Julie Pryor

Falls and fallers in traumatic brain injury (TBI) rehabilitation settings: an integrative review

Abstract Purpose: To critically appraise the research literature on the nature of falls and fallers in traumatic brain injury (TBI) rehabilitation settings. Method: An integrative review of the literature using thematic analysis was undertaken. Papers identified via a systematic search strategy were independently appraised by two reviewers. A data extraction instrument was developed to record results and to aid identification of themes in the literature. Critical Appraisal Skills Programme instruments were utilised to conduct a methodological critique of the papers included. Results: Thirteen studies were identified as having between 4% and 100% TBI patients in their study cohorts. From these papers, up to 71% of falls took place in a patient’s bedroom occurring in peaks and troughs over a 24-h period. With some divergent results, nine themes were identified describing faller characteristics including: (1) functional mobility impairments; (2) dizziness; (3) bladder and bowel dysfunction; (4) certain medications and number of medications prescribed; (5) executive functioning; (6) patient age; (7) fear of falling; (8) coma length following TBI; and (9) Functional Independence Measure (FIM™) total score, subscale scores and particular individual items. Conclusions: Being a multifactorial phenomenon, falls are a complex clinical issue. Despite the heterogeneity of diagnosis related groups (DRGs) in the included studies, TBI patients were identified as a high falls risk patient population in several studies. Implications for Rehabilitation Due to multisystem impairments, falls in the traumatic brain injury (TBI) rehabilitation context are a multifactorial and significant clinical issue. When interpreting and generalising results from research into falls, clinicians need to be mindful that falls and faller characteristics may be dependent on study setting and patient population. There is need for context specific research into faller characteristics following a TBI; particularly in relation to post-traumatic amnesia.

A Case-control Study Examining the Characteristics of Patients who Fall in an Inpatient Traumatic Brain Injury Rehabilitation Setting.

Objective:The purpose of the study was to describe the characteristics of patients who fall in the inpatient traumatic brain injury (TBI) rehabilitation setting. Setting:Specialized inpatient TBI rehabilitation unit. Participants:Fifty-four patients with history of falls and 55 nonequivalent patients without history of falls. Design:Retrospective nonequivalent case-control study. Main Measures:The Functional Independence Measure, Glasgow Coma Scale, Westmead Post-traumatic Amnesia Scale, demographic and functional characteristics, and behavior and medication variables. Results:No significant difference between patients with and without history of falls for age, sex, medication class or total number of medications administered on admission, and median admission Westmead Post-traumatic Amnesia Scale score was observed. Patients with history of falls had a significantly longer duration of post-traumatic amnesia, rehabilitation length of stay, and lower mean total admission Functional Independence Measure score and median Glasgow Coma Scale score at the time of injury. Patients with history of falls were more than 10 times more likely than patients without history of falls to require assistance on admission for activities of daily living, transfers, and continence/toileting. Neurobehaviors including noncompliance and anosognosia were significantly associated with patients with history of falls. Conclusions:A patient in the rehabilitation setting with a more severe TBI characterized by multisystem impairments is at an increased risk of falling, whereas some traditional fall risk factors were not associated with patients who fall. Rehabilitation settings should consider cohort-specific fall risk profiling. The Ontario STRATIFY Falls Risk Screening Tool is perhaps not the best tool to screen for falls in this inpatient population.

Predicting falls: considerations for screening tool selection vs. screening tool development

AIMS This paper discusses considerations for falls risk screening tool selection vs. the need to develop new tools. BACKGROUND Inpatient falls are a complex patient safety issue that represent a significant burden for the healthcare system. In the inpatient context, falls risk screening tools are most often used for predicting falls, but in some populations assessment tools are more suited, however in others, a clinicians clinical judgment may be just as effective. Limited external validity is a central issue with falls risk screening tools when used in different populations than the original study. There is clinical need for guidance regarding screening tool selection vs. the need to development new tools and how to effect change in relation to the prediction of falls. DESIGN Discussion paper. DATA SOURCES This discussion paper is based on our own experiences and research and is supported by literature. IMPLICATIONS FOR NURSING This paper provides clinicians with a better understanding of considerations for falls risk screening tool selection vs. the need to develop new tools. In doing so, it provides clinicians guidance on how to critique the efficacy and utility of their falls risk screening tool. This paper equips clinicians for effecting change in relation to the prediction of falls. CONCLUSION Falls risk prediction is a particularly complex patient safety issue. Clinicians need to be aware of the limitations of their tool used to predict falls.

