Acquired brain injury (ABI) is a major public health issue and a leading cause of disability [1]. Clinical practice guidelines emphasize the importance of goal-directed rehabilitation and maximizing the amount of active therapy to address set goals [2,3]. The Royal Australian College of Physician Standards for Provision of Inpatient Adult Rehabilitation Medicine Services recommend that the appropriate amount of therapy that patients receive will range from a minimum of 3 hours for patients who have the capacity to tolerate this amount of therapy, down to lesser amounts, based on patient need and capacity to participate [4]. Despite these recommendations, inpatient rehabilitation units have historically struggled to meet activity targets. In addition to structured therapy time, engagement in meaningful activities is also an important aspect of patient recovery and well-being. The National Institute for Health and Care Excellence (NICE) Quality Statement defines meaningful activity as including physical, social, and leisure activities that are tailored to the person’s needs and preferences [5]. Therefore, complete activity content cannot be considered as structured therapy time alone, as there are opportunities for engagement across all waking hours.

A 2012 review of hospitalized stroke patients [6] found that they spent most of their day inactive (median 48.1%), alone (median 53.7%), and in their bedroom (median 56.5%). Similarly, a 2004 study [7] observed that stroke patients spent >50% of the therapeutic day in bed, 28% sitting out of bed, and >60% alone. Inactivity is not unique to stroke patients; the literature [8] also indicates that hospitalized general medical patients spend 88% of their therapeutic day in their rooms, 25% doing nothing, and an additional 17% watching television. A 2014 observational study [9] with behavior mapping of a 20-bed mixed rehabilitation unit sought to determine whether rehabilitation had improved over the previous decade and to understand if levels of inactivity differed between weekdays and weekends, and reported that rehabilitation inpatients remain inactive and alone, and were 5% less physically active on weekends [9].

While all these studies have reported low levels of physical and cognitive activity in rehabilitation settings [6-9] it remains unknown whether these findings are comparable in the younger, brain injury population, where patient goals are likely to differ. Additionally, the relationships between patient activity in rehabilitation, goals set, and patient affect have not yet been investigated. The goals pursued in rehabilitation and the levels of patient involvement and empowerment influence rehabilitation outcomes [10]. Therefore, this study aimed to explore how frequently ABI rehabilitation inpatients engaged (participated) in meaningful activities, whether there was a difference in participation in activity levels on weekdays versus weekends, and whether there was a relationship between levels of activity, goal engagement, and patient affect.

Nine inpatients (33% female) aged 25–59 years (mean, 40 years) participated in the study. Five participants were diagnosed with non-traumatic brain hemorrhage (one with a dual diagnosis of encephalitis), and four were diagnosed with traumatic brain injury. Two participants walked unaided at the time of the audit, two used a wheeled walking frame, four used a wheelchair independently, and one was non-ambulant (required attendant-propelled wheelchair). Table 1 compares the participants’ characteristics to all inpatients admitted to the same ward over the preceding 12 months for reference.

Over the 42 hours of observation, a minimum of 164 individual observations per participant were recorded (median number of observations, 171), producing a total of 1,550 data points.

Between 08:30 and 16:30 (therapeutic day), patients spent 29% of their time with allied health therapists, 62% of the time in their single rooms, and 49% of their time alone. These proportions were very similar among patient locations during awake time and on both weekdays and weekend days. Patients were physically and socially inactive 76% and 74% of their awake time (i.e., excluding sleep time), respectively. Organized activities such as communal dining and group therapy programs increased both physical and social activity levels in patients who participated. Patients were only actively participating in activities related to their rehabilitation goals for 25% of their awake time and 36% of the therapeutic day, with 80% of the time spent by an allied health therapist on goal-related activities.

The correlations between activity type, participation, and people present, activity location, and day of the week (weekend versus weekday) are shown in Table 2. The presence of visitors and nursing staff significantly increased the odds of participating in physical and social activities, as observed from the role they played for some participants in supporting self-practice therapy programs prescribed by allied health therapists.

