Developing a Virtual Environment for Discharge Planning after Stroke :A Preliminary Study Interactive Technologies and Games (ITAG) Conference 2014 Health, Disability and Education Dates: Thursday 16 October 2014 - Friday 17 October 2014 Location: The Council House, NG1 2DT, Nottingham, UK

1. Dr Kate Threapleton

2. Background
After a stroke, patients may have new and significant levels of impairment on discharge from hospital (Whitehead et al., 2014)
Pre-discharge home assessment visits are part of routine occupational therapy practice after stroke (Chibnall, 2011)

3. Background
After a stroke, patients may have new and significant levels of impairment on discharge from hospital (Whitehead et al., 2014)
Pre-discharge home assessment visits are part of routine occupational therapy practice after stroke (Chibnall, 2011)
However, this process can vary greatly across stroke services due to differing policies and resources (Drummond et al., 2012; Whitehead et al., 2014)
Is there scope for other methods to be used as part of discharge planning to support current practice?
Could virtual environments be an appropriate alternative tool?

4. Virtual Environments
Virtual environments are computer simulations of real world or strategically designed settings
User can explore and interact with the environments via an avatar – a digital representation of themselves
Used widely in health education and increasing application within stroke rehabilitation
Potential for pre-discharge planning?

5. Research Aims
To explore the potential of a virtual environment designed to simulate a generic layout of a home with issues relevant to patients after stroke
Initial qualitative study to explore both therapist and patient perspectives of this concept
Potential to support ward-based discussions regarding discharge with patients and carers

6. The Virtual Environment
The virtual environment was created using OpenSimulator software to simulate a generic layout of a bungalow
All on one level with four rooms: a kitchen, living room, bathroom and a bedroom
Users were able to navigate and explore the virtual home
Included standard furniture and household items
Contained 50 safety risks

7. Safety risks:
Trip hazards
Out of date food in the kitchen
Overloaded plug sockets
Faulty oven ignition
Iron with frayed cable

8. Method
Individual semi-structured interviews were conducted with three groups:
Occupational therapists from two Stroke Units
In-patients diagnosed with a stroke
Stroke survivors from a community setting
Interviews explored:
Perceptions of the virtual home for clinical use
Acceptability and perceived barriers
Participants were shown the virtual home at the start of the interview and given the opportunity to try the software

9. Results
•Occupational Therapists (N=13) were recruited
6 from acute stroke wards; 7 from stroke rehabilitation wards
•Patients (N=8) were recruited
2 male: 6 female;
Mean age = 68 years (range 23-93 years; SD 23.73)
6 had no previous use of computers
•Stroke survivors (N=4) were recruited
Stroke onset ranged from 1999 to 2011
2 male: 2 female;
Mean age = 70 years (range 65-78 years; SD 9.18)
1 had no previous use of computers

10. Interview Findings
Data was analysed thematically (Braun & Clarke, 2006)
1.Perceived clinical uses
a)Patient and carer education
b)Tool to screen and assess patient insight into safety risks
2.Barriers and limitations
3.Identified modifications

11. 1. A. Patient & Carer Education
Therapists thought it could be used as a educational package to help patients and carers prepare for discharge
Visual way to facilitate discussions
Prompts about own home and any changes required
Increase awareness of safety risks
“It could definitely be used as an educational tool, and more of a prompt for our initial interview that we do with the family. Just to make sure we are not missing anything, because it is amazing what families forget to tell us.” (OT9)

12. Patient & Carer Education
Patients and stroke survivors also viewed it as a appropriate tool to facilitate discussions
“You can look at and say ‘Well, how would you cope with that? How are you going to cope with heating? How are you going to cope with getting to the loo?’ or whatever. So it is something, it is always a good idea to have a picture. A picture paints a thousand words” (Stroke Survivor 1)

13. Patient & Carer Education
•Thought useful to help visualise equipment needed at home
Grab rails, toilet frames, hospital beds, perch stools, and the logistics of fitting, moving and storing
“I always think that the family don’t really understand the amount of space that things might require.” (OT1)

14. 1. B. Patient Assessment
Therapists felt would be improved if it could be more interactive
Could then be used to screen and assess patient insight into different safety risks and scenarios
“They could look around and find hazards, and it would give you a talking point to discuss what they had seen and what they’d not seen.” (OT7)

15. Patient Assessment
Patients and stroke survivors were able to make comparisons to their own home and could identify relevant safety risks within the virtual home
“Well, it has made me be aware. Yes more aware, because I wasn’t even thinking about the safety aspect at all really” (Patient 5)

16. 2. Barriers & Limitations
Limited use for those with significant cognitive or visual impairments
"I think if you got patients that have got a marked visual impairment, they might struggle with it, and patients that are probably too cognitively impaired really to sort of grab the concept really.” (OT1)
“I think for certain patients, it could be a bit confusing if it’s not their home.” (OT2)

17. Barriers & Limitations
Therapists cautious about it being used to fully replace home visit assessments
“The reason we are doing home visits is to replicate them in their home environment, so the virtual environment won’t do that.” (OT12)
“I don’t know how this would represent the complex things that we often see on home visits and that we don’t anticipate” (OT9)

18. Barriers & Limitations
Age and computer literacy viewed as a potential barrier
Therapists felt that it was more suited to ‘younger patients’
“The majority of patients we have are elderly, and technical things like these just totally frighten them. So I think the concept of this would work perhaps better with younger patients.” (OT10)

19. Barriers & Limitations
However, this was felt more so by therapists and stroke survivors than patients
Even though the majority of patient interviewees had never owned a computer, they were able to engage with it
“I think it is brilliant because it can be shown to people, even people that don’t understand computers. You could go through that couldn’t you, even not understanding computers” (Patient 2)

20. 3. Identified Modifications
More content needed
General household items - ‘clutter’; more furniture; steps/stairs; door thresholds; equipment – hospital beds, grab rails etc
Improving the usability of the software
Easier navigation controls; view of the avatar; bigger font sizes; patterns and colours used

21. Conclusion
The research demonstrated potential for the wider use of virtual technologies within stroke rehabilitation
Further development of the virtual home is warranted
Number of modifications were identified to develop the virtual home appropriately for clinical use
These are currently being addressed in the next phase of the research

22. The Research Team
University of Nottingham
Prof Avril Drummond - Professor of Healthcare Research
Prof Penny Standen - Professor of Health Psychology & Learning Disabilities
Dr Niki Sprigg – Associate Professor of Stroke Medicine
Emily Birks – Researcher
University of Derby
Greg Sutton – Software Developer
Karen Newberry – OT Lecturer
Pauline Rowe - OT Lecturer

23. With thanks to our funders