Male nurse practice in inpatient rehabilitation. Finding a safe way: a grounded theory.

BACKGROUND: Research interest in nursing's contribution to inpatient rehabilitation is growing. Nurses contribute to rehabilitation specifically by teaching patients how to care for themselves. This contribution is largely reported from a female or genderneutral perspective. Despite the work of male nurses being examined in a range of other specialities, their work within inpatient rehabilitation remains underexplored. OBJECTIVE: To report on a grounded theory study to identify and make visible male nurse practice in inpatient rehabilitation in Australia. DESIGN: Constructivist grounded theory informed by symbolic interactionism. SETTING(S): Stage 1 data were collected in locations of participants choosing throughout Australia. Stage 2 data collection centred on seven data collection sites across two specialist rehabilitation hospitals in two states of Australia. PARTICIPANTS: Twenty-three male nurses and 15 patients participated in the study. METHODS: Stage 1 (October 2013 to June 2014) consisted of semi-structured interviews with 11 male nurses. Stage 2 (February to April 2015) consisted of semi-structured interviews and 63.5 h of non-participant observation with 12 male nurses. Fifteen interviews with patients as recipients of male nurse care were also conducted. Data analysis included initial coding, focused coding, and theoretical coding using constant comparative methods, memo writing and diagramming. RESULTS: Nurse participants were aware of patient perceptions about nursing being an occupation for women and male nurses being perceived as sexual threats, which led to an everyday concern of potential for misinterpretation. To address this concern, male nurses engaged in a three-phase process known as assessing and managing risk in order to minimise risk and to keep themselves safe in practice. However, two contextual conditions, type of care and urgency of care, influenced engagement in assessing and managing risk. The core category and substantive grounded theory to explain these results is finding a safe way. CONCLUSIONS: Gender stereotypes affected the daily working lives of male nurses in inpatient rehabilitation. To counter the risk of misinterpretation male nurses used a range of strategies to address the barriers encountered daily in their working lives. However, male nurse efforts were often influenced by conditions outside of their control. In inpatient rehabilitation, male nurses practised cautiously to keep themselves safe in order to practise nursing.

The usual bowel care regimes of people living in the community with spinal cord injury and factors important for integrating bowel care into everyday life.

PURPOSE: To describe the usual bowel care regimes of people living in the community with spinal cord injury and factors important for integrating bowel care into everyday life. METHODS AND MATERIALS: Descriptive and interpretive thematic analysis of transcribed semi-structured interviews with 11 men living with spinal cord injury, aged 23-77 years, 8-45 years post injury. RESULTS: Participants had different levels and types of injuries. While there were common aspects of the bowel care routines of study participants, none was exactly the same as any other. Each had developed a routine in accordance with the needs of their own body, preferences, and convenience in relation to availability of carers and work commitments. Personal factors in the person with SCI were important for successful integration of bowel care into their everyday life. CONCLUSION: An appropriate and consistent bowel care routine was found to be significant in enabling people with spinal cord injury to experience wellness and quality in their everyday lives. Characteristics and actions of the person with SCI enabled the person to actively drive the process of integrating bowel care into their everyday life. How best to foster the development of these personal factors warrant further investigation.IMPLICATIONS FOR REHABILITATIONSupport for the ongoing development of self-management of bowel dysfunction expertise by people living with spinal cord injury needs to continue after discharge from hospital.Characteristics of the person with spinal cord injury, such as a state of mind indicating acceptance of their situation, motivation to avoid bowel accidents and constipation, and willingness to take responsibility, are important factors influencing the integration of bowel care into everyday life.Actions undertaken by the person with spinal cord injury, such as discipline to establish, refine and maintain a bowel care regime, and proactive self-management are important factors influencing the integration of bowel care into everyday life.This small study suggests the role of personal factors in the development of self-management expertise, for example the development of a self-management mindset and the acquisition of skills to drive that process, should be considered during rehabilitation.

Potential for misinterpretation: An everyday problem male nurses encounter in inpatient rehabilitation.

