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Abstract

Novice occupational therapists struggle with clinical reasoning when interpreting cognitive assessments and planning interventions for patients with an acquired brain injury (ABI), impacting patient rehabilitation outcomes. This study aimed to establish expert consensus on a self-directed learning package (SDLP) for novice occupational therapists to support clinical reasoning when planning cognitive rehabilitation. A mixed-methods design consisting of an initial survey, then three virtual Nominal Group Technique focus groups, including 21 expert occupational therapists, prioritized SDLP content and teaching methods. Experts identified: “neuroanatomy,” “evidence-based practice guidelines”, “interpretation of functional errors,” “delivery of cognitive rehabilitation,” “goal setting,” and “progress measurement” as the most important content. They prioritized video demonstrations, case studies, online modules, and practical assignments as methods to deliver the SDLP. The virtual focus groups enabled rapid consensus of the content and teaching methods for an SDLP which can now be developed to support novices’ clinical reasoning when planning cognitive rehabilitation.

Plain Language Summary

Developing a Cognitive Rehabilitation Learning Package for Novice Occupational Therapists: A Study Using the Nominal Group Technique

This study wanted to find out what support new occupational therapists need when learning to plan rehabilitation for patients with acquired brain injuries (that is, people who have an injury to their head) so we can make a new learning package for these occupational therapists. Previous studies found that some occupational therapists find it hard to plan rehabilitation, which might mean patients do not reach their goals. The study involved 21 expert occupational therapists who answered a survey and then talked together via video conference. The experts agreed that the learning package should include information on how rehabilitation can improve thinking skills and goal setting. They also agreed that new occupational therapists should be taught using videos, case studies, and practical homework. Using the video conference, the experts decided on the information to include and the types of teaching methods to use in the new learning package.

Keywords

cognition education rehabilitation occupational therapy mixed methods

Introduction

Cognition describes the brain’s complex information processes completed consciously or unconsciously (American Occupational Therapy Association [AOTA], 2019). Cognition is essential for everyday occupations such as self-care, domestic activities, work, play, and leisure (Champagne et al., 2019). After an acquired brain injury (ABI), that is, a stroke or brain injury, cognitive impairment is a common occurrence, negatively impacting functional performance (Stolwyk et al., 2021; Stroke Foundation, 2019). Cognitive rehabilitation involves education to facilitate self-awareness of cognitive deficits and strategy training to re-learn activities or learn new ways of completing tasks (van Schouwen-van Kranen, 2014). Occupational therapists play a key role in cognitive rehabilitation by enabling patients with an ABI to learn to manage their cognitive impairments and participate in valued occupations (Giles et al., 2020). Failure to provide appropriate and accurate assessment and treatment of functional cognition may result in poorer patient outcomes postdischarge from the hospital (Giles et al., 2020).

Internationally, evidence-based practice (EBP) guidelines for ABI provide general recommendations for cognitive rehabilitation but lack information on how to transfer these recommendations into practice (Jeffay et al., 2023; Stroke Foundation, 2019). Moreover, occupational therapists face challenges in planning cognitive rehabilitation, such as difficulty interpreting assessment findings (Goodchild et al., 2023). In addition, occupational therapists struggle with pragmatic reasoning and prioritizing areas of cognition to address (Nott et al., 2020) and reasoning to implement evidence into practice (Holmqvist et al., 2012). Occupational therapists report low confidence in planning cognitive rehabilitation, due to the complexity of clinical reasoning required (Wheatcroft et al., 2024).

