broader applicability of the RiL-approach across various rehabilitation settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe kindly thank all participants of the study and the founders of Rehab Academy for providing insight in the concept of the ‘Rehabilitation is all about Learning’ approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of funding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of authors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by … and …. All authors discussed analysis till consensus was reached. The first draft of the manuscript was written by … and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Ethical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Ethical Committee Brabant (Protocol number: NW2021-22) on February 22, 2021. The research was conducted in accordance with the Declaration of Helsinki and local regulations concerning medical research involving human subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Informed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants received both written and oral information about the study and gave their written informed consent prior to participation. The consent procedure was approved by the Medical Ethical Committee Brabant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration data availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe anonymised dataset is available upon reasonable request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRevalidatie Nederland. Brancherapport Revalidatie 2020. 2022. Revalidatie Nederland. \u003c/li\u003e\n\u003cli\u003eHilberink SR, van der Slot WM, Klem M. Health and participation problems in older adults with long-term disability. \u003cem\u003eDisability and Health Journal\u003c/em\u003e. 2017;10(2):361-6.\u003c/li\u003e\n\u003cli\u003eT\u0026ouml;rnbom K, Lund\u0026auml;lv J, Sunnerhagen KS. Long-term participation 7-8 years after stroke: Experiences of people in working-age\u003cem\u003e. PloS one\u003c/em\u003e. 2019;14(3):e0213447.\u003c/li\u003e\n\u003cli\u003eBoerboom W, Heijenbrok-Kal MH, Van Kooten F, Khajeh L, Ribbers GM. Unmet needs, community integration and employment status four years after subarachnoid haemorrhage. \u003cem\u003eJournal of rehabilitation\u003c/em\u003e \u003cem\u003emedicine\u003c/em\u003e. 2016;48(6):529-34.\u003c/li\u003e\n\u003cli\u003eLevack WM, Dean SG, Siegert RJ, McPherson KM. Navigating patient-centered goal setting in inpatient stroke rehabilitation: how clinicians control the process to meet perceived professional responsibilities. \u003cem\u003ePatient education and counseling\u003c/em\u003e. 2011;85(2):206-13.\u003c/li\u003e\n\u003cli\u003eMudge S, Kayes N, McPherson K. Who is in control? Clinicians\u0026rsquo; view on their role in self-management approaches: a qualitative metasynthesis. \u003cem\u003eBMJ open\u003c/em\u003e. 2015;5(5):e007413.\u003c/li\u003e\n\u003cli\u003eMeulenkamp T, Van der Hoek L, Cardol M. \u003cem\u003eDeelname aan de samenleving van mensen met een beperking, ouderen en de algemene bevolking\u003c/em\u003e. Utrecht: NIVEL Figuur A. 2015;1.\u003c/li\u003e\n\u003cli\u003eLangford AT, Sawyer DR, Gioimo S, Brownson CA, O\u0026apos;Toole ML. Patient-Centered. \u003cem\u003eThe Diabetes Educator\u003c/em\u003e. 2007;33(S6):139S-44S.\u003c/li\u003e\n\u003cli\u003evan der Eijk M, Nijhuis FA, Faber MJ, Bloem BR. Moving from physician-centered care towards patient-centered care for Parkinson\u0026apos;s disease patients. \u003cem\u003eParkinsonism \u0026amp; related disorders\u003c/em\u003e. 2013;19(11):923-7.\u003c/li\u003e\n\u003cli\u003eJ. Barlow, C. Wright, J. Sheasby, A. Turner, J. Hainsworth, Selfmanagement approaches for people with chronic conditions: a review, \u003cem\u003ePatient Educ. Couns\u003c/em\u003e.48 (2002) 177\u0026ndash;187.\u003c/li\u003e\n\u003cli\u003eK.R. Lorig, H. Holman, Self-management education: history, definition, outcomes, and mechanisms, \u003cem\u003eAnn. Behav. Med\u003c/em\u003e. 26 (2003) 1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eVuijk I. \u003cem\u003eRevalideren is Leren\u003c/em\u003e. 2nd ed. Amsterdam: Studio HB; 2019. 264 p\u003c/li\u003e\n\u003cli\u003eChoi BCK, Pak AWP. Multidisciplinarity, interdisciplinarity and transdis_ciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. \u003cem\u003eClin Invest Med. \u003c/em\u003e2006 Dec;29(6):351\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003ePatton MQ. \u003cem\u003eQualitative evaluation and research methods\u003c/em\u003e: SAGE Publications, inc; 1990.