AIMS: This study aims to report on the everyday concern of the 'potential for misinterpretation', which was the basic social problem revealed in a grounded theory study exploring male nurse practice in inpatient rehabilitation in Australia. BACKGROUND: Male nurses account for approximately 10% of nursing workforce across western countries and they practice in a range of clinical areas; however, how they practice in inpatient rehabilitation remains unexplored. METHODS: Constructivist grounded theory was used in this study and was conducted in two phases: (i) involved semi-structured interviews with 11 male nurses from October 2013 to June 2014 and (ii) observation of practice of 12 male nurses and semi-structured interviews with male nurses and 15 patients from February to April 2015. RESULTS: Nurse participants encountered the intersection of two pervasive patient ideologies about male nurses. Patients perceived nursing to be women's work and that male nurses are sexual threats. These two intersecting ideologies created a concern for male nurses working in inpatient rehabilitation and that concern was labelled 'potential for misinterpretation'. CONCLUSION: Gender stereotypes impacted on the ability of male nurses to practise nursing in inpatient rehabilitation. Male nurses were mindful on a daily basis that misinterpretation could, and did, happen in inpatient rehabilitation.

An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation.

AIM: To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation. DESIGN: A retrospective cohort design. METHODS: Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care. RESULTS: Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N = 38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care. CONCLUSION: Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes. IMPACT: Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.

Chronic Constipation in the Community: A National Survey of Australian Adults.

PURPOSE: The aim of this study was to determine the prevalence of chronic constipation and identify factors associated with chronic constipation in community-dwelling adults. DESIGN: Cross-sectional study. METHODS: The target population was community-dwelling Australian adults; 1978 participants completed an online questionnaire exploring symptoms, management, and factors potentially associated with constipation. Chronic constipation was identified using Rome III criteria. Multivariate logistic regression model was used to identify factors associated with chronic constipation. RESULTS: The prevalence of chronic constipation was 23.9%. Factors significantly associated with chronic constipation in the multivariate model were female gender (odds ratio [OR] = 1.42, 95% confidence interval [CI], 1.12-1.81), current employment (OR = 1.45, 95% CI, 1.11-1.88), regular smoking (OR = 1.60, 95% CI, 1.19-2.14), poor self-rated health (OR = 2.57, 95% CI, 1.28-5.19), thyroid disease (OR = 1.77, 95% CI, 1.21-2.79), depression (OR = 1.49, 95% CI, 1.08-2.06), hemorrhoids (OR = 2.98, 95% CI, 1.84-4.83), irritable bowel syndrome (OR = 2.45, 95% CI, 1.73-3.46), and use of anti-inflammatory/antirheumatic medications (OR = 2.06, 95% CI, 1.15-3.68). In contrast to these factors, use of medications acting on the renin-angiotensin system was associated with a reduced likelihood of chronic constipation (OR = 0.47, 95% CI, 0.24-0.91). CONCLUSIONS: Chronic constipation is prevalent among community-dwelling adults. Various factors associated with chronic constipation have been identified, and knowledge of these factors may help health care professionals recognize individuals who are at high risk of chronic constipation.

Use of over-the-counter laxatives by community-dwelling adults to treat and prevent constipation: a national cross-sectional study.

PURPOSE: Constipation is commonly self-managed with over-the-counter laxatives. The study aim was to explore laxative choice, healthcare professional recommendations in laxative selection, and laxative effectiveness when laxatives are used for treatment and for prevention of constipation by community-dwelling adults. METHODS: A nationally representative sample of community-dwelling adults in Australia was surveyed. Participants completed an online questionnaire. Z tests for differences in proportions were used to compare the proportion of laxatives by class when used either for treatment or for prevention of constipation by choice of laxative, healthcare professional recommendation, and perceived effectiveness. RESULTS: The questionnaire was completed by 2024 participants. Laxatives were used by 37% (n = 747) of participants with 31.3% using laxatives for treatment, 19.3% for prevention, and 49.7% using laxatives for both purposes. The most common laxatives used for treatment and prevention were contact laxatives (39.8% and 31.1% respectively) and bulk-forming laxatives (34.3% and 44.6% respectively). Of all laxatives used, 56.4% of laxatives were chosen with healthcare professional recommendation, and 53.5% of laxatives were found effective. CONCLUSION: Laxatives were used both for treatment and for prevention of constipation. However, laxatives are often perceived to be ineffective and healthcare professionals are not always involved in laxative choice. Modified guidelines which address the use of laxatives for both treatment and prevention, and increased healthcare professional involvement in appropriate choice and use of laxatives, may be required to improve constipation management in the community.

A comparison of patients managed in specialist versus non-specialist inpatient rehabilitation units in Australia.