Planning cognitive rehabilitation is a complex process that involves multiple modes of clinical reasoning (Holmqvist et al., 2009). Clinical reasoning, also known as professional reasoning, encompasses the thinking processes that guide clinical practice (Unsworth, 2004). This process is dynamic, complex, and multifaceted, developing not solely from years of experience but also through reflective practice and experiential learning (Sánchez-Zamorano et al., 2025). Clinical reasoning is fundamental to our professional ability to manage the complex process of integrating assessment, therapy planning, and intervention (Márquez-Álvarez et al., 2019). It may be influenced by an individual’s worldview, political and health care environment and resources available (Sánchez-Zamorano et al., 2025; Unsworth, 2025). In one of the foundation studies of clinical reasoning in occupational therapy, Mattingly and Fleming (1994) described how experts could simultaneously keep track of their reasoning around the very different aspects of patient issues, which they called the “three-track” mind. Thinking with a “three-track mind” is particularly evident among clinicians working in complex practice areas such as cognitive rehabilitation, where occupational therapists integrate research evidence with assessment findings while considering the patient’s context (Nott et al., 2020). This approach to explicating clinical reasoning draws on Ryle’s (1946) philosophy of “knowing that” and “knowing how.” The practical “knowing how” to plan cognitive rehabilitation and the “ways and methods of doing things” depends on the “ knowing that” of the underlying cognitive impairments and the evidence-base for practice around these impairments to apply this theory in practice (Ryle, 1946). Novice occupational therapists may find the “knowing how” to plan cognitive rehabilitation difficult due to the complex interplay between the person and their cognitive impairments, environment, and occupation factors. Thus, clinical reasoning is key to enhancing novice occupational therapists’ work with patients who require cognitive rehabilitation following ABI (Unsworth, 2017), and methods to facilitate expert clinical reasoning are required.

Clinical reasoning develops through experience, training, reflection, self-monitoring, and practice with mentorship (King et al., 2007); however, the majority of the research conducted in this area has been in nursing rather than occupational therapy (Pérez-Perdomo & Zabalegui, 2023). An occupational therapist’s cognitive skills are crucial for connecting and interpreting information to create “scripts” or “frames” (Carr & Shotwell, 2018) to develop therapy. These frames are mentally gathered, stored in long-term memory, and used by occupational therapists with a range of patients (Benner & Tanner, 1987). Building clinical reasoning capability in novice clinicians in the area of cognitive rehabilitation can be facilitated through mentorship, group education or self-directed learning (SDL; Paterson et al., 2002). Evidence on effective educational methods for improving clinical reasoning in occupational therapy is limited, especially for graduate clinicians (Unsworth & Baker, 2016). Burke and colleagues (2024) developed educator consensus on teaching reasoning, reflective practice, and evidence-based strategies for student occupational therapists. Case studies, simulations, and problem-based learning were essential strategies for advancing students’ clinical reasoning development (Burke et al., 2024). However, this work has not been replicated in qualified occupational therapists. Case-based learning shows positive effects in clinical practice, noting that mentorship and reflection are important (Maruyama et al., 2024).

SDL supports health professionals in enhancing their performance and clinical reasoning (Mamary & Charles, 2003). This cost-effective approach leverages self-assessment to enhance knowledge and reasoning skills (Paterson et al., 2002). SDL may include case studies, which can be presented in video format, for clinicians to engage with Neistadt (1998; Rodríguez-Bailón et al., 2021; Schettino & Capone, 2022). Once developed, case-based education/learning packages must be evaluated for effectiveness. A recent study by Behrendt and Smallfield (2024) describes the development of an e-learning module for functional cognition for occupational therapy students, but the training’s effectiveness is unclear. Similarly, SDL education courses on cognitive rehabilitation exist, such as the American Congress of Rehabilitation Medicine (ACRM; https://cognitiverehabilitation.org/), Braintree (https://www.braintreetraining.co.uk/), and Multicontext (https://multicontext.net/workshops), but their effectiveness remains unknown.

Powell et al. (2020) surveyed paraprofessionals working with brain injury patients to identify their training needs, finding cognition to be a top priority. Consequently, an online training program was provided to 79 paraprofessionals, most with less than 5 years of experience. The online program showed promising results; however, the study lacked objective measures of clinician improvement (Powell et al., 2021).

