Dementia care practices among community healthcare workers in Vietnam: a qualitative descriptive study.

BACKGROUND: Vietnam is one of the most rapidly aging countries in the world and the likelihood that someone may have dementia rises dramatically as the population ages. Although caring for persons living with dementia is important, little is known about the circumstances under which community healthcare professionals in Vietnam provide dementia care. This study aimed to describe the practice of caring for persons with dementia among community healthcare professionals in Vietnam. METHODS: This qualitative descriptive study was conducted with 23 community healthcare professionals recruited from 10 primary healthcare centers, representing 10 of 24 districts in Ho Chi Minh City, Vietnam. Participants were physicians (n = 11), physician's assistants (n = 8) and community nurses (n = 4). Data were collected through in-depth face-to-face semi-structured interviews. Interview data were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: The mean age of the 23 participants was 44.6 ± 8.8 years; most were female (n = 16, 69.6%); and the mean time of working in the field of dementia care was 15.9 ± 8.4 years. Analysis of the interview data revealed five categories, which informed how care was provided: 1) Knowledge about dementia and its prevalence among older adults; 2) Identification of dementia in Vietnam; 3) Lack of attention to early diagnosis of dementia and difficulty in providing continuous care; 4) Dependence on family members for prompt and continuous care; and 5) challenges to providing dementia care. Despite having knowledge about dementia, some healthcare professionals incorrectly viewed dementia as an inevitable part of the ageing process. Participants reported that their limited training and practical experience in caring for persons with dementia caused a lack of confidence in dementia care. CONCLUSIONS: The quality of care provided to persons living with dementia was negatively impacted by the limited training of healthcare personnel. The diagnosis, treatment, and provision of supportive services to persons living with dementia and their families are substantial challenges for the Vietnamese healthcare system. It is crucial to initiate and cultivate dementia care education programs aimed at expanding curricula for physicians, physicians' assistants, and nurses.

Predictors of Abnormal Sleep Duration in Older Adults With Hip Fracture and Diabetes.

BACKGROUND: Abnormal sleep duration affects recovery in older adults with hip fracture and diabetes mellitus (DM) negatively. However, the predictors of abnormal sleep duration in this population remain unknown. PURPOSE: This study was designed to explore the predictors of abnormal sleep duration among older adults with hip fracture and DM within 6 months of hospital discharge. METHODS: A longitudinal study using secondary data from a randomized controlled trial was implemented. Data on fracture-related factors (diagnosis, surgical methods) were collected from medical charts. Information on the duration of DM, methods of DM control, and diabetes-related peripheral vascular disease was collected by asking simple questions. Diabetic peripheral neuropathy was assessed using the Michigan Neuropathy Screening Instrument. Sleep duration outcomes were determined using data collected from a SenseWear armband. RESULTS: Having more comorbidities (OR = 3.14, p = .04), having undergone open reduction (OR = 2.65, p = .005), having undergone closed reduction with internal fixation (OR = 1.39, p = .04), and having DM (OR = 1.18, p = .01), diabetic peripheral neuropathy (OR = 9.60, p = .02), or diabetic peripheral vascular disease for a longer duration (OR = 15.62, p = .006) were all associated with a higher risk of abnormal sleep duration. CONCLUSIONS: The findings indicate that patients with more comorbidities or who had undergone internal fixation, had a long DM history, or had complications are more likely to have abnormal sleep duration. Thus, greater attention should be focused on the sleep duration of diabetic older adults with hip fracture who are affected by these factors to achieve better postoperative recovery.

Factors associated with the intention to engage in care planning among persons with mild cognitive impairment and dementia.

This study examined factors associated with the intention to engage in advance care planning among persons with cognitive impairment. This cross-sectional study recruited 116 persons with cognitive impairment by convenience sampling from two teaching hospitals in Northern Taiwan from November 1, 2018, to December 31, 2020. Fewer than 50% of the participants intended to engage in advance care planning, and less than 10% signed the living will for hospice and palliative care. Multivariate linear regression determined factors influencing advance care planning intention included education level, a proxy signed do-not-resuscitate document, belief that family members would provide a signed do-not-resuscitate at their end-of-life, and necessity of explaining future care in advance. It is recommended to popularize advance care planning education and ensure the rights of persons with cognitive impairment to enable them to fully participate in their own care plans through family-centered advance care planning.

