Provider perspectives on rehabilitation of patients with polytrauma

Friedemann-Sánchez G, Sayer NA, Pickett T. Provider perspectives on rehabilitation of patients with polytrauma.

Objectives

To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation.

Design

Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison.

Setting

The 4 VA polytrauma rehabilitation centers (PRCs).

Participants

Fifty-six purposefully selected PRC providers and providers from consulting services.

Interventions

Not applicable.

Main Outcomes Measures

Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves.

Results

According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding.

Conclusions

The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.     

The voice of Florence Nightingale on advocacy

Modern nursing is complex, ever changing, and multi focused. Since the time of Florence Nightingale, however, the goal of nursing has remained unchanged, namely to provide a safe and caring environment that promotes patient health and well being. Effective use of an interpersonal tool, such as advocacy, enhances the care-giving environment. Nightingale used advocacy early and often in the development of modern nursing. By reading her many letters and publications that have survived, it is possible to identify her professional goals and techniques. Specifically, Nightingale valued egalitarian human rights and developed leadership principles and practices that provide useful advocacy techniques for nurses practicing in the 21st century. In this article we will review the accomplishments of Florence Nightingale, discuss advocacy in nursing and show how Nightingale used advocacy through promoting both egalitarian human rights and leadership activities. We will conclude by exploring how Nightingale's advocacy is as relevant for the 21st century as it was for the 19th century.     

Advocacy in nursing: perceptions and attitudes of the nursing elite in the United Kingdom

Advocacy in nursing: perceptions and attitudes of the nursing elite in the United Kingdom ¶In recent years, patient advocacy has been claimed as an integral part of the nurse’s role in health care delivery in the United Kingdom (UK). Support from the nursing leadership/elite is seen as important in the promulgation and diffusion of any ‘new’ role in nursing. This paper explores the perceptions and attitudes of nurse leaders in the UK to the adoption of the patient advocate role as an ‘innovation’ in nursing. Using a qualitative methodology, semi-structured interviews with six of nursing’s ‘elite’ were conducted over a period of 5 months. Results revealed contradictions and paradoxes within the views of the elite. Although leaders recognized patient advocacy as a role integral to the moral value system in nursing enhanced by the nurse–patient relationship, they objected to the professionalization of the role, seeing an exclusive claim to patient advocacy as intensifying interprofessional conflicts in health care. It is argued that unless professionalized, the individual nurse will continue this potentially risky activity without adequate authority or support systems. The results overall question the role of the nursing leadership in the diffusion of innovations in nursing.     

Developing a polytrauma rehabilitation center: a pioneer experience in building, staffing, and training

The military operations in Iraq and Afghanistan have resulted in patterns of injury not commonly seen in previous conflicts. Improvised explosive devices are the primary weapon, and exposure to blast is the most common mechanism of injury. Blasts can result in polytrauma injury, in which multiple body systems, including the head and brain, are injured. Nursing and rehabilitation care can be further challenged by other blast sequelae such as pain, amputation, blindness or low vision, hearing impairment, and aphasia. This article describes the process by which one Veterans Affairs Medical Center developed its inpatient rehabilitation service into a polytrauma rehabilitation center to meet the medical and rehabilitation needs of these patients. Special attention is given to the education and training program developed to solidify the membership of the center's nursing staff in the interdisciplinary treatment team.     

Expanding the Scope of Staff Education: Brain Injury to Polytrauma

Staff members who care for the polytrauma population need diverse educational programs even if they have many years of experience working in the brain‐injury rehabilitation field. This article explores key concepts that help guide rehabilitation nursing practice, strengthen clinical skills, increase family involvement, and identify educational resources.     

Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror

Sayer NA, Chiros CE, Sigford B, Scott S, Clothier B, Pickett T, Lew HL. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror.

Objective

To describe characteristics and rehabilitation outcomes among patients who received inpatient rehabilitation for blast and other injuries sustained in Iraq and Afghanistan during the Global War on Terror.

Design

Observational study based on chart review and Department of Veterans Affairs (VA) administrative data.

Setting

The 4 VA polytrauma rehabilitation centers (PRCs).

Participants

Service members (N=188) admitted to a PRC during the first 4 years of the Global War on Terror for injuries sustained during Operation Iraqi Freedom or Operation Enduring Freedom.

Intervention

Multidisciplinary comprehensive rehabilitation program.

Main Outcomes Measures

Cognitive and motor FIM instrument gain scores and length of stay (LOS).

Results

Most war-injured patients had traumatic brain injury, injuries to several other body systems and organs, and associated pain. Fifty-six percent had blast-related injuries, and the pattern of injuries was unique among those with injuries secondary to blasts. Soft tissue, eye, oral and maxillofacial, otologic, penetrating brain injuries, symptoms of post-traumatic stress disorder, and auditory impairments were more common in blast-injured patients than in those with war injuries of other etiologies. The mechanism of the injury did not predict functional outcomes. LOS was variable, particularly for those with blast injuries. Patients with low levels of independence at admissions made the most progress but remained more dependent at discharge compared with other PRC patients. The rate of gain was slower in this low-functioning group.