An examination of patient characteristics that contribute to falls in the inpatient traumatic brain injury rehabilitation setting

Abstract Purpose: To examine patient characteristics that contribute to falls in the inpatient traumatic brain injury (TBI) rehabilitation setting. Method: A three-round modified Delphi technique that engaged a multidisciplinary panel of 11 health experts was used. Group median score and disagreement index were used to measure agreement between participants about patient characteristics that contribute to falls. Results: All panel members participated in each questionnaire round. Several factors (such as, a fall since admission to hospital, cognitive impairment and motor impairment) were interpreted as contributing to falls in the TBI rehabilitation setting; but others were not (such as, antecedent falls and medication class). Some salient themes identified in participants’ comments include: (1) the need to differentiate between what is an activity (e.g., mobility) and impairment (e.g., ataxic gait)-based falls risk factor; (2) over the course of a 24-h day and inpatient rehabilitation stay, a patient’s risk of falling is not linear; and (3) Functional Independence Measure and predictors of TBI severity have varied sensitivity in predicting falls. Conclusions: In the TBI rehabilitation setting, falls result from a combination of many patient factors. Some factors are believed to be more relevant at different time points over a 24-h day and, at particular times during the course of a patient’s rehabilitation. The utility and statistical significance of risk factor of falls are both important concepts when determining their clinical relevance. Implications for Rehabilitation Clinicians should be mindful that the rehabilitation context can present unique falls risk factors, some of which emerge at different times during a patient’s rehabilitation. Over the course of a patient’s rehabilitation their risk of falling is not linear; therefore, rehabilitation clinicians should undertake periodic falls risk screening. The utility value and statistical significance of falls risk factors are both important aspects to consider when determining their clinical utility.

The characteristics of falls in an inpatient traumatic brain injury rehabilitation setting

AIMS AND OBJECTIVES To describe the nature of falls in an inpatient traumatic brain injury rehabilitation setting. BACKGROUND Falls are the most frequently recorded patient safety incident in the inpatient context. However, higher rates of falls are reported in rehabilitation settings compared to acute care settings. In the rehabilitation setting, patients with a traumatic brain injury have been identified as at a high risk of falling. However to date, research into the nature of falls involving this patient population is limited. DESIGN Five-year retrospective cohort study design. METHODS Falls data from an inpatient traumatic brain injury rehabilitation unit were retrieved from the NSW Ministry of Health Incident Information Management System and patient clinical notes; nursing shift data were retrieved from the local rostering system. RESULTS The fall rate was 5·18 per 1000 patient bed days. Over a 24-hour period falls (n = 103) occurred in a trimodal pattern. The median fall free period after admission was 14 days and 22% of traumatic brain injury patients had at least one fall. 53% of falls occurred in the patients bedroom and 57% were attributed to loss of balance. At time of fall, 93% of fallers had impaired mobility and 85% required assistance for transfers. CONCLUSION Falls within inpatient traumatic brain injury rehabilitation are a significant and complex clinical issue. While many patients continued to be at risk of falling several months after admission, a repeat fallers first fall occurred earlier in their admission than a single fallers. RELEVANCE TO CLINICAL PRACTICE Generic falls prevention measures are insufficient for preventing falls in the brain injury rehabilitation population. Falls prevention initiatives should target times of high patient activity and situations where there is decreased nursing capacity to observe patients. Rehabilitation clinicians need to be mindful that a patients risk of falling is not static and in fact, may increase over time.