An Outpatient-Based Training Program Improves Family Caregivers' Preparedness in Caring for Persons With Mild Cognitive Impairment: A Randomized Controlled Trial.

BACKGROUND: Little is known regarding the effects of training programs on family caregivers of older persons with mild cognitive impairment because of the significant differences in outcome variables measured in the various studies in the literature. PURPOSE: This study was designed to examine the effects of an outpatient-based caregiver training program on the preparedness, health-related quality of life, and depressive symptoms of participants responsible for caring for older persons with mild cognitive impairment. METHODS: A randomized clinical trial was implemented. Of the 54 family caregiver participants who provided complete and valid data, 28 and 26 were assigned to the experimental and control groups, respectively. The experimental group participated in a researcher-developed training program that provided information on mild cognitive impairment, strategies for maintaining and promoting cognitive function in persons with mild cognitive impairment, managing their own and their care recipients' healthcare, and managing their own emotional support and stress. Outcomes (caregiver preparedness, health-related quality of life, and depressive symptoms) were assessed before the start of the training program (baseline) and at 1, 3, and 6 months after completion of the program. RESULTS: After controlling for baseline cognitive function of the care recipients and of caregiver preparedness, the experimental group was shown to be significantly less prepared than the control group at baseline (ß = -1.41, p = .031) and better prepared than the control group at all three posttests (group differences: 1.3, 1.53, and 4.24, respectively), with the difference at the third posttest (6 months) reaching statistical significance (p = .008). No impact of the intervention on caregiver depressive symptoms or health-related quality of life was found at posttest. CONCLUSIONS: The training intervention in this study was found to increase the perceived preparedness of the family caregiver participants to handle various aspects of providing care to persons with mild cognitive impairment. However, no changes were found in depressive symptoms or health-related quality of life.

Enhancing Nurse-Robot Engagement: Two-Wave Survey Study.

BACKGROUND: Robots are introduced into health care contexts to assist health care professionals. However, we do not know how the benefits and maintenance of robots influence nurse-robot engagement. OBJECTIVE: This study aimed to examine how the benefits and maintenance of robots and nurses' personal innovativeness impact nurses' attitudes to robots and nurse-robot engagement. METHODS: Our study adopted a 2-wave follow-up design. We surveyed 358 registered nurses in operating rooms in a large-scale medical center in Taiwan. The first-wave data were collected from October to November 2019. The second-wave data were collected from December 2019 to February 2020. In total, 344 nurses participated in the first wave. We used telephone to follow up with them and successfully followed-up with 331 nurses in the second wave. RESULTS: Robot benefits are positively related to nurse-robot engagement (ß=.13, P<.05), while robot maintenance requirements are negatively related to nurse-robot engagement (ß=-.15, P<.05). Our structural model fit the data acceptably (comparative fit index=0.96, incremental fit index=0.96, nonnormed fit index=0.95, root mean square error of approximation=0.075). CONCLUSIONS: Our study is the first to examine how the benefits and maintenance requirements of assistive robots influence nurses' engagement with them. We found that the impact of robot benefits on nurse-robot engagement outweighs that of robot maintenance requirements. Hence, robot makers should consider emphasizing design and communication of robot benefits in the health care context.

How do three components of professional commitment influence nurse-reported patient-centred care and care quality?