When considering the development of SDL education for novices, it is essential to consider the characteristics of this group. Dreyfus and Dreyfus (1980) developed a theory of the development of skills such as clinical reasoning, which poses five key stages: novice, advanced beginner, competent, proficient, and finally, expert. This work was translated into nursing by Benner and Tanner (1987) and subsequently across allied health (King et al., 2007; Unsworth, 2021). Novice therapists may have basic knowledge of cognitive theories, practices, and patient characteristics but may be unable to apply this knowledge (Benner, 1982). As a result, they require expert supervision to identify and develop rehabilitation plans (Jeffery et al., 2020), such as those addressing cognitive impairments. Novice occupational therapists in hospitals must develop clinical reasoning skills for effective inpatient cognitive rehabilitation. Neglecting this will ultimately impact patient recovery. Therefore, drawing insights from expert occupational therapists in cognitive rehabilitation to guide novice therapists is essential for shaping SDL education content. Through years of experience with novice therapists, expert occupational therapists can guide the delivery of SDL to support clinical reasoning in busy hospital environments. Definitions of expertise are complex (Dewitt et al., 2021) and have not been well developed in occupational therapy. An emerging perspective of this concept is adaptive expertise (Benfield, 2025). This perspective views adaptive experts as those who progress beyond routine expertise by engaging in reflection and critical analysis to expand their knowledge and become innovative practitioners (Gube & Lajoie, 2020). Further research is required to explore this perspective and identify the hallmarks of adaptive expertise within occupational therapy practice. However, occupational therapy experts in cognition are often defined as those employed in a specialist setting working with people with cognitive impairment, seeking opportunities for experiences that enhance their understanding of EBP and self-improvement, and acting as mentors to others in this specialized area (Halle et al., 2018; King et al., 2008; Nott et al., 2020; Rassafiani, 2009; Thomas et al., 2023).

This study aimed to establish expert consensus on the content and teaching methods of a self-directed learning package (SDLP) targeted at novice occupational therapists working with people with ABI within the hospital setting. This work focuses on the content and methods that assist novice inpatient occupational therapists in developing their clinical reasoning rather than researching the reasoning process themselves. Specifically, expert consensus was sought regarding the following: (a) What core content should be included in an SDLP to support novice inpatient clinicians in developing their clinical reasoning when planning cognitive rehabilitation for patients with an ABI? and (b) what methods or teaching tools should be considered within the SDLP to support the development of clinical reasoning in relation to cognitive rehabilitation?

Method

Study Design

The project used a mixed-methods research design with pragmatic epistemology (Creswell, 2018). Methods included an initial survey followed by focus groups using a virtual Nominal Group Technique (vNGT) format to facilitate the involvement of a wide geographical range of occupational therapy experts in cognitive rehabilitation (Mason et al., 2021). The NGT is a highly flexible technique that generates and prioritizes ideas to facilitate group consensus on a topic (McMillan et al., 2014; Thier & Mason, 2019). This study followed Potter et al.’s (2004) adaptation of the original NGT protocol, which includes five stages: (1) introduction, (2) silent idea generation, (3) round robin, (4) clarification, and (5) scoring (Potter et al., 2004; see Figure 1). This procedure was adapted for an online or virtual nominal group technique (vNGT), thus facilitating participation from experts across Australia (Mason et al., 2021). The NGT was selected over other consensus methods, like the Delphi method, due to greater flexibility in scoring and rapid capacity to gain consensus (McMillan et al., 2014; Thier & Mason, 2019). While the literature presents various descriptions of the ranking or scoring process in the NGT, it is commonly performed individually through Likert-type ratings that are subsequently ranked and then aggregated (Thier & Mason, 2019). Federation University Human Research Ethics Committee (2022/055) approved this study, and all participants provided informed consent before participating.

Figure 1.

Adapted Nominal Group Technique (NGT) Process (Potter et al., 2004)

Participants

Snowball recruitment with Australian occupational therapists was completed over 8 weeks through social media, that is, X, Facebook, the Occupational Therapy Listserv, and the Occupational Therapy Australia (OTA) research webpage. Experts in cognitive rehabilitation were also purposefully recruited via email through the researchers’ established clinical and academic networks. Therapists received a AU$20 voucher, a participation certificate, and a learning package overview upon completion.

Participants self-identified as experts if they currently work or have worked in a hospital setting with people with ABI cognitive impairment; have a high level of specialist knowledge, skills, and ability in cognitive assessment and rehabilitation; have completed relevant courses in neurological rehabilitation; and act as a mentor in cognition.

Instruments

1. Survey—Before the vNGT focus group, an online survey was sent via Qualtrics to collect consent, demographic information, and initial content ideas for an SDLP and its delivery methods. The two key questions asked were:

Q1. What core content should be included in a learning package to support novice clinicians in developing their clinical reasoning in relation to planning cognitive rehabilitation for inpatients with an ABI?

Q2. What methods or teaching tools should be considered within the learning package to support the development of clinical reasoning in relation to cognitive rehabilitation?

2. vNGT Focus group Guide—The three focus groups were conducted by asking participants to respond to the two research questions.

3. Mentimeter—Ideas from the vNGT focus groups in response to the two questions were entered into Mentimeter (www.menti.com), and participants rated them on a Likert-type scale (1 = very unimportant, 2 = unimportant, 3 = neutral, 4 = important, 5 = very important).