Aim: To compare the rehabilitation of patients with brain and spinal cord injury in specialist rehabilitation units and non-specialist rehabilitation units in Australia over a 10-year period.Method: A retrospective cohort study design was used. Epidemiological descriptive analysis was used to examine inpatient rehabilitation data held in the Australasian Rehabilitation Outcomes Centre Registry Database at four discrete time points: 2007, 2010, 2013 and 2016. Data sets included patient demographics, length of stay and the Functional Independence Measure. Data sets were examined for differences between specialist and non-specialist rehabilitation units.Results: Over the 10-year study period, compared to patients admitted to non-specialist rehabilitation units patients admitted to specialist rehabilitation units: (1) were younger and more likely to be male; (2) had a longer time between onset of illness/injury and rehabilitation admission; (3) had a longer median rehabilitation length of stay; (4) had a higher burden of care on admission to rehabilitation; however (5) had a greater functional gain. Patients in specialist rehabilitation units had a lower relative functional efficiency per day of rehabilitation, but higher percentage of Functional Independence Measure gain. In 2016, 66% of brain injury and 51% of spinal cord injury patients were not rehabilitated in specialist rehabilitation units.Conclusion: There are differences in the characteristics of patients admitted to specialist versus non-specialist rehabilitation units. Patients admitted to specialist rehabilitation units have greater functional gain. A noteworthy proportion of brain and spinal cord injury patients are not being rehabilitated in specialist rehabilitation units, particularly patients with non-traumatic injuries.Implications for rehabilitationPatients with a brain or spinal cord injury rehabilitated in specialist rehabilitation units achieve a greater functional gain than those in non-specialist units.Development of best practice admission guidelines would better enable the right care for the right patient in the right setting at the right time.There is a need for longitudinal examination of patient outcomes to better understand the long-term benefits of being rehabilitated in specialist rehabilitation units compared to non-specialist rehabilitation units.

Examination of the dependency and complexity of patients admitted to in-patient rehabilitation in Australia.

Objective The aim of this study was to determine whether there has been a measurable change in the dependency and complexity of patients admitted to in-patient rehabilitation in Australia between 2007 and 2016. Methods A retrospective cohort study design was used to examine in-patient rehabilitation data held in the Australasian Rehabilitation Outcomes Centre Registry Database for the period 2007-16. Epidemiological descriptive analysis was used to examine datasets for difference between four discrete years (2007, 2010, 2013 and 2016). Datasets included patient demographics, length of stay (LOS), comorbidities, complications and the Functional Independence Measure (FIM™). Results Between 2007 and 2016, rehabilitation in-patients as a whole: (1) had a mean decrease in total admission FIM score; (2) became more complex, as evidenced by the increased proportion of particular comorbidities impacting on rehabilitation, namely cardiac and respiratory disease, dementia, diabetes and morbid obesity; and (3) had a mean decrease in total discharge FIM score. However, there was an increase in the proportion of patients discharged home from rehabilitation (from 86.5% to 92%) and decreases in onset and rehabilitation LOS of 2.2 and 2.5 days respectively. Conclusion The dependency and complexity of patients admitted to in-patient rehabilitation in Australia has increased between 2007 and 2016. What is known about the topic? Anecdotal reports suggest that rehabilitation patients in Australia have become more complex, necessitating increased active management of their presenting health condition and comorbid health conditions. However, to date, no systematic investigation has been undertaken to examine trends in rehabilitation in-patient dependency and complexity over time. What does this paper add? This study provides measurable evidence of increased dependency and complexity in patients admitted to rehabilitation in Australia. Further, compared with 2007, rehabilitation in-patients as a whole had an increased burden of care on discharge from rehabilitation in 2016. What are the implications for practitioners? The changes in patient dependency and complexity reported in this study have implications for rehabilitation service delivery. This is because the increased need for illness or injury and comorbidity management may result in increased potential for acute complications and health deterioration, and compensatory care for patients during rehabilitation. Clinicians may need to widen their skill set to include more acute and chronic illness management.

Predictors of unplanned readmission to acute care from inpatient brain injury rehabilitation.