AIMS AND OBJECTIVES: To test how the three components of professional commitment (i.e. affective, continuance and normative professional commitment) are associated with nurse-reported patient-centred care and care quality. BACKGROUND: Patient-centred care and care quality are the two critical care outcomes. However, no study has yet examined how the three components of professional commitment are related to nurse-reported patient-centred care and care quality, showing a research gap. DESIGN: This study adopted a two-wave design (first wave in 2017 and second wave in 2019), which is known to reduce the possibility of reverse causality, and which was conducted in a large hospital in Northern Taiwan. METHODS: Proportionate random sampling was used. Full-time nurses were surveyed, while nursing students, interns, nurse practitioners and nursing supervisors were excluded. The first wave included 524 nurses, and 438 nurses were retained in the second wave. We used confirmatory factor analysis to verify the psychometric properties of the measures. Structural equation modelling was used to implement hypothesis testing. We used the Professional Commitment Scale of Meyer et al. (Journal of Applied Psychology, 1993, 78, 538), the Patient-Centered Care Scale of Laird-Fick et al. (Patient Education and Counseling, 2011, 84, 90) and the Care Quality Perceptions Scale of Teng et al. (Journal of Nursing Management, 2010, 18, 275). The STROBE statement was chosen as the EQUATOR checklist. RESULTS: Affective professional commitment was positively associated with nurse-reported patient-centred care (ß = .18, p = .002 and .01), which was positively associated with nurse-reported care quality (ß = .85, p < .001). Affective and normative professional commitment were also positively associated with nurse-reported care quality (ß = .17, p < .001). CONCLUSIONS: Our findings offer insights for nursing managers that nurses' affective and normative professional commitment could help upgrade care outcomes. Hospital managers should consider professional commitment as relevant to their workforce. RELEVANCE TO CLINICAL PRACTICE: Nursing managers could publicise reports documenting nurses' significant contributions to public health. This could strengthen affective professional commitment among nurses.

How robots impact nurses' time pressure and turnover intention: A two-wave study.

AIMS: To examine the relationships among effort ensuring robots' smooth operation (EERSO), time pressure, missed care, and nurses' turnover intention, and how robot performance moderates such relations. BACKGROUND: Robots may reduce nurses' workload but typically still require some effort of nurses for robots' smooth operation. However, the negative impact of EERSO on nurses' workplace outcomes is unknown. METHODS: This study used a two-wave follow-up design. Data were collected in a medical center in Taiwan, with first wave collected in 2019 and second wave collected between 2019 and 2020. A total of 331 participants were followed through the two waves. RESULTS: EERSO is positively linked to missed care and time pressure. Time pressure is also positively linked to missed care and turnover intention. Positive robot performance weakens the positive link between EERSO and time pressure. CONCLUSION: Using robots may help reduce nurses' workload, but it also requires nurses' efforts to maintain robots' continuous operation, that is, EERSO. It may adversely impact nursing professional workplaces. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should reduce nurses' time pressure whilst suggest hospital managers to seek robots that require minimal EERSO.

Relationship between psychological ownership of the nursing profession and turnover intention: A correlational survey among Taiwanese nurses.

AIMS: The aim of this study is to examine the relationship between psychological ownership of the nursing profession and turnover intention. BACKGROUND: There is a severe shortage of nurses worldwide. Research is needed to understand how nurses' intention to leave hospitals and the nursing profession can be alleviated. METHODS: This study adopted a cross-sectional design and a survey method. Proportionate random sampling was used to ensure sample representativeness. This study surveyed 430 registered nurses in a medical centre in Taiwan between December 2021 and January 2022. We used Turnover Scale and Self-Efficacy Scale and developed Having a Place Scale. RESULTS: Psychological ownership comprises three dimensions: self-efficacy, nurse identity and 'having a place' in the nursing profession. This research is the first to examine how these three dimensions of psychological ownership of the nursing profession are related to the intention to leave a hospital or the nursing profession. Self-efficacy and 'having a place' are negatively related to nurses' intention to leave a hospital (r = -.23 and -.31, p < .001). Nurse identity is negatively related to nurses' intention to leave the nursing profession (r = -.38, p < .001). Intention to leave a hospital is positively related to nurses' intention to leave the profession (r = .76, p < .001). CONCLUSION: The findings provide novel insights for retaining nurses. Nurse managers could use strategies such as including nurses in making workplace decisions and encouraging them to personalize their workspace. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can enhance nurses' self-efficacy and sense of 'having a place' to retain nurses in hospitals, while enhancing nurse identity to retain nurses in the profession.

Functional Status in Older Persons After Hip Fracture Surgery: A Longitudinal Study of Indonesian Patients.