\u003c/li\u003e\n\u003cli\u003eKeyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Acceptability, reliability, and validity of a brief measure of capabilities, opportunities, and motivations (\u0026ldquo;COM‐B\u0026rdquo;). \u003cem\u003eBritish journal of health psychology\u003c/em\u003e. 2020;25(3):474-501.\u003c/li\u003e\n\u003cli\u003eMichie S, Atkins L, West R. \u003cem\u003eThe behaviour change wheel. A guide to designing interventions\u003c/em\u003e. 1st ed Great Britain: Silverback Publishing. 2014:1003-10.\u003c/li\u003e\n\u003cli\u003eHuber M, van Vliet M, Giezenberg M, et al. Towards a \u0026lsquo;patient-centred\u0026rsquo; operationalisation of the new dynamic concept of health: a mixed methods study. \u003cem\u003eBMJ Open\u003c/em\u003e 2016;5:e010091\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. \u003cem\u003eQualitative research in psychology\u003c/em\u003e. 2006;3(2):77-101.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups\u003cem\u003e. Int J Qual Health Care\u003c/em\u003e. 2007;19(6):349-357.\u003c/li\u003e\n\u003cli\u003eDeci EL, Ryan RM. (2012). Motivation, personality, and development within embedded social contexts: An overview of self-determination theory. In Ryan RM, editors. \u003cem\u003eThe Oxford handbook of human motivation\u003c/em\u003e. Oxford: Oxford University Press; 2012. 85\u0026ndash;107.\u003c/li\u003e\n\u003cli\u003eLaal M, Ghodsi SM. \u003cem\u003eBenefits of collaborative learning\u003c/em\u003e. Procedia-social and behavioral sciences. 2012;31:486-90.\u003c/li\u003e\n\u003cli\u003ePeters M. Does constructivist epistemology have a place in nurse education? \u003cem\u003eJ Nurs Educ\u003c/em\u003e. 2000 Apr;39(4)(166\u0026ndash;72). \u003c/li\u003e\n\u003cli\u003eFens M, Beusmans G, Limburg M, van Hoef L, van Haastregt J, Metsemakers J, et al. A process evaluation of a stroke-specific follow-up care model for stroke patients and caregivers; a longitudinal study. \u003cem\u003eBMC Nurs\u003c/em\u003e. 2015 Jan 16;14(1):1. \u003c/li\u003e\n\u003cli\u003eGraff MJL, Vernooij-Dassen MJM, Thijssen M, Dekker J, Hoefnagels WHL, Olderikkert MGM. Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: A randomized controlled trial. \u003cem\u003eJournals Gerontol - Ser A Biol Sci Med Sci. \u003c/em\u003e2007 Sep 1;62(9):1002\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCameron JI, Gignac MAM. \u0026ldquo;Timing It Right\u0026rdquo;: A conceptual framework for addressing the support needs of family caregivers to stroke survivors from the hospital to the home. Vol. 70, \u003cem\u003ePatient Education and Counseling. \u003c/em\u003e2008. p. 305\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eVloothuis JDM, Mulder M, Nijland RHM, Goedhart QS, Konijnenbelt M, Mulder H, et al. Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): A randomized controlled trial. \u003cem\u003ePLoS One\u003c/em\u003e. 2019 Apr 1;14(4).\u003c/li\u003e\n\u003cli\u003eMcKenna S, Martin S, Jones F, Gracey J, Lennon S. The Bridges Stroke Self-Management program for Stroke Survivors in the Community: Stroke, Carer and HealthProfessional Participants\u0026rsquo; Perspectives. \u003cem\u003ePhysical Medicine and Rehabilitation-International\u003c/em\u003e. 2015;2(1):1030-6.\u003c/li\u003e\n\u003cli\u003eLorig KR, Holman HR. Self-management education: history, definition, outcomes, and mechanisms. \u003cem\u003eAnnals of behavioral medicine\u003c/em\u003e. 2003;26(1):1-7.\u003c/li\u003e\n\u003cli\u003eSteenbeek R, Schellart AJ, Mulders H, Anema JR, Kroneman H, Besseling J. \u003cem\u003eThe development of instruments to measure the work disability assessment behaviour of insurance physicians.\u003c/em\u003e 2011.\u003c/li\u003e\n\u003cli\u003eD\u0026rsquo;Amour, D., Ferrada-Videla, M., San Martin Rodriguez, L., Beaulieu, M.D., 2005. The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. \u003cem\u003eJ. Interprof. Care\u003c/em\u003e 19 (Suppl. 1), 116\u0026ndash;131\u003c/li\u003e\n\u003cli\u003eGeorge P, Reis S, Nothnagle M. Using a learning coach to teach residents evidence-based medicine. \u003cem\u003eFamily Medicine\u003c/em\u003e-Kansas City. 2012;44(5):351.\u003c/li\u003e\n\u003cli\u003eYoung HM, Apps LD, Harrison SL, Johnson-Warrington VL, Hudson N, Singh SJ. Important, misunderstood, and challenging: a qualitative study of nurses\u0026rsquo; and allied health professionals\u0026rsquo; perceptions of implementing self-management for patients with COPD. \u003cem\u003eInternational journal of chronic obstructive pulmonary disease\u003c/em\u003e. 2015:1043-52.