Ingrid Poulsen

Validation of a new assessment tool for qualitative research articles

AIM This paper presents the development and validation of a new assessment tool for qualitative research articles, which could assess trustworthiness of qualitative research articles as defined by Guba and at the same time aid clinicians in their assessment. BACKGROUND There are more than 100 sets of proposals for quality criteria for qualitative research. However, we are not aware of an assessment tool that is validated and applicable, not only for researchers but also for clinicians with different levels of training and experience in reading research articles. METHOD In three phases from 2007 to 2009 we delevoped and tested such an assessment tool called VAKS, which is the Danish acronym for appraisal of qualitative studies. Phase 1 was to develop the tool based on a literature review and on consultation with qualitative researchers. Phase 2 was an inter-rater reliability test in which 40 health professionals participated. Phase 3 was an inter-rater reliability test among the five authors by means of five qualitative articles. RESULTS The new assessment tool was based on Gubas four criteria for assessing the trustworthiness of qualitative inquiries. The nurses found the assessment tool simple to use and helpful in assessing the quality of the articles. The inter-rater agreement was acceptable, but disagreement was seen for some items. CONCLUSION We have developed an assessment tool for appraisal of qualitative research studies. Nurses with a range of formal education and experience in reading research articles are able to appraise, relatively consistently, articles based on different qualitative research designs. We hope that VAKS will be used and further developed.

Impact of professionalism in nursing on in-hospital bedside monitoring practice.

AIM This article reports a study exploring nursing practice of monitoring in-hospital patients including intra- and interprofessional communication and collaboration. BACKGROUND Sub-optimal care in general in-hospital wards may lead to admission for intensive care, cardiac arrest, or sudden death. Reasons may include infrequent measurements of vital parameters, insufficient knowledge of their predictive values, and/or sub-optimal use of Medical Emergency Teams. This study was designed to improve understanding of nursing practice and to identify changes required to support nursing staff in improving standards of clinical monitoring practice and patient safety in general in-hospital wards. DESIGN The study was designed as a qualitative descriptive clinical study, based on method triangulation including structured individual observations and semi-structured individual interviews. METHODS In the spring of 2009, structured observations and semi-structured interviews of 13 nurses were carried out at a university hospital in Copenhagen, Denmark. The observational notes and interview transcriptions were analysed using content analysis. RESULTS One theme (Professionalism influences nursing monitoring practice) and two sub-themes (Knowledge and skills and Involvement in clinical practice through reflections) were identified. Three categories (Decision-making, Sharing of knowledge, and Intra- and interprofessional interaction) were found to be associated with the theme, the sub-themes, and with each other. CONCLUSION Clinical monitoring practice varies considerably between nurses with different individual levels of professionalism. Future initiatives to improve patient safety by further developing professionalism among nurses need to embrace individual and organizational attributes to strengthen their practice of in-hospital patient monitoring and management.

Surviving severe traumatic brain injury in Denmark: incidence and predictors of highly specialized rehabilitation.

Purpose To identify all hospitalized patients surviving severe traumatic brain injury (TBI) in Denmark and to compare these patients to TBI patients admitted to highly specialized rehabilitation (HS-rehabilitation). Patients and methods Patients surviving severe TBI were identified from The Danish National Patient Registry and The Danish Head Trauma Database. Overall incidence rates of surviving severe TBI and incidence rates of admission to HS-rehabilitation after severe TBI were estimated and compared. Patient-related predictors of no admission to HS-rehabilitation among patients surviving severe TBI were identified using multivariable logistic regression. Results The average incidence rate of surviving severe TBI was 2.3 per 100,000 person years. Incidence rates of HS-rehabilitation were generally stable around 2.0 per 100,000 person years. Overall, 84% of all patients surviving severe TBI were admitted to HS-rehabilitation. Female sex, older age, and non-working status pre-injury were independent predictors of no HS-rehabilitation among patients surviving severe TBI. Conclusion The incidence rate of hospitalized patients surviving severe TBI was stable in Denmark and the majority of the patients were admitted to HS-rehabilitation. However, potential inequity in access to HS-rehabilitation may still be present despite a health care system based on equal access for all citizens.