BACKGROUND: Hip fractures are one of the most serious injuries affecting older adults. Evidence-based knowledge regarding the functional status of older persons after hip fracture can provide information critical for developing effective continuous-care and rehabilitation programs. PURPOSE: This study was developed to examine the post-hospital-discharge outcome measures and predictors of functional status in older adults in Indonesia after hip fracture surgery. METHODS: The functional status of 109 patients discharged from an orthopedic hospital in Indonesia after hip fracture surgery was evaluated in this prospective cohort study. Functional status was evaluated using measures of physical and independent activities of daily living (PADL and IADL, respectively) at 1, 3, and 6 months postdischarge. Predictors of changes in functional status, including age, length of hospital stay, comorbidity, prefracture walking ability, type of surgery, status of depression and nutrition, type of insurance, and residential status (urban vs. rural), were also examined. Data were analyzed using generalized estimating equations. RESULTS: Significant improvements in PADL were found at 3 and 6 months, and significant improvements in IADL were found at 6 months. Predictors of poor outcomes found in this study included age, a dependent prefracture walking ability, depression, and having public health insurance. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The findings of this study support the effectiveness of using presurgery assessments to identify individuals at a higher postdischarge risk of having poor PADL and IADL outcomes. Home nursing or subacute rehabilitation is recommended to improve and maintain functional status in older persons after hip fracture surgery. In addition, interventions and rehabilitation should take into consideration different recovery periods for PADL and IADL after hospital discharge after hip fracture surgery.

Trajectory of adherence to home rehabilitation among older adults with hip fractures and cognitive impairment.

This study aimed to identify different trajectories of adherence to home rehabilitation for older adults with hip fracture and cognitive impairment, to examine associations between different adherence trajectories and postoperative recovery outcomes, and to explore the predictors of adherence trajectories. Group-based trajectory modeling showed two adherence trajectories: low (39.06%) and high (60.94%) adherence. The high adherence group had better activities of daily living (ß=11.77, p<.001), instrumental activities of daily living (ß=0.56, p<.01), femoral muscular strength (ß=3.35, p<.01) on the fractured side and quality of life (ß=-0.81, p=.02) than the low adherence group. Participants who established exercise habits (OR=6.49, p<.01) and consulted a physical therapist (OR=4.29, p=.03) during hospitalization were more likely to be in the high adherence group.

Reducing turnover intention to improve care outcome: A two-wave study.

AIMS: To ascertain how professional turnover intention impacts nurse-assessed care outcomes, including patient-centered care and care quality. BACKGROUND: Patient-centered care and care quality are critical to care outcomes. However, we do not know whether care outcomes would be improved by reducing nurses' professional turnover intention. DESIGN: We implemented a two-wave correlational follow-up design. METHODS: This study was conducted in a large-scale general in Taiwan during January and February 2018, and January and February 2019. We successfully obtained responses from 448 nurses in 2018 and subsequently followed up (in 2019). Most were women (97.5%), reflecting the profile of the local nurse population. Structural equation modeling was used to test hypotheses. RESULTS: Our findings indicate that nurses' professional turnover intention is negatively related to nurse-assessed, patient-centered care. Nurses' professional turnover intention is also negatively related to all the five perceptions of nurse-assessed care quality: that is, assurance, reliability, responsiveness, empathy, and tangibles. Moreover, years of working as a nurse is also positively related to nurse-assessed, patient-centered care and all the five perceptions of nurse-assessed care quality. CONCLUSION: This study examined nurses' professional turnover intention as an antecedent of nurse-assessed, patient-centered care and care quality. Our study shows that professional turnover intention may predict care outcomes. Overall, our study suggests that professional turnover intention not only impacts workforce stability but also impacts health-care outcomes. IMPACT: Our findings suggest that reduction of nurses' turnover intentions could benefit care outcomes. Hospital managers should know that nurses' turnover negatively impacts care outcomes.

Impact of professional commitment on professional capability improvement and care quality dimensions: A multi-wave study.

AIMS AND OBJECTIVES: To examine how the three dimensions of professional commitment impact professional capabilities improvement and five key dimensions of care quality. BACKGROUND: While professional commitment is known to retain nurses, we do not know how its three dimensions-affective, continuance and normative commitment-formulate five care quality dimensions: assurance, reliability, responsiveness, empathy and tangibles. DESIGN: We used a three-wave, follow-up design to follow a sample of nurse participants. METHODS: We collected responses from 430 nurses who worked for a medical centre in Northern Taiwan during 2017-2019. Most (78.9%) of the respondents had an age between 20-40 years. We used Professional Commitment Scale of Meyer et al. (Journal of Applied Psychology, 1993, 78, 538) and Care Quality Scale of Teng et al. (Journal of Nursing Scholarship, 2010, 41, 301). STROBE statement was chosen as EQUATOR checklist. RESULTS: We found that affective professional commitment is positively related to intention to improve professional capabilities, action to improve professional capabilities and thus to four dimensions of care quality: assurance, reliability, responsiveness and empathy. CONCLUSIONS: Our model explains how three key dimensions of professional commitment contribute to care quality. Our findings support the link between action to improve professional capabilities and dimensions of care quality. RELEVANCE TO CLINICAL PRACTICE: Nursing managers can inform nurses of positive patient feedback, thus enhancing nurses' affective professional commitment, which would likely motivate their devotion to upgrading their professional capabilities, thus further contributing to the quality of the care they provide.