AIMS AND OBJECTIVES: To identify the predictors of unplanned readmission to acute care (RTAC) from inpatient brain injury rehabilitation and to develop a risk prediction model. BACKGROUND: RTAC from inpatient rehabilitation is not uncommon. Individual rehabilitation patient populations require their own body of evidence regarding predictors of RTAC. DESIGN: Retrospective cohort study. METHODS: Adult patients with new onset acquired brain injury admitted to a stand-alone rehabilitation facility between 1 January 2012-31 December 2018 were included in the study. The main measures were RTAC, sensitivity, specificity, the C-statistic and Youden's index. This paper is reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: Of 383 patients admitted for rehabilitation, 83 (22%) experienced a RTAC; 69 (18%) patients had at least one unplanned RTAC episode. Patients requiring unplanned RTAC were more likely to have lower Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) scores on rehabilitation admission, a higher burden of care on rehabilitation discharge and be discharged to a nonhome residence. Rehabilitation admission GCS and motor FIM were identified as the independent RTAC predictors in multivariate regression modelling. The combined C-statistic was 0.86. A GCS cut-off score of ≤14 and motor FIM cut-off score of ≤40 were identified as optimal, yielding a combined Youden's index of 0.56 (sensitivity = 0.72; specificity = 0.83). CONCLUSION: Patients requiring an unplanned RTAC had a lower functional status on rehabilitation admission. A prediction model for unplanned RTAC has been developed using validated and readily available clinical measures. RELEVANCE TO CLINICAL PRACTICE: The developed RTAC risk prediction model is the first step in preventing unplanned RTAC from inpatient brain injury rehabilitation. Future research should focus on discrete interventions for preventing unplanned RTAC from inpatient brain injury rehabilitation.

Predictors of Readmission to Acute Care from Inpatient Rehabilitation: An Integrative Review.

Readmission to acute care (RTAC) from inpatient rehabilitation can have negative consequences for individuals and associated financial costs are increasing. Consequently, preventing avoidable RTAC represents a target for improvement in quality of care. The aim of this integrative review was to identify predictors of RTAC from inpatient rehabilitation. A systematic search of MEDLINE, EMBASE, ProQuest, and CINAHL databases was used. Thematic analysis was used to examine extracted data. Strong evidence indicating that the principal predictors of RTAC are lower functional status on admission to rehabilitation, a more severe injury and a higher number of comorbidities was identified in this review. This is despite the heterogeneous nature of impairment groups and factors/measures examined. However, the relevance of some predictors of RTAC (such as patient demographics, invasive devices and primary diagnoses) may be dependent on rehabilitation setting, impairment group or time between rehabilitation admission and RTAC (eg, below 3 vs 30 days). Consequently, findings of this integrative review highlight that RTAC is a complex, multifactorial patient issue with a complex interplay between the predictors and reasons for RTAC. LEVEL OF EVIDENCE: IV.

Defining constipation to estimate its prevalence in the community: results from a national survey.

BACKGROUND: Different definitions of constipation have been used to estimate its prevalence in the community but this creates difficulties when comparing results from various studies. This study explores the impact of different definitions on prevalence estimates in the same population and compares the performance of simple definitions with the Rome III criteria. METHODS: The prevalence of constipation in a large nationally representative sample of community-dwelling adults was estimated using five simple definitions of constipation and compared with definitions based on the Rome III criteria. The sensitivity, specificity, and positive and negative predictive values, were calculated for each definition using the Rome III criteria as the gold standards for chronic and sub-chronic constipation. RESULTS: Prevalence estimates for the five simple definitions ranged from 9.4 to 58.9%, while the prevalence estimates using the Rome III criteria were 24.0% (95%CI: 22.1, 25.9) for chronic constipation and 39.6% (95%CI: 37.5, 41.7) for sub-chronic constipation. None of the simple definitions were adequate compared to the Rome III criteria. Self-reported constipation over the past 12 months had the highest sensitivity (91.1%, 95%CI: 88.8, 93.4) and negative predictive value (94.5%, 95%CI: 93.1, 96.1) compared to the Rome III criteria for chronic constipation but an unacceptably low specificity (51.3%, 95%CI: 48.8, 53.8) and positive predictive value (37.1%, 95%CI: 34.4, 39.9). CONCLUSIONS: The definition used to identify constipation within a population has a considerable impact on the prevalence estimate obtained. Simple definitions, commonly used in research, performed poorly compared with the Rome III criteria. Studies estimating population prevalence of constipation should use definitions based on the Rome criteria where possible.

Development of the Sydney Falls Risk Screening Tool in brain injury rehabilitation: A multisite prospective cohort study.