Procedure

The five stages of the vNGT process were amended by completing Stages 1 (introduction) and 2 (silent idea generation) via online survey before the group to enable rapid assimilation of information (Figure 1). The three vNGT focus groups took place online via Microsoft Teams over 2 weeks. Additional ideas were added (NGT Stage 2), followed by the round robin (NGT Stage 3) and clarification stage (NGT Stage 4; see Figure 1; Potter et al., 2004). When no further ideas arose and all were discussed, consensus was reached. Participants took a short break while researchers entered key ideas into Mentimeter. Then, participants ranked (NGT Stage 5) using the Mentimeter software on their personal devices.

Data Analysis

Three stages of data analysis were completed to identify the core content and methods to include in an SDLP.

First, before the vNGT, the survey data on the two research questions were downloaded, and initial thematic analysis of Steps 1 and 2 (Potter et al., 2004) was conducted adhering to Braun and Clark’s (2022) six-stage analysis process. This enabled preliminary analysis of the core content and methods to base the vNGT focus group discussion.

The survey’s core content themes were presented to the participants, with each vNGT building further on the combined themes. After completing the vNGT focus groups, thematic data from Question 1 (What is the core content) and content analysis of Question 2 (What are the teaching methods) data were further analyzed across the three groups. Thematic data analysis was completed initially by the primary author (J.W.), and subsequently, 10% of the data were coded by two other researchers (A.M.B. and C.A.U.) for consistency (O’Connor & Joffe, 2020). Content analysis was used for Question 2 because the data’s homogeneity necessitated pattern analysis over thematic exploration (Braun & Clarke, 2022). Discrepancies were discussed until a consensus was reached. Simple tabulations quantified mean ranks of idea importance.

Third, the Mentimeter software calculated weighted averages for each content and teaching method. Experts’ item mean scores (with SDs) were tabulated and ranked by importance. Demographic data from Qualtrics were summarized and presented descriptively.

The survey themes from the focus groups (FGs) were analyzed and tabulated (see Table 2). As three FGs were conducted, participants in each had to rank all items because simple ratings could not be aggregated across groups. The additional ideas/themes identified by participants during the vNGT focus groups were combined into Table 2—and can be identified by an asterisk (*). Finally, the themes were associated with Ryle’s (1946) structure for Ways of Knowing: knowing what, knowing how, and doing (see Figure 2).

Figure 2.

Thematic Representation of the Content of a Learning Package on Cognitive Rehabilitation, Drawing on Ryle’s (1946) Classification

Results

Participant Characteristics

Twenty-three occupational therapists completed the survey, with 22 consenting to participate in one of three vNGTs (see Table 1). Two groups had seven participants, and one group had eight—all ideal numbers for vNGT (McMillan et al., 2016). One participant withdrew due to personal reasons, leaving three groups of seven. Each group lasted 90 min.

Table 1.

Demographic Details of the Expert Occupational Therapy Participants (n = 23).

Variable	M	Min	Max	SD
Years of experience:
As an occupational therapist	15.7	7	35	6.9
Working with patients with an ABI	12.5	5	25	6.3
Working in a hospital setting	13.7	7	35	6.3
	Data, n (%)
Gender:
Female	22 (96%)
Male	1 (4%)
State or Territory of Australia:
Victoria	15 (65%)
Queensland	6 (26%)
Tasmania	1 (4%)
New South Wales	1 (4%)
South Australia, Western Australia, Northern Territory, Australian Capital Territory	0 (0%)
Highest level of qualification:
Bachelor/ Undergraduate Masters	8 (35%)
Postgraduate certificate/ diploma	4 (17%)
Masters	10 (44%)
Ph.D./ doctoral qualification	1 (4%)
Occupational category:
Occupational Therapy Clinician	1 (4%)
Senior Clinician	17 (68%)
Manager	4 (16%)
Researcher/ Academic /Educator/ Lecturer	0 (0%)
Other	1 (4%)
Completed postgraduate training/ courses in cognition (%)	Yes = 22 (96%)No = 1(4%)
Trained other occupational therapists in cognition.	Yes 22 (100%)(1 x missing data)
Type of training led:
Supervision	22 (100%)
Practical mentoring sessions	17 (77%)
In-service training	16 (72%)
Teaching/ Tutoring Undergraduates	9 (41%)
Teaching/ Tutoring Postgraduates	3 (18%)