Consistency in End-of-Life Care Preferences Between Hospitalized Elderly Patients and Their Primary Family Caregivers.

PURPOSE: This study explored the consistency between preferences for end-of-life care for elderly hospitalized patients and their primary caregivers and predictors of consistency. PATIENTS AND METHODS: This cross-sectional correlational study recruited 100 dyads of elderly hospitalized patients and their primary caregivers from a medical center in Central Taiwan. A structural questionnaire about preferences for seven end-of-life medical treatment options involved cardiopulmonary resuscitation, intravenous therapy, nasogastric tube feeding, intensive care unit, blood transfusion, tracheotomy, and hemodialysis. RESULTS: The consistency was 42.28% for preferences of end-of-life medical care between patients and caregivers. The Kappa values for seven life-sustaining medical treatments ranged from 0.001 to 0.155. Logistic regression showed that the predictors of consistency for preferences of treatment were: a patient with a signed living will (odds ratio [OR] = 6.20, p<0.01) and a male family caregiver (OR= 0.23, p<0.01) for cardiopulmonary resuscitation; a patient who visited relatives in the intensive care unit (OR= 2.94, p< 0.05) and a spouse caregiver (OR= 3.07, p< 0.05) for nasogastric tube feeding; a spouse caregiver (OR=3.12, p<0.05) and a caregiver who visited the intensive care unit (OR= 5.50, p<0.01) for tracheotomy; and a spouse caregiver (OR= 2.76, p<0.05) and a caregiver who visited the intensive care unit (OR= 4.42, p<0.05) for hemodialysis. CONCLUSION: End-of-life medical treatment preferences were inconsistent between patients and family caregivers, which might be influenced by Asian culture, the nature of the relationship and individual experiences. Implementation of advance care planning that respects the patient's autonomy and preferences about end-of-life care is recommended.

Influence of headaches on nurse intentions to leave the profession and the hospital: a cross-sectional survey.

Background: Few studies had examined whether headaches impact emotional exhaustion among nurses, and nurses' intentions to leave the hospital (current employer) or nursing profession. Objectives/Aims/Hypotheses: To examine the impact of headaches on nurses' self-efficacy and emotional exhaustion, and nurses' intentions to leave the hospital or the profession. Design: A cross-sectional survey design with proportional random sampling was used to collect data. Methods: This study was conducted in one medical center in Taiwan during February and March 2017. Inclusion criteria were full-time registered nurses. Totally, 570 full-time registered nurses were surveyed. Results: Nurse headaches were positively related to emotional exhaustion, which was positively related to the intention to leave the hospital, further positively related to the intention to leave the profession. Self-efficacy was negatively related to the intention to leave the profession. Impact statement and Conclusions: Our findings advise nurse managers to take actions to reduce nurses' headaches.

Job Demands and the Effects on Quality of Life of Employed Family Caregivers of Older Adults With Dementia: A Cross-Sectional Study.