Conclusions

Blasts produce a unique constellation of injuries but do not make a unique contribution to functional gain scores. Findings underscore the need for assessment and treatment of pain and mental health problems among patients with polytrauma and blast-related injuries. Patients with polytrauma have lifelong needs, and future research should examine needs over time after community re-entry.     

Geriatric rehabilitation nursing: developing a model

In this paper, we describe a geriatric rehabilitation nursing model developed on the basis of the nursing and rehabilitation literature. That literature comprised some 120 articles addressing the rehabilitation of elderly patients and the work done by nurses in that process, various philosophical questions and the results of geriatric rehabilitation. One-third of these articles has been evaluated on the strength of the articles' evidence, and these are discussed in this paper. The findings show that the main factors in geriatric rehabilitation nursing are the patient with health or functional problems and the nurse with professional values, knowledge and skills. The patient is part of a family and the nurse works as part of a multidisciplinary team. In the geriatric rehabilitation process, the patient and the nurse work in close interaction. The aims of rehabilitation depend upon the patient's commitment to the objective and upon the nurse's commitment to help the patient achieve that objective. A health orientation, goal-oriented work, nursing decision-making and a rehabilitative approach to work are all central to this effort. Work is organized in multidisciplinary teams where nurses have equal responsibilities with other professional staff. Testing and development of the model is ongoing.     

脑卒中患者主要照顾者护理知识调查

目的了解脑卒中家庭主要照顾者护理知识掌握情况。方法采用自行设计的调查表对250例脑卒中家庭主要照顾者的护理知识和健康教育需求进行调查。结果77.6％照顾者了解疾病的临床症状，说明对疾病有一定的认识，但缺乏康复护理知识和基本护理技巧。92.4％照顾者希望通过提供护理示范指导，90.4％希望进行个别指导，84.0％希望开办疾病专题讲座等方式从医务人员处获得护理知识和护理技能。结论医护人员应重视脑卒中患者家属健康教育需求，有针对性地进行宣教和指导，帮助家属掌握护理要点，以利于患者康复，提高生活质量。     

护理领导力在患者护理中的应用现状

总结护理领导力在患者病死率、安全、舒适度、并发症等方面的应用现状,指出护理领导力在患者护理中的应用启示,为我国护理人员发展、应用护理领导力提供借鉴。     

Role of the family in nursing home care

Family participation is extremely important in managing the nursing home patient. In order to attract and maintain close family involvement in the care, the physician and the nursing staff should design an ongoing program of family participation in the physical, psychologic and social rehabilitation of the patient. By maintaining a continuous rapport with the family, the physician can make sure that all who are concerned are satisfied with the patient's care.     

Developing and testing a new measure of staff nurse clinical leadership: the clinical leadership survey

Patrick A., Laschinger H.K.S., Wong C. & Finegan J. (2011) Journal of Nursing Management 19 , 449–460
Developing and testing a new measure of staff nurse clinical leadership: the clinical leadership survey Aim To test the psychometric properties of a newly developed measure of staff nurse clinical leadership derived from Kouzes and Posner’s model of transformational leadership. Background While nurses have been recognized for their essential role in keeping patients safe, there has been little empirical research that has examined clinical leadership at the staff nurse level. Methods A non-experimental survey design was used to test the psychometric properties of the clinical leadership survey (CLS). Four hundred and eighty registered nurses (RNs) providing direct patient care in Ontario acute care hospitals returned useable questionnaires. Results Confirmatory factor analysis provided preliminary evidence for the construct validity for the new measure of staff nurse clinical leadership. Structural empowerment fully mediated the relationship between nursing leadership and staff nurse clinical leadership. Conclusion The results provide encouraging evidence for the construct validity of the CLS. Implications for nursing management Nursing administrators must create empowering work environments to ensure staff nurses have access to work structures which enable them to enact clinical leadership behaviours while providing direct patient care.     

A pilot study of selected Japanese nurses' ideas on patient advocacy

This pilot study had two purposes: (1) to review recent Japanese nursing literature nursing advocacy; and (2) to obtain data from nurses on advocacy. For the second purpose, 24 nurses at a nursing college in Japan responded to a questionnaire. The concept of advocacy, taken from the West, has become an ethical ideal for Japanese nurses but one that they do not always understand, or, if they do, they find it difficult to fulfil. They cite nursing leadership support as necessary to enacting this role. Discussion on meaning of and the rationale for advocacy in a society where goodness or badness is relative to social situations and its impact may reveal two parallel but overlapping views of morality. Such a situation would not only influence notions of advocacy but also possibly render them more complex.     