Most participants were classified as senior clinicians (68%) and self-identified as highly experienced occupational therapists, having worked with ABI patients for an average of 12.5 years (SD = 3.6; see Table 1). Nearly all participants (96%) had completed postqualification cognitive rehabilitation training, such as Braintree or ACRM training. In addition, over half of the participants (65%) had completed or were engaged in postgraduate studies. All participants had trained or supervised occupational therapists in cognitive rehabilitation (100%). They were experienced in providing practical mentoring sessions (77%) and in-service training (72%). Nearly half had experience using educational methods alongside their clinical expertise, with 41% having taught undergraduate and 18% having delivered postgraduate occupational therapy training (Table 1).

Content of the Learning Package

Ten themes related to the learning package’s content were highlighted and mapped to Ryle’s (1946) Ways of Knowing (see Figure 2 and Table 2). The most frequently reported themes were (a) understanding cognitive rehabilitation and EBP theory, (b) delivering cognitive rehabilitation strategies, (c) goal setting, and (d) functional neuroanatomy of cognition.

Table 2.

Expert-Identified Content for a Cognitive Rehabilitation Learning Package for Novice Occupational Therapists.

KNOWING THAT/WHAT: underpins cognitive rehabilitation (propositional knowledge for cognitive rehabilitation)		Frequency of subthemes occurring in the survey(overall ranking)
1. Context: that rehabilitation will occur	• Funding sources and timeframes for rehab • Setting/ Hospital environmental context, i.e., acute/ rehab • Funding bodies and requirements^a • Setting rehabilitation timeframes and prognostic indicators^a	2
2. ABI (neuroanatomy) and cognition	• What is cognition, and what are the domains of cognition, i.e., attention, memory, executive functioning, speed of processing, and self-awareness? • Hierarchy of cognition • Understanding cognition^a • Understanding ABI neuroanatomy^a effects/ impairments and linking to impact on function • ICF activity and participation • Effects/ impairments prognostic indicators and linking to impact on function	17(4)
3. Occupational therapy role in cognitive rehab	• Role of OT and other health professionals –occupation-focused cog rehab vs other roles. • Occupational Therapy role in cognitive rehabilitation^a • How OT theory is included, i.e., occupation focused • Family-centered/patient-centered care	10(6)
4. Cognitive rehabilitation evidence-based practice theory	• Clinical Practice Guidelines and Key Evidence (General, not strategy specific), including evidence around worksheets and computer-based training/apps. • Models and approaches to cognitive rehabilitation, i.e., Compensation vs restoration/remediation • Learning Stages of Cognitive Rehab^a: acquisition, application, and adaptation • Evidence-based practice theory and guidelines^a	26(1)
KNOWING HOW: To put information together to formulate a plan (non-propositional knowledge for cognitive rehabilitation.
5. Planning cognitive rehabilitation by integrating information about the person, their environment, and their occupations.	• Previous and current level of functioning • Person, environment, and occupations/ roles previous and current • Interpretation of cog and occupational Ax/ Activity analysis-impairments affecting function • Activity analysis types/ interpreting errors^a • Factors/considerations for planning cognitive rehabilitation^a • PMHx • Speech and visual impairments • Self-awareness/ Insight • Previous strategy use • Time post-injury/ Recovery profile • Personality/ coping style	13(5)
DOING: applying specific cog rehab strategies, setting goals, monitoring and modifying rehab, etc.
6. Setting goals and measuring progress, i.e., evaluation of intervention effectiveness/rehab outcomes	• Goal setting as measurement/ evaluation of rehab, i.e., pre/ post goal measurement • Prioritization of goals concerning discharge planning • Goal Setting^a	19(3)
7. Delivering Cognitive Rehabilitation Techniques/ Strategies in practice (evidence for these)	• External Memory aids^a • Errorless Learning/ Systematic instruction^a /Daily routine re-training • Reorientation—PTA^a & DOC Mx • PTA management^a • Environmental modification^a • Self-Awareness^a / Insight– strategies to build awareness. • Pause, Prompt Praise^a • Goal Management Training^a / Metacognitive Strategy Training • Chaining and vanishing cues^a • Carer and Patient Education, including handouts/ fact sheets	24(2)
8. Develop and implement a cognitive rehab program	• How to achieve consistency/ intensive rehab, i.e., use of assistants, groups & family • How to structure a cog rehab session^a • Establishing a routine, that is, managing fatigue^a • Grading of activities/ interventions monitoring and modifying rehabilitation • Therapeutic alliance and support • Monitoring and modifying cognitive rehabilitation: grading^a to get the “just right” challenge	7(7)
9. Communication of the cognitive rehab plan	• Documenting cognitive rehabilitation plans^a • Communicating cognitive rehabilitation plans, i.e., with MDT, family, carers, etc	2
10. Discharge planning	• Transitioning to home environment/ community rehab • Evaluation of cognitive impairment risk and safety in discharge planning • Transitioning home and risks^a	3