Lower incidence of unexpected in-hospital death after interprofessional implementation of a bedside track-and-trigger system

BACKGROUND In-hospital patients may suffer unexpected death because of suboptimal monitoring. Early recognition of deviating physiological parameters may enable staff to prevent unexpected in-hospital death. The aim of this study was to evaluate short- and long-term effects of systematic interprofessional use of early warning scoring, structured observation charts, and clinical algorithms for bedside action. METHODS A prospective non-randomized controlled study of unexpected in-hospital death before and after implementation of a clinical intervention in a medical and surgical ward setting at an urban Danish university hospital. Information was obtained over three four-month study periods - a pre-interventional one in 2009 (1st March-30th June), and two postinterventional ones in 2010 (1st September-31st December) and 2011 (1st March-30th June). The incidence of unexpected patient death, the primary study outcome, was calculated as the rate of unexpected patient mortality based on in-hospital risk time. RESULT The adjusted unexpected patient mortality rate was significantly lower during the second postinterventional study period than before the intervention, 17 versus 61 per 100 adjusted patient years (P=0.013), corresponding to a rate ratio of 0.271 (95% confidence interval (CI) 0.097-0.762). A tendency to reduced unexpected mortality was found during the first postinterventional study period (25 versus 61 per 100 adjusted patient years, P=0.053; rate ratio 0.404, CI 0.161-1.012). CONCLUSION Clinical intervention comprising systematic monitoring practice, early warning scoring, an observation chart, and an algorithm for bedside management, implemented by interprofessional teaching, training, and optimization of communication and collaboration, may significantly reduce unexpected in-hospital mortality.

Occurrence and severity of agitated behavior after severe traumatic brain injury

Purpose To investigate the occurrence and severity of agitation in patients after severe traumatic brain injury (TBI), to identify predictors of agitation and to study interrater reliability for a translated version of the Agitated Behavior Scale (ABS). Design Prospective observational study. From November 1, 2006, through October 2007, 46 consecutive patients with TBI were included in the early rehabilitation phase following neurosurgical intervention. Agitated behavior was assessed by the ABS, which was implemented in clinical practice. Logistic regression analysis identified predictors of agitated behavior and Intra Class Correlation was used to analyze reliability. Findings Agitated behavior occurred in 41% of patients, of whom one third exhibited severely agitated behavior. The interrater reliability between three nurses was good to excellent. Conclusions Using ABS as a tool in care of patients with agitated behavior may be effective through working as a common language. Clinical Relevance We recommend the use of ABS as a routine assessment in early rehabilitation of patients with TBI.

Functional recovery after severe traumatic brain injury: an individual growth curve approach.

OBJECTIVE To examine person, injury, and treatment characteristics associated with recovery trajectories of people with severe traumatic brain injury (TBI) during inpatient rehabilitation. DESIGN Observational prospective longitudinal study. SETTING TBI rehabilitation units. PARTICIPANTS Adults (N=206) with severe nonpenetrating TBI admitted directly to inpatient rehabilitation from acute care. Participants were excluded for prior disability and intentional etiology of injury. INTERVENTIONS Naturally occurring treatments delivered within comprehensive multidisciplinary teams were recorded daily in 15-minute units provided to patients and family members, separately. MAIN OUTCOME MEASURES Motor and cognitive FIM were measured on admission, discharge, and every 2 weeks in between and were analyzed with individual growth curve methodology. RESULTS Inpatient recovery was best modeled with linear, cubic, and quadratic components: relatively steep recovery was followed by deceleration of improvement, which attenuated prior to discharge. Slower recovery was associated with older age, longer coma, and interruptions to rehabilitation. Patients admitted at lower functional levels received more treatment, and more treatment was associated with slower recovery, presumably because treatment was allocated according to need. Therefore, effects of treatment on outcome could not be disentangled from effects of case mix factors. CONCLUSIONS FIM gain during inpatient recovery from severe TBI is not a linear process. In observational studies, the specific effects of treatment on rehabilitation outcomes are difficult to separate from case mix factors that are associated with both outcome and allocation of treatment.

How Do Intensity and Duration of Rehabilitation Services Affect Outcomes From Severe Traumatic Brain Injury? A Natural Experiment Comparing Health Care Delivery Systems in 2 Developed Nations

OBJECTIVE To determine the effects of inpatient and outpatient treatment intensity on functional and emotional well-being outcomes at 1 year after severe traumatic brain injury (TBI). DESIGN Prospective, quasiexperimental study comparing outcomes in a U.S. TBI treatment center with those in a Denmark (DK) center providing significantly greater intensity and duration of rehabilitation. SETTING Inpatient and outpatient TBI rehabilitation. PARTICIPANTS Persons with severe TBI (N=274). INTERVENTIONS Inpatient rehabilitation interventions were counted daily by discipline. Outpatient treatments were estimated per discipline using a structured interview administered to patients, caregivers, or both, at 12 months. MAIN OUTCOME MEASURES FIM, Glasgow Outcome Scale-Extended, Disability Rating Scale, Participation Assessment with Recombined Tools-Objective, Perceived Quality of Life, Medical Outcomes Study 12-Item Short-Form Health Survey, Brief Symptom Inventory-18-item version. RESULTS Despite identical inclusion criteria, patient severity on admission was greater at the DK site. After adjustment for patient/injury characteristics, there were no site differences in either functional or emotional outcome at 12 months. Significantly more inpatient plus outpatient treatment was administered to DK patients than to those in the U.S. For functional but not emotional treatments, more severely impaired patients received higher doses. One-year outcomes were predicted by admission severity, age, employment, and other baseline characteristics. CONCLUSIONS Contrary to expectation, DK patients who received significantly more rehabilitation services during the year after severe TBI did not differ in outcome from their less intensively treated U.S. counterparts, after adjusting for initial severity. The negative association of functional treatment dose with extent of early disability suggests that dose was driven by unmeasured factors reflecting need for services. Improved measures of injury-related factors driving treatment allocation are needed to model the independent effects of treatment on outcomes.