\u003c/li\u003e\n\u003cli\u003eSatink T, Cup EH, de Swart BJ, Nijhuis-van der Sanden MW. Self-management: challenges for allied healthcare professionals in stroke rehabilitation\u0026ndash;a focus group study. \u003cem\u003eDisability and rehabilitation\u003c/em\u003e. 2015;37(19):1745-52.\u003c/li\u003e\n\u003cli\u003eNorman SL, Taha AA. Delirium knowledge, self-confidence, and attitude in pediatric intensive care nurses. \u003cem\u003eJ Pediatr Nurs\u003c/em\u003e. 2019 May 1;46:6\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eSatink T, Josephsson S, Zajec J, Cup EHC, Swart BJM, Nijhuis-van der Sanden MWG. Self-management develops through doing of everyday activities\u0026mdash;a longitudinal qualitative study of stroke survivors during two years post-stroke. \u003cem\u003eBMC Neurology\u003c/em\u003e. 2016:16(221)\u003c/li\u003e\n\u003cli\u003eFishbein MA, Ajzen I. \u003cem\u003eBelief, attitude, intention and behaviour: An introduction to theory and research. \u003c/em\u003eReading, MA: Addison-Wesley; 1975.\u003c/li\u003e\n\u003cli\u003eAjzen I, Fishbein M\u003cem\u003e. Understanding attitudes and predicting social behavior\u003c/em\u003e. Englewood Cliffs, N.J.: Prentice-Hall; 1980.\u003c/li\u003e\n\u003cli\u003eThe Association for Talent Development. \u003cem\u003eBuilding a culture of learning. The foundation of a successful organization\u003c/em\u003e. Alexandria, Virginia: ATD Research; 2016.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eTable 1: demographic data of the interviewed healthcare professionals and patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Healthcare professionals\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Occupational therapist\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Nurse\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Social worker\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Physiotherapist\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Speech and language therapist\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Healthcare assisstent\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Patients\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Cerebrovascular Accident (CVA)\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Covid-19\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Benign brain tumor surgery\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Muscle disease and CVA\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;CVA and Covid-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eN=10\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=3\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=2\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=2\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=1\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=1\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=1\u003c/p\u003e\n \u003cp\u003eN=10\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=4\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=3\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=1\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=1\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;N=1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eGender (Male/Female)\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Healthcare professionals\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1/9\u003c/p\u003e\n \u003cp\u003e5/5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Healthcare professionals\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMean: 42.7 (29-59)\u003c/p\u003e\n \u003cp\u003eMean: 62.9 (48-72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003ePatients\u0026rsquo; duration of rehabilitation (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eMean: 12 weeks (5-26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eWork experience healthcare professionals\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Total (years)\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;At Tolbrug (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMean 20.5 (7-39)\u003c/p\u003e\n \u003cp\u003eMean 10.7 (1-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eHome situation patients\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Single\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Partner\u003c/p\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp;Partner