The psychometric properties of a modified client-centred rehabilitation questionnaire in an Australian population

Abstract Purpose: To identify the face validity of the Client-Centred Rehabilitation Questionnaire (CCRQ) and to determine the internal consistency reliability and factorial validity of a modified CCRQ. Materials and methods: This study was conducted in 2 phases. Phase 1 consisted of 5 focus groups to examine the face validity of the CCRQ, resulting in the development of a modified CCRQ. Phase 2 consisted of a multi-site cross sectional survey, involving 408 rehabilitation inpatients, to examine the internal consistency reliability and factorial validity of the modified CCRQ. Chronbach’s coefficient alpha, composite reliability coefficients, and single factor congeneric models with maximum likelihood confirmatory factor analysis were used. Results: Based on feedback from the focus groups the CCRQ was modified with the word ‘rehabilitation’ replacing ’program’ throughout. The three negatively worded items had poor item-to-total correlations of <0.3. Removing these items resulted in subscale alphas of 0.74–0.86 and composite reliability coefficients of 0.66–0.87. Six of the seven sub-scales had good model fit and the other one had moderate fit following removal of the negatively worded item. Conclusions: This study supports the underlying structure and internal consistency of the modified CCRQ. Implications for Rehabilitation Person-centredness is an important characteristic of effective rehabilitation service delivery that warrants measurement. A modified Client-Centered Rehabilitation Questionnaire has been found to have good face validity, internal consistency reliability and construct validity in an Australian sample of inpatient rehabilitation patients. Use of a modified Client-Centered Rehabilitation Questionnaire incorporating the 7 sub-scales in the original Client-Centered Rehabilitation Questionnaire is supported for use in inpatient rehabilitation. Both sub-scale and item level responses to the modified Client-Centered Rehabilitation Questionnaire provide detailed feedback to rehabilitation service providers looking for opportunities to make their services more person-centred.

Insights into the nature of female sexuality from the perspective of female stroke survivors

Abstract Aim: The purpose of this study was to provide insights into the nature of female sexuality from the perspective of one group of women following a stroke. Method: Nine female stroke survivors from metropolitan and surrounding districts of Sydney, Australia participated in face to face semi-structured interviews about sexuality after stroke. The age of stroke survivors ranged from 31 to 70 years. The majority of females identified as heterosexual (n = 8). Length of time between stroke and interview ranged from 1 year, 2 months to 15 years, 9 months. The interviews were digitally recorded and transcribed. Braun and Clarke’s 6 steps of thematic analysis were used to answer the question: what is the nature of female sexuality? Results: The women in this study saw themselves as sexual beings and communicated a tacit knowledge of the nature of female sexuality. Female sexuality was described as having two distinct, but related aspects, that captured “the being” and “the doing” of female sexuality. These encompassed a woman’s way of being female and expressions of that way of being through engagement in specific activities. Conclusions: The findings of this study underline the importance of addressing sexuality as part of rehabilitation and provide some guidance about what might be important to address. Implications for Rehabilitation Sexuality should be addressed by clinicians as part of person-centred rehabilitation. Understanding “the being” and “the doing” of female sexuality is a pre-requisite for understanding female sexuality post-stroke. Idealised constructions of being female formulated pre-stroke may continue to be points of reference for self-assessment post-stroke, hence need to be understood when seeking to support a positive sense of self. The influence of significant others on the self-esteem of females may be important to consider for some individuals post-stroke.

Spirituality and its relationship with positive adjustment following traumatic brain injury: a scoping review

ABSTRACT Objective: To identify the extent of research which has investigated spirituality or closely related meaning-making constructs after traumatic brain injury (TBI). Design: A scoping review was employed to capture the broadest possible range of studies. Methods: Search terms ‘spirituality’, ‘religion’, ‘beliefs’, ‘faith’, ‘hope’, ‘meaning’, ‘purpose in life’, ‘sense of coherence’ and ‘posttraumatic growth’ were combined with search terms related to TBI. Findings were restricted to empirical studies published in English, in peer-reviewed journals and conducted over a 20-year period between 1997 and 2016. Results: Nine studies were identified, conducted in the USA, Canada and the UK. These included eight quantitative studies and one qualitative study. Definitions and measurement of spirituality varied widely among the studies. Findings revealed that spirituality was closely related to a number of positive outcomes following TBI including psychological coping, physical health, mental health, productivity, life satisfaction, functional independence and posttraumatic growth. Conclusions: The limited research conducted into spirituality following TBI suggests it can play an important role in the recovery process. Further research is necessary to identify the particular spiritual needs of this population, and how clinical staff may be supported to address such needs.