Genetic and Genomic Public Health Strategies: Imperatives for Neonatal Nursing Genetic Competency

Proficient nursing care for neonates includes anticipating and meeting future demands of genetic competency. Three strategies where emerging issues presently call for neonatal nursing genetic competency development are increased power and significance of neonatal family health histories, population genetic biobanking, and newborns' family genetic advocacy. Neonatal nurses in their advocate, educator, and leadership roles can develop or maintain genetic competency in newborn care by targeting:

• collaborative efforts between nurse and family regarding neonatal family health history preparation and understanding of its genetic implications;

• referrals to and partnerships with genetic advocacy groups in programs and leadership that empowers neonate's families;

• methods to assure privacy and protection of present infants' genetic information while also serving the interests of future infants who may derive benefit of scientific use of the present infant's DNA; and

• support and collaboration with parents who will be making biobanking decisions regarding their child's DNA becoming part of population-based and/or genetic advocacy biobanks.

Genetic and genomic public health strategies frame areas where it is imperative for neonatal nursing to investigate best practice for future and present newborn population's outcomes.     

A Family Psychoeducation Model for Long Term Rehabilitation

When one member of a family is medically compromised, the combined effects of disability and institutional stressors jeopardize the integrity and adaptive strength of the patients and the family. A psychoeducational program was designed to meet the needs of patients, families, and staff of a 912-bed chronic rehabilitation and nursing facility. Results are discussed in terms of positive changes in patient, family, and staff relationships, the utility of a family group intervention and its unique relevance as a preventive as well as rehabilitative treatment.     

Treating Pain on the Battlefield: A Warrior’s Perspective

The current conflicts in Afghanistan (Operation Enduring Freedom; commenced October 2001) and Iraq (Operation Iraqi Freedom; commenced March 2003) have been remarkable due to the more than 90% survival rate among wounded warriors. Although this statistic is a historic achievement by the military’s medical services, other medical issues have taken on greater emphasis as more casualties from war survive than ever before. Pain management of United States wounded, in particular, has been a medical issue of increasing importance, as modern understanding of the detrimental effects of pain on recovery and rehabilitation becomes clearer. In this review, a warrior’s perspective of military pain management is explored and potential for improvement discussed.     

Advocacy at end-of-life research design: an ethnographic study of an ICU

BACKGROUND: Clinicians worldwide are being called upon to reconcile accountability for patient outcomes with the resources they consume. In the case of intensive care, contradictory pressures can arise in decisions about continuing treatment where benefit is diminishing. As concern grows about the cost effectiveness of treatment at end-of-life, nursing expertise and advocacy become significant factors in decision making. OBJECTIVES: To explore the potential for a nursing advocacy role within a specific regime of nursing practice: end-of-life care; specifically to examine the concept of nursing advocacy from the literature, to consider its application in the workplace and to assess the capacity for nurses to advocate for people who die in institutions such as intensive care units. DESIGN: Open-ended interviews with nurse managers and educators (4), palliative care specialists (2), chaplain (1), medical managers (2), intensives (7); focus groups with nurses (4 focus groups and 29 participants); patient case studies (13); observation of family conferences (6 conferences and 15 participants); observation of ward rounds (3 ward rounds and 11 participants). Total number of participants: 84. SETTING: A large ICU in a principal referral and teaching hospital in Sydney, Australia. PARTICIPANTS: Clinical staff within, and clinical and non-clinical caregivers external to the unit. METHOD: Qualitative, ethnographic study. RESULTS: Spurious economic imperatives, primacy given to medical intervention, conflict between medical and nursing clinicians about patient management and absence of nursing operational autonomy and organizational authority, impede the opportunity for nurses to define and enact an advocacy role. CONCLUSIONS: If nurses are to be effective patient advocates at end-of-life, they will need to develop clear criteria within which nursing assessments of patient status can be framed, the specialized skills to manage the non-medical needs of dying people and the organizational and political skills to negotiate changing clinical practice and workplace relations.     

Heterotopic ossification in combat amputees from Afghanistan and Iraq wars: five case histories and results from a small series of patients

Heterotopic ossification (HO) is excess bone growth in soft tissues that frequently occurs in the residual limbs of combat amputees injured in Operation Iraqi Freedom and Operation Enduring Freedom, or Iraq and Afghanistan wars, respectively. HO can interfere with prosthetic use and walking and delay patient rehabilitation. This article describes symptomatic and/or radiographic evidence of HO in a patient series of combat amputees rehabilitating at a military amputee care clinic (27 patients/33 limbs). We conducted a retrospective review of patient records and physician interviews to document evidence of HO symptoms in these limbs (e.g., pain during prosthetic use, skin breakdown). Results showed HO-related symptoms in 10 of the 33 residual limbs. Radiographs were available for 25 of the 33 limbs, and a physician identified at least moderate HO in 15 of the radiographs. However, 5 of the 15 patients who showed at least moderate radiographic HO did not report adverse symptoms. Five individual patient histories described HO onset, symptoms, treatments, and outcomes. These case histories illustrated how HO location relative to pressure-sensitive/pressure-tolerant areas of the residual limb may determine whether patients experienced symptoms. These histories revealed the uncommon but novel finding of potential benefits of HO for prosthetic suspension.