CLINICALLY SIGNIFICANT CHANGES IN THE EMOTIONAL CONDITION OF RELATIVES OF PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY DURING SUB-ACUTE REHABILITATION

OBJECTIVE To investigate clinically significant change in the emotional condition of relatives of patients with severe traumatic brain injury during sub-acute rehabilitation. METHODS Participants were 62 pairs of relatives and patients. Relatives completed the anxiety and depression scales from the Symptom Checklist-90-R (SCL-90-R) when the patients were admitted to sub-acute rehabilitation and at discharge. Improvement in emotional condition was investigated using the following criteria: (i) statistically reliable improvement; and (ii) clinically significant change (CSC). RESULTS At admission, 53.2% and 58.1% of relatives had scores above cut-off values on the anxiety and depression scales, respectively. On the anxiety scale 69.7% of these experienced a reliable improvement according to the Reliable Change Index (RCI) and 45.5% also obtained CSC, as their end-point was below the cut-off value. On the depression scale the corresponding figures were 44.4% and 41.7%, respectively. When comparing relatives with and without CSC, we found that CSC in symptoms of anxiety was associated with significantly better functional improvement during rehabilitation and a shorter period of post-traumatic amnesia in the patients. CONCLUSION Of the relatives who reported scores above cut-off values on the anxiety and depression scales at patients admission, approximately 40% experienced CSC in anxiety and depression during the patients rehabilitation. Relatives of patients experiencing improvement during inpatient rehabilitation are more likely to experience CSC in anxiety.

Call for human contact and support: an interview study exploring patients’ experiences with inpatient stroke rehabilitation and their perception of nurses’ and nurse assistants’ roles and functions

Abstract Purpose: To describe patients’ experiences with inpatient stroke rehabilitation and their perception of nurses’ and nurse assistants’ roles and functions during hospitalisation. Materials and methods: In a qualitative study, 10 interviews with stroke patients were conducted, transcribed, and analysed using qualitative content analysis. Results: The patients’ experiences with inpatient stroke rehabilitation and their perception of nurses’ and nurse assistants’ roles and functions during hospitalisation were found to be related to one overall theme derived from 10 categories. As a recurring motif in the patients’ interviews, they experienced existential thoughts, and these thoughts unquestionably affected their experiences within the rehabilitation unit. These thoughts enhanced their need for human contact, thereby affecting their relationships with and perceptions of the nursing staff. Conclusion: The findings deepen our understanding of how patients experience inpatient rehabilitation. The patients struggled with existential thoughts and concerns about the future and therefore called for human contact and support from the nursing staff. They perceived the nursing staff as mostly polite and helpful, but were unclear about the nursing staff’s function in rehabilitation which, in the patients’ perspective, equals physical training. Implications for Rehabilitation Nursing staff need to pay attention to the patients’ needs, existential thoughts and concerns during inpatient rehabilitation. Meaningful goals for the rehabilitation of stroke patients are crucial, and it is vital that the patients commit to the goals. Patients expected polite and helpful nurses, but did not see them as therapeutic and active stakeholders, thus it is important that nursing staff present themselves as part of the interdisciplinary rehabilitation. There is a need for training and education of nursing staff, both pre and post graduate.

Maternal and Child Awareness and Expectations of Child Overweight

Objective: We investigated mothers’ and children’s assessments of body weight and their expectations about perceived body size in relation to overweight of the children. Methods: We performed a case-control study of 111 cases of overweight children and 149 controls of non-overweight children (mean age 8.1 years) and their mothers. All were examined and interviewed about their assessment of body weight and their perception of a normal, attractive and acceptable body size. Results: Case children were less able than control children to correctly assess their own body weight (p < 0.001), as were mothers of overweight children (MOC) to assess their children’s body weight (p < 0.001). The majority of mothers from both groups wished their children to have a normal body size, but 18% of MOC wished their children to have an overweight body size (p < 0.013). The majority of case children, control children and mothers found a normal body size for boys and girls to be the most attractive and socially acceptable, but more MOC found overweight among boys to be the most attractive (p = 0.006). Conclusion: Overweight children and their mothers show increased uncertainty in the assessment of overweight and obesity, but the perception of a normal, attractive and socially acceptable body size is not distorted.