with children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=3\u003c/p\u003e\n \u003cp\u003eN=6\u003c/p\u003e\n \u003cp\u003eN=1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"autonomy, interdisciplinary collaboration, learning principles, participation, patient-centred, self-management skills","lastPublishedDoi":"10.21203/rs.3.rs-6377146/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6377146/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjective: \u003c/strong\u003e\u003c/em\u003eTo explore the facilitators and barriers of implementing the ‘Rehabilitation is all about Learning’ approach from both healthcare professionals’ and patients’ perspectives.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003ePhenomenological qualitative study using semi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSubjects:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eHealthcare professionals and inpatient patients of Tolbrug Rehabilitation engaged in the ‘Rehabilitation is all about Learning’ approach\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eThe interview guide for healthcare professionals was based on the Theoretical Domains Framework, and for patients, on the Positive Health Model. Themes emerged after thematic analyses.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e Three main themes emerged: competence, autonomy, and relatedness. Healthcare professionals experienced tensions between their medical expertise and coaching roles. Patients initially relied on guidance but later gaining confidence in self-directed rehabilitation. Interdisciplinary collaboration enhanced patient-centered care, although unclear role boundaries posed challenges in coordinating treatment. While empowerment motivated proactive patients, it raised concerns for those with cognitive impairments. Peer and organizational support were essential for healthcare professionals’ confidence, while patients valued communal spaces and peer support for increased motivation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eA patient-centred, learning-based approach such as ‘Rehabilitation is all about Learning’, fosters autonomy, ownership, and participation. Successful implementation relies on healthcare professionals’ competence and confidence in their evolving roles as coaches, as well as their ability to collaborate effectively within interdisciplinary teams. Continuous feedback and on-the-job coaching are essential for improving implementation. Future research should explore how the RiL-approach can be adapted and implemented in diverse rehabilitation settings to enhance long-term patient autonomy and team collaboration.\u003c/p\u003e","manuscriptTitle":"Implementing the ‘Rehabilitation is all about learning’ approach; a qualitative study providing insight into facilitators and barriers from both healthcare professionals’ and patients perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 14:43:59","doi":"10.21203/rs.3.rs-6377146/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-22T12:03:05+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"41121477722310793552390576324523880139","date":"2026-04-01T12:27:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T06:49:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225268075550120597325892117000497740120","date":"2026-03-29T07:00:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-05T11:14:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321570440571940051162410570096763964397","date":"2025-08-25T07:33:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T07:10:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-18T18:16:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-18T08:44:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-18T08:44:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Humanities and Social Sciences Communications","date":"2025-04-04T14:50:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"70aaa151-d170-434f-829e-c1fd8fb640e1","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":53177270,"name":"Humanities/Health humanities"},{"id":53177271,"name":"Humanities/Medical humanities"}],"tags":[],"updatedAt":"2026-05-26T14:08:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 14:43:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6377146","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6377146","identity":"rs-6377146","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}