BACKGROUND: Employed family caregivers are affected by job demands, which can affect quality of care provided to recipients. However, it is important to understand how job demands and the ability to reconcile employment and caregiving influence family caregivers' quality of life. PURPOSE: The aim of this study was to examine the extent to which job demands influenced quality of life for employed family caregivers of older adults with dementia in Taiwan. METHODS: This cross-sectional study analyzed secondary data from self-completed questionnaires collected from December 2010 to December 2011. Participants were 214 employed family caregivers of older adults with dementia in Taiwan. How job demands and caregiving influence quality of life was determined with hierarchical multiple regression analysis. Job demands included working hours, workplace inflexibility, work inefficiency, and difficulty in reconciling work and family caregiving. RESULTS: After controlling for demographics, caregiving resources, and caregiving role demands, employed family caregivers of older adults with dementia with fewer working hours and greater work efficiency reported significantly better quality of life (ß = -.130, p = .049; ß = -.263, p < .001) than those with more working hours and less work efficiency. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Employed family caregivers of older adults with dementia who had more working hours and less work efficiency had a greater likelihood of poorer quality of life than other employed family caregivers. Clinicians could use these findings to identify groups at high risk for poor quality of life. We suggest developing policies and interventions to help employed family caregivers of older adults with dementia to reduce working hours and improve work efficiency in order to improve quality of life, which could also improve quality of care for recipients.

Changes in Health-Related Quality of Life for Older Persons With Cognitive Impairment After Hip Fracture Surgery: A Systematic Review.

BACKGROUND: Hip fractures in persons with cognitive impairments represent a major public health issue in older populations that often results in poor health-related quality of life (HRQoL). PURPOSE: The aim of this systemic review was to examine the changes in HRQoL in older, cognitively impaired patients with hip fracture who had received surgical treatment. METHODS: A literature search of PubMed, Scopus, MEDLINE, PsycINFO, and CINAHL (EBSCO) databases was conducted for studies published up to July 2018 that addressed the issue of HRQoL in cognitively impaired patients with hip fracture after surgery. Studies that met the following criteria were included: Patients with hip fracture were over 60 years old and had cognitive impairment or dementia, patients had undergone hip fracture repair surgery, HRQoL was determined using standardized questionnaires, a descriptive or interventional methodology was used, and the full-text article was available in English. RESULTS: A primary search of databases yielded 1,528 studies, 621 duplicates were removed, and the remaining 907 abstracts were screened. Thirty-four full-text articles were deemed relevant for full review; of these, 10 articles met the criteria for inclusion in the review. Cognitive impairment was found to impact negatively on the patients' HRQoL after hip fracture surgery (n = 809). Severity of cognitive impairment was correlated with deterioration in HRQoL after hospital discharge. When compared with prefracture measures of HRQoL, the greatest deterioration in HRQoL postsurgery occurred during the first 4 months after discharge. Impacts on HRQoL for patients with cognitive impairment at later time points differed depending on type of hip fracture and type of surgical treatment. However, for most of the patients, HRQoL remained relatively unchanged at 6, 12, and 24 months postdischarge. CONCLUSIONS: We recommend nursing care interventions for older persons with cognitive impairment be initiated immediately after surgery for hip fracture to prevent a significant decline in HRQoL. Further examination of interventions that are effective in maintaining HRQoL for these patients such as interdisciplinary care is necessary. In addition, the influences of hip fracture type and surgical approach on changes in HRQoL suggest a need for further investigations to determine what contributed to the observed inconsistencies in the outcomes.

Adherence to Home-Based Rehabilitation in Older Adults With Diabetes After Hip Fracture.

BACKGROUND: Adherence to rehabilitation is beneficial to patients with hip fracture. However, the relationships between different levels of adherence and postoperative recovery among older adults after hip fracture have not been addressed thoroughly in the literature. OBJECTIVES: The aims of this study were to explore the trajectories of adherence to home-based rehabilitation during the 12-month period after hospital discharge and to examine the effects of adhering to prescribed home-based rehabilitation on postoperative recovery of physical functions. METHODS: We employed a secondary data analysis, and 88 hip-fractured older adults with diabetes were recruited. The Chinese Barthel Index was used to measure daily physical functions, a goniometer was used to measure range of motion, and the MicroFET2 dynamometer was used to measure muscle power. Adherence was measured as the rate of adherence to the suggested frequency of home-based rehabilitation activities. RESULTS: Adherence to home-based rehabilitation decreased over time. The high-adherence group was more likely to recover prefracture physical functions than was the low-adherence group, and the high-adherence group had better self-care abilities, greater range of motion for ankle extension, and higher muscular strength on both adduction and abduction than did the low-adherence group. DISCUSSION: The results of our study suggest that patients adhere to more than 50% of prescribed rehabilitation. Future studies should continue to explore interventions to enhance rehabilitation adherence after hospital discharge.