Consistent with the stroke literature, a comparative sample of inpatients in the ABI rehabilitation ward spent most of the day inactive and alone in their rooms. While this finding is not new, it is interesting to note that this significantly younger ABI sample (mean age, 40 years) did not demonstrate increased overall activity levels compared to those in the older stroke rehabilitation cohort (mean age, 78 years) observed in previous literature [9]. This study additionally correlated spaces and presence of staff, noting that participation was greatest in presence of a nurse, visitor, or allied health team member, and when the participants were outside of their rooms. Observations of solitude and inactivity were consistent between hours within and outside of the therapeutic day, as well as weekdays and weekend days, suggesting that higher staffing levels alone (weekdays during the therapeutic day) did not appear to increase patient engagement levels. These novel and important findings could be used to improve patient activity, with directed staff efforts focused on individualized activity targets.

Nurses could be targeted as leaders of initiatives to increase patient activity and participation within rehabilitation units. Nursing staff are in a prime position to practice learned therapy strategies, embed strategies into patients’ daily routines, and encourage patient independence. Theofanis [17] described the importance of nursing engagement beyond the standard paradigm of routine interventions, encouraging a focus on “the wider essential care aspects to enable faster and more complete recovery. This study echoes earlier research [18] reporting the value of nursing input on brain injury recovery. We also found limited patient engagement in activities outside of regular therapeutic hours. Consistent with previous studies on rehabilitation [7], these findings suggested the need for changes at an organizational level to increase levels of participation in rehabilitation. The engagement of nursing staff in co-treatment sessions with allied health, working parties, and post-graduate and point-of-care education strategies may be essential for increasing inpatient activity towards clinical guideline recommendations.

Our findings emphasize the importance of rehabilitation. Social activity was higher when the patients were involved in communal dining, while physical activity was higher when visitors were involved in the rehabilitation programs and nursing staff carried over therapy programs outside of therapy sessions. Social activity levels were also higher when the participants were outside, indicating that the entire rehabilitation environment should be considered when seeking opportunities to increase activity levels. Strategies such as increasing environmental opportunities for independent or semi-supervised patient practice may also be valuable. An accessible outdoor garden, kitchen, independent practice gym, and welcoming spaces for socializing, as well as providing family skill training and education may allow patients to participate in rehabilitation activities outside of therapeutic hours. Around-the-clock engagement and encouragement from within a service may also impact patient affect. The patients in the present study rarely displayed a positive effect: reduced activity levels may have influenced their affect, which may have further decreased their motivation to participate. Thus, changing service delivery may have far-reaching consequences. Increasing accessible and appropriately goal-focused activities should be a target during inpatient rehabilitation for patients of all ages. Our findings reinforce the importance of the whole environment, as well as strategies such as communal dining and family engagement. The regular provision of practice tasks by allied health may encourage increased patient activity outside of therapeutic day; however, this passive activity should be coupled with education and encouragement and allied health should be optimally placed to ensure that family and caregivers can facilitate after-hours therapy. The findings revealed the lowest activity levels in the presence of medical staff, highlighting the lack of physician involvement in promoting engagement. Medical focus on patient activity is crucial and suggests an opportunity to coordinate and plan active and person-centered interventions. While around-the-clock nursing shifts provide regular occasions for nurses to play a pivotal role in increasing activity out of hours, all clinicians must seek to change the culture to increase opportunities for additional therapy.

This study had several limitations. While this study observed only nine inpatients, the large number of continuous observations (>1,500) increased the robustness of the findings. The repeated-measures methodology simultaneously increased the statistical power and reduced the costs of the study [19]. However, the observational design led to inherent sources of error. With overt observation, it is plausible that both clinicians and patients could alter their behaviors. We do not believe this to have been the case, as previous audit studies have reported similar results. To mitigate this potential Hawthorne effect, we used a large number of continuous observations and a 34-hour continuous observation period; however, this potential limitation must be acknowledged.

In conclusion, while a substantial body of knowledge exists regarding how much rehabilitation is needed to improve outcomes [20], audit results indicate that clinicians continue to struggle to meet these clinical practice guidelines. The findings of this study demonstrate the need for enhanced engagement in meaningful activities outside of prescribed allied health hours. An increased focus on enhancing opportunities for engagement in meaningful activities is required for rehabilitation. The findings of this study also underscore the need for a collective effort to implement models of rehabilitation that maximize physical, cognitive, and social activities to enhance meaningful participation after ABI.