Denotes items identified in the vNGT focus group but not in the survey.

The Mentimeter ratings indicated that experts’ top five rated areas were (a) activity analysis and interpreting errors, (b) monitoring and modifying cognitive rehabilitation, (c) evidence-based theory and guidelines, (d) understanding cognition and its domains, and (e) goal setting (see Table 3).

Table 3.

Importance of Content and Methods for Inclusion in a Self-Directed Learning Package, Weighted Average Ranking From Most to Least Important.

Question 1: Please rate the content statements for a cognitive rehabilitation learning package for novice occupational therapists	Weighted average(in descending order)^a	Question 2: Please rate the teaching methods for a cognitive rehabilitation learning package for novice occupational therapists	Weighted average(in descending order)^a
1. Activity analysis types/ interpreting errors	4.7	1. Video demonstrations of cognitive rehab strategies	4.7
2. Monitoring and modifying cognitive rehabilitation: grading	4.7	2. Case studies/ examples of impairments in function	4.7
3. Evidence-based practice theory and guidelines	4.6	3. Online modules/ package, i.e., PowerPoint with voiceover	4.5
4. Understanding cognition	4.6	4. Practical tasks to complete between modules/ trial strategies	4.3
5. Goal Setting	4.6	5. Therapy ideas/examples resources for goal setting & rehab	4.3
6. How to structure a cognitive rehabilitation session	4.4	6. Flow chart/ decision aid	3.9
7. Carer and patient education	4.4	7. Frameworks for guiding clinical reasoning, i.e., CPPF	3.9
8. Occupational Therapy role in cognitive rehabilitation	4.4	8. Online materials/ links	3.9
9. Errorless learning/ systematic instruction	4.4	9. Scripts and how to create	3.8
10. Setting rehabilitation timeframes and prognostic indicators	4.3	10. Quizzes interactive self-testing/ feedback on tasks	3.8
11. Factors/considerations for planning cognitive rehabilitation	4.3	11. Quick reference summaries	3.8
12. Transitioning home, and risks	4.3	12. Theory book/ manual	3.6
13. Post-Traumatic Amnesia (PTA) management	4.2	13. Reading/ prereading	3.5
14. Documentation/ communication rehab plan	4.2	14. Learning Objectives	3.4
15. Learning stages of Cognitive Rehab	4.1	15. Reflection sheets	3.3
16. Pause, Prompt, Praise	4.1	16. Training log	2.9
17. Self-awareness strategies	4.0
18. External memory aids	4.0
19. Establishing a routine to manage fatigue & behavior	3.9
20. Reorientation: for PTA	3.9
21. Therapeutic alliance & support	3.8
22. Chaining and vanishing cues	3.7
23. Environmental modification	3.6
24. Understanding ABI neuroanatomy	3.5
25. Goal Management Training	3.4
26. Funding bodies and requirements, that is, NDIS	3.2
27. Group vs 1:1 rehab	2.7

Likert-type scale (5 = very important to 1 = very unimportant).

Participants ranked the five most essential teaching methods as (a) video demonstrations, (b) case studies/examples of functional impairments, (c) online modules/packages, (d) activities to trial strategies, and (e) therapy ideas and resources.

Delivery Methods for the Learning Package

The experts’ content analysis of delivery methods identified 15 items (see Table 2). The most frequently suggested methods were (a) case studies/case examples (n = 21); (b) videos (n = 15); (c) online modules, that is, PowerPoint packages with voiceover (n = 10); (d) interactive elements, that is, self-testing quizzes; and so on (n = 7). The Mentimeter results were consistent with the content analysis, noting the methods ranked highest by participants were (a) video demonstrations, (b) case studies/case examples, (c) online modules/packages with voiceover, and (d) practical tasks to trial strategies (see Table 3).

