"It's been a long hard road": challenges faced in the first three years following traumatic brain injury.

PURPOSE: There is limited qualitative research exploring challenges experienced following severe traumatic brain injury (TBI). We investigated challenges to recovery identified by individuals who sustained severe TBI three years earlier or their close others (COs), as well as suggestions for managing these challenges. MATERIALS AND METHODS: Nine participants with TBI and 16 COs completed semi-structured interviews. Using reflexive thematic analysis, challenges were identified across several timeframes (i.e., at the injury, acute care, inpatient rehabilitation, outpatient rehabilitation, and at home/other location). RESULTS: Challenges experienced across all timeframes included: lack of information and poor communication, pre-existing conditions, missed injuries, and issues with medical staff, and continuity of care. From acute care onwards, there were TBI-related consequences, issues with coping and emotional adjustment, negative outlook, insufficient treatment, lack of support for COs, and issues with compensation and funding for rehabilitation needs. Some challenges were unique to a specific timeframe (e.g., over-stimulating ward setting during acute care, and limited or unsupportive families once injured individuals went home). Suggestions for managing some of the challenges were provided (e.g., information provision, having peer supports). CONCLUSION: Suggestions should be considered to promote successful outcomes following severe TBI.IMPLICATIONS FOR REHABILITATIONRecovery following a severe traumatic brain injury can be hindered by challenges, such as poor communication, limited information provision, injury-related consequences, limited services and emotional support for the injured individual and their Close Others, and a need for education of the broader community about traumatic brain injury.Suggestions for managing these challenges (e.g., peer supports; services closer to home) could be used to inform clinical guidelines that could be used in a rehabilitation context.These suggestions ultimately aim to improve the post-injury experience and outcomes of individuals with traumatic brain injury and their Close Others.

Traumatic injury survivors' perceptions of their future: a longitudinal qualitative study.

Aim: Persistent disability following traumatic injuries can disrupt future plans and create uncertainty about how to mitigate future impacts. It is unknown how or whether perceptions of the future change in the years after injury. Therefore, the aim of this study was to explore trauma survivors' perceptions of their future over time.Methods: A longitudinal qualitative study, nested within a population-based longitudinal cohort study, was undertaken in Victoria, Australia with survivors of serious injury. Sixty-six seriously injured adults (≥16 years) without severe neurotrauma were interviewed at 3 years post-injury (n = 66), and re-interviewed at 4 (n = 63) and 5 years (n = 57) post-injury. A longitudinal thematic analysis was performed.Results: Many traumatically injured people had persistent physical and mental impacts. Participants reported being anxious about pain, mobility, work, housing and accommodation, social activities, and finances in their future. Others were hopeful and optimistic regarding their future and developed coping strategies and adopted new viewpoints.Conclusion: Over time, most seriously injured people's perceptions of the future remained consistent. Some had enduring anxiety and others sustained hopeful approaches. Personalised and targeted interventions that address specific concerns could reduce anxiety and support positive adjustment following traumatic injury.Implications for rehabilitationMany seriously injured people, particularly people who sustained orthopaedic injuries, held concerns about experiencing persistent pain, physical impairment, and reduced mobility in the future.Personalised and targeted interventions that address specific concerns about future financial, social, housing and employment issues could reduce anxiety and support coping and adjustment strategies.In addition to their direct impacts on post-injury recovery, health, rehabilitation, occupational, social, and insurance systems all have a role in facilitating positive responses of injury survivors that draw on their strengths and sources of resilience.

Communicating with patients, families and health professionals about managing medications in intensive care: A qualitative observational study.

OBJECTIVES: To explore communication between patients, families, and health professionals about managing medications in intensive care. DESIGN: A qualitative exploratory study was undertaken using participant observations. A thematic analysis of the data was performed. SETTING: The setting comprised an intensive care unit at a public, teaching hospital in Melbourne, Australia. FINDINGS: Three themes were identified: provision of information, therapeutic relationships, and patient and family centred care. Nurses and pharmacists communicated regularly about medications with patients and family members. Doctors were occasionally present at the bedside during medical ward rounds or in undertaking medical procedures and subsequently their patient and family interactions about managing medications tended to be minimal. Pharmacists spent time in clarifying patients' medication history prior to their admission to the intensive care unit. Nurses were at the forefront of communication with patients and their family members. However, nurses sometimes missed cues and valuable opportunities to respond to families' concerns during their interactions. Communication was commonly hampered by time constraints and competing responsibilities of health professionals. CONCLUSION: Communication tended to involve clarification of patients' medication history and the ways in which medications affected patients' clinical status or medical condition. Attention is needed in attending to cues from families in communicating about medications.

Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings.

BACKGROUND: Communication problems contribute enormously to medication errors and adverse events. Encouraging patient engagement can help to facilitate effective medication management. OBJECTIVES: To examine barriers and enablers affecting how patients engage with managing their medications in specialty hospital settings. DESIGN: An exploratory qualitative design was used involving in-depth interviews with doctors, nurses, pharmacists, patients and family members. SETTING: An Australian public, metropolitan teaching hospital was the study site and five specialty hospital settings were used, including cardiac care, emergency care, intensive care, oncology care and perioperative care. RESULTS: In all, 21 health professionals, 11 patients and 12 family members participated in the study (n = 44). Barriers and enablers involved intrapersonal, interpersonal and environmental aspects, and differences in perceptions and experiences were found between the various settings. Health professionals had preconceived notions of what was appropriate behaviour in conveying information about medications. Many health professionals stated that they deliberately chose not to provide medication-related knowledge. Different barriers for patient engagement existed in various settings - in emergency care, patients could only stay for 4 h; in intensive care, medication changes regularly happened; in cardiac care, patients were discharged prematurely due to urgent need of beds; in oncology, there was lack of availability of oncology consultants; while in perioperative care, surgeons and anaesthetists were available just before surgery. CONCLUSIONS: Complex barriers and enablers are associated with patient engagement in specialty clinical settings. By developing an understanding of these barriers and enablers, health professionals can help patients to understand and participate in their medication management.

Effects of patient-, environment- and medication-related factors on high-alert medication incidents.

OBJECTIVE: To measure the rate of medication incidents associated with the prescription and administration of high-alert medications and to identify patient-, environment- and medication-related factors associated with these incidents. DESIGN: A retrospective chart audit design was conducted of medical records for patient admissions from 1 January 2010 to 31 December 2010. SETTING: Five practice settings (cardiac care, emergency care, intensive care, oncology care and perioperative care) at a public teaching hospital in Melbourne, Australia. PARTICIPANTS: Patients were considered for inclusion if they were prescribed at least one high-alert medication and if they were admitted to one of five practice settings. MAIN OUTCOME MEASURES: High-alert prescribing and administering incidents were measured in each of the five practice settings. Generalized linear mixed modeling was used for data analysis. RESULTS: There were 6984 opportunities for high-alert medication incidents across the five clinical settings. The overall medication incident rate was 1934/6984 (27.69%). There were 1176 prescribing incidents (16.84%) and 758 administering incidents (10.85%). Statistical modeling showed that, in each of the five clinical settings, an increased number of ward transfers was associated with increased odds of prescribing incidents. In addition, statistical modeling demonstrated that an increased number of ward transfers was associated with increased odds of administering incidents in emergency care and perioperative care. CONCLUSIONS: Complex relationships were found in managing high-alert medications in specialty clinical settings. Employing measures to address patients' movements across ward settings can reduce high-alert medication incidents and improve quality of care.