AIMS AND OBJECTIVES: To develop a falls risk screening tool (FRST) sensitive to the traumatic brain injury rehabilitation population. BACKGROUND: Falls are the most frequently recorded patient safety incident within the hospital context. The inpatient traumatic brain injury rehabilitation population is one particular population that has been identified as at high risk of falls. However, no FRST has been developed for this patient population. Consequently in the traumatic brain injury rehabilitation population, there is the real possibility that nurses are using falls risk screening tools that have a poor clinical utility. DESIGN: Multisite prospective cohort study. METHODS: Univariate and multiple logistic regression modelling techniques (backward elimination, elastic net and hierarchical) were used to examine each variable's association with patients who fell. The resulting FRST's clinical validity was examined. RESULTS: Of the 140 patients in the study, 41 (29%) fell. Through multiple logistic regression modelling, 11 variables were identified as predictors for falls. Using hierarchical logistic regression, five of these were identified for inclusion in the resulting falls risk screening tool: prescribed mobility aid (such as, wheelchair or frame), a fall since admission to hospital, impulsive behaviour, impaired orientation and bladder and/or bowel incontinence. The resulting FRST has good clinical validity (sensitivity = 0.9; specificity = 0.62; area under the curve = 0.87; Youden index = 0.54). The tool was significantly more accurate (p = .037 on DeLong test) in discriminating fallers from nonfallers than the Ontario Modified STRATIFY FRST. CONCLUSION: A FRST has been developed using a comprehensive statistical framework, and evidence has been provided of this tool's clinical validity. RELEVANCE TO CLINICAL PRACTICE: The developed tool, the Sydney Falls Risk Screening Tool, should be considered for use in brain injury rehabilitation populations.

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

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.

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 clinician's 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.

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 patient's 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 faller's first fall occurred earlier in their admission than a single faller's. 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 patient's risk of falling is not static and in fact, may increase over time.

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.

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

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.

Testing differences in proportions.

This paper is the sixth in a series of statistics articles recently published by Australian Critical Care. In this paper we explore the most commonly used statistical tests to compare groups of data at the nominal level of measurement. The chosen statistical tests are the chi-square test, chi-square test for goodness of fit, chi-square test for independence, Fisher's exact test, McNemar's test and the use of confidence intervals for proportions. Examples of how to use and interpret the tests are provided.

Symptoms and treatment-seeking responses in women experiencing acute coronary syndrome for the first time.

BACKGROUND AND OBJECTIVE: Many women do not recognize their risk for coronary heart disease, or identify and respond to cardiac symptoms by seeking medical assistance when symptoms occur. These factors contribute to delays in presentation at hospital, which means that women then have fewer treatment options. This study aimed to describe women's symptom experiences and treatment-seeking responses to first-time acute coronary syndrome (ACS). SUBJECTS AND METHODS: Ten women who had experienced their first ACS event, and who had undergone a percutaneous coronary intervention within 24 hours of presentation, consented to participate in semistructured interviews that focused on their experiences. These women's narratives of their symptoms and treatment-seeking responses were thematically analyzed. RESULTS AND CONCLUSION: Women described several issues that contributed to quite complex, multifaceted decision-making processes, from symptom onset to treatment-seeking response, which often contributed to delays. These issues included the occurrence of sometimes intermittent early-warning or prodromal symptoms, the diversity of their symptom experience, beliefs in low vulnerability to coronary heart disease by the women themselves, and health professionals' responses, which did not always match their needs. Lack of awareness may be particularly important in first-time ACS event. Effective strategies need to be developed to address these issues, including public-education campaigns, and specific education regarding women for health professionals.

The Self-Directed Learning Readiness Scale for nursing education revisited: a confirmatory factor analysis.

The Self-Directed Learning Readiness Scale for Nursing Education (SDLRSNE) was initially developed as an alternative to Guglielmino's [Guglielmino, L.M. 1977. Development of the Self-Directed Learning Readiness Scale. Unpublished Doctoral Dissertation, University of Georgia. Dissertation Abstracts International, vol. 38 (11a), p. 6467] Self-Directed Learning Readiness Scale. The aim of this study was to re-examine the factor structure of the subscales of the SDLRSNE and provide evidence of its validity. Data was collected using a cross-sectional survey of 227 first year undergraduate nursing students. To examine the factor structure of the SDLRSNE three one-factor congeneric models, each representing a different subscale, were tested with maximum likelihood confirmatory factor analysis. The model fit indices of the three one-factor congeneric models indicate that the resultant models fit the data well, providing support for the factorial validity of the SDLRSNE. Of the 40 items, 11 items had to be removed from the analyses as they failed to provide good fit with their subscales. Further research investigating the factor validity of the SDLRSNE is encouraged, specifically to examine the stability of the items across factors using multi-factor models.