Discussion

The vNGT focus groups enabled the rapid assimilation of experts’ perspectives on the content and teaching methods for an SDLP designed for novice occupational therapists to support clinical reasoning when planning cognitive rehabilitation. Experts identified that key content should include EBP theory and guidelines, delivering cognitive rehabilitation strategies, setting goals and measuring progress, understanding neuroanatomy and cognition, and planning cognitive rehabilitation. Experts ranked the modification of cognitive rehabilitation through activity analysis and understanding the evidence-based guidelines as key areas to address.

Experts identified that the SDLP delivery should include video demonstrations, case studies showcasing difficulties encountered in daily routines, an online package with voiceover, practical activities, and resources to aid in goal setting and rehabilitation planning. The content analysis aligned with Mentimeter ratings, where experts ranked these three methods as the priority teaching tools. These methods correspond with the literature, underscoring the importance of providing real-life examples to enhance clinical reasoning among novice occupational therapists (Neistadt, 1998). Participants emphasized the importance of using case studies, including video case studies, to develop clinical reasoning, which is consistent with current literature on approaches to enhance education (Burke et al., 2024; Rodríguez-Bailón et al., 2021; Schettino & Capone, 2022). In addition, participants recognized reflection, self-assessment, and EBP resources as methods to support novice clinicians, aligning with occupational therapy literature on developing expertise (Benfield, 2025).

Experts ranked activity analysis highly, indicating that novice occupational therapists must develop skills to identify functional errors and reason about patient performance before planning cognitive rehabilitation. This analysis connects directly to planning cognitive rehabilitation by integrating information about the individual, environment, and occupations. In hospitals, occupational therapists must apply clinical reasoning to analyze errors from standardized and functional tasks for effective discharge recommendations (Giles et al., 2020). This is supported by Bottari and colleagues (2007), who found that even expert occupational therapists require contextual information concerning the person, environment, and occupations to analyze errors, target treatment, and plan discharge accurately. Hence, an essential component of a learning package will be to facilitate novices to consider the patient’s individual factors, environment, and occupations when analyzing errors.

Participants raised the topic of cognitive assessment in both the survey and during vNGT focus groups. While the primary focus of the research question was on rehabilitation rather than assessment, the experts considered assessment an essential component of occupational therapists’ clinical reasoning in planning rehabilitation. Consequently, this suggests that the topic of assessment needs to be incorporated into the SDLP module through the exploration of cognitive impairments and functional performance errors to inform the development of effective cognitive rehabilitation strategies.

Identified content not prioritized through the ranking process included environmental modification, understanding neuroanatomy of ABI, goal management framework/training (GMF/T), funding bodies, and group versus 1:1 rehabilitation. There are several potential reasons why experts did not prioritize these themes. One reason is the perception that specific topics, such as ABI neuroanatomy, are more suitable for undergraduate-level content education. In addition, some themes, including GMF, may be considered more relevant to outpatient than inpatient settings. Furthermore, topics like funding may not be viewed as directly pertinent to providing cognitive rehabilitation. While this content does not need to be covered in any detail (if at all) within an SDLP, neuroanatomy, given its association with functional outcomes, should be included in introductory modules related to procedural reasoning.

Streamlining the Five-Step NGT process by conducting initial brainstorming through an online survey was advantageous. This approach helped navigate the complex nature of the questions and facilitated thematic assimilation before the group discussion. Furthermore, using an online rather than a traditional face-to-face focus group enabled occupational therapists across Australia to participate, reducing geographical and time barriers that might impact recruitment. The participants were highly experienced in cognitive rehabilitation and most had postgraduate education, supporting the validity of the findings (Murphy et al., 1998).

Limitations

Online data collection methods are commonplace following the COVID-19 pandemic (Willemsen et al., 2022). However, a potential limitation of this study is that many participants were drawn from one country and only two of the eight states and territories; they were predominantly from the states where the lead author had preexisting professional networks. It is also noted that definitions of expertise are not well-established in occupational therapy, and the definition of “experts” in cognitive rehabilitation was developed for use in this study. While 41% of participants had educational experience, it is important to note that they were primarily clinical experts. As such, while they understood the clinical needs of novices, they may have lacked expertise in relation to approaches for delivering cognitive rehabilitation education. Furthermore, it is acknowledged that identifying experts is challenging. This study listed several criteria that participants needed to meet to qualify as an expert, including clinicians’ self-identification, which relies on their insight into their abilities. Future studies need to consider whether self-identification of expertise is sufficiently reliable, particularly given the emerging perspective of adaptive expertise (Benfield, 2025) and how this might be operationalized to identify experts.

