Objectives Behavioural Initiation is defined as the innate ability to trigger action. There is rich literature describing the high prevalence of motivational disorders and poor behavioural initiation during rehabilitation following acquired brain injury. This is not only due to their neurological conditions, but also that they might have spent many weeks in the wrong environment, with no stimulation other than receiving essential care. There is no established measure for behaviour initiation specific for a rehabilitation setting. This project aim to develop a tool that is sensitive to patients’ level of behavioural initiation, and support evidence-based decision making in formulating treatments in the Multi-Disciplinary Teams (MDT).

Methods We proposed the 10-item nurse-rated Behavioural Initiation Rating Scale (BIRS). BIRS items were tailored to measure patient behaviour in day-to-day scenarios in inpatient rehabilitation. Included statements were shortlisted from a large pool of comments and observations from the MDT, and a review of literature on the topic. Following basic training with the nursing staff, we piloted a feasibility trial of BIRS for 4 weeks at an 18-bed Neurorehabilitation Unit. We arranged two focus-groups with MDT therapists and the nursing team, to reflect on the implementation of BIRS, and further refinement of scale items. Opinions from the focus-groups were used to revise the current version of BIRS.

Results It takes less than 2 minutes to administer and score BIRS. BIRS appears to be sensitive to improvement in behavioural initiation, and in agreement with clinical impressions from MDT and feedback from carers. BIRS has been well-implemented into routine practice, and has resulted a cultural shift in the unit. We identified some levels of between-rating variation in using BIRS, which was addressed by clarifying the instruction manual and giving specific examples for the ambiguous items.

Secondary to our aim, the implementation of BIRS has improved the communication between nursing staff and therapists in delivering cohesive neurorehabilitation.

Conclusions BIRS appears to be a promising tool to evaluate patient behavioural initiation in a rehabilitation setting. A multi-centre trial of BIRS is currently being planned to establish its psychometric properties.