Finally, applying a 5-point Likert-type scale in this study may not have allowed for granularity in the Mentimeter ratings. Experts considered many themes as important or very important; thus, adopting a more refined scaling approach could have improved the ability to differentiate between the varying levels of importance assigned to each theme.

Implications for Practice and Future Research

The findings indicate that an SDLP to enhance the clinical reasoning of novice clinicians in cognitive rehabilitation should incorporate videos and case studies demonstrating the application of EBP guidelines to set goals, structure, modify, and complete occupation-based cognitive rehabilitation. For clinical educators who seek to develop clinical reasoning among their new graduate occupational therapists, there should be an emphasis on staff improving their understanding of cognitive impairments and interpretation of cognitive errors during activity analysis. This may help prepare occupational therapists to work with patients who have acquired brain injuries more effectively.

For novice occupational therapists, the findings highlight key priority areas that they should focus on and actively engage with. New graduates can significantly enhance their skills in this field by concentrating on essential aspects of cognitive rehabilitation, such as their understanding of cognitive impairments and interpretation of cognitive errors during activity analysis. Furthermore, for mentors and hospital-based educators, the recommendations for SDLP content and delivery methods may be employed to develop competencies and generate practical tutorial topics for staff. The priorities identified from this study can now be used to develop an SDLP to support novice occupational therapists’ clinical reasoning when planning cognitive rehabilitation, and the effectiveness of such learning packages can be assessed.

Conclusion

Many novices struggle with their clinical reasoning when planning cognitive rehabilitation following assessment for their patients with ABI. Hence, this study aimed to determine what experts perceive novice occupational therapists need from an SDLP to enhance clinical reasoning when working with inpatients with cognitive impairments following ABI. Experts identified that the key content of an SDLP should include evidence-based cognitive rehabilitation practice, neuroanatomy, goal setting, interpreting errors, and planning and delivering rehabilitation strategies. To teach this content via an SDLP, experts recommended methods to enhance clinical reasoning should include case studies, videos, online modules, and self-testing. Through identifying these learning priorities and content, future studies can now develop and evaluate an SDLP. This SDLP aims to foster the development of clinical reasoning among inpatient novice occupational therapists, ultimately enhancing the delivery of cognitive rehabilitation for inpatients with brain injuries.

Footnotes

Acknowledgements

The authors express gratitude to the expert participants for their time and acknowledge Dr. Karen Roberts, Alfred Health’s Occupational Therapy Manager, for her support in allowing researchers and participants time release to engage in the study.

Authors’ Note

All authors have been involved in the study’s implementation and in the decision to prepare and submit the article, accept responsibility for its publication, and be accountable for its publication.

Data Availability Statement

The data supporting this study’s findings are available on request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: J.W. is supported by an Australian Government Research Training Program (RTP) Fee-Offset Scholarship through Federation University Australia. N.A.L. is supported by a Heart Foundation (Australia) Future Leader Fellowship (#2).

Ethical Approval

This study was given ethical clearance by the Federation University Human Research Ethics Committee (2022/055).

Informed Consent

Before beginning the survey, each participant electronically signed consent and eligibility forms using the Qualtrics online platform. If participants consented to be contacted for the focus group, they provided their details to the researcher.

ORCID iDs

Jacqueline Wheatcroft

Natasha A. Lannin

Anne M. Baker

Carolyn A. Unsworth

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Expert Consensus on a Cognitive Rehabilitation Learning Package for Novice Occupational Therapists

Abstract

Plain Language Summary

Keywords

Introduction

Method

Study Design

Participants

Instruments

Procedure

Data Analysis

Results

Participant Characteristics

Content of the Learning Package

Delivery Methods for the Learning Package

Discussion

Limitations

Implications for Practice and Future Research

Conclusion

Footnotes

Acknowledgements

Authors’ Note

Data Availability Statement

Declaration of Conflicting Interests

Funding

Ethical Approval

Informed Consent

ORCID iDs

References