Pressure to Progress: Severe Traumatic Brain Injury and Slow Recovery in the Current Health Care Environment

Social work-generated evidence in traumatic brain injury from 1975 to 2014: A systematic scoping review

The International Network for Social Workers in Acquired Brain Injury (INSWABI) commissioned a systematic scoping review to ascertain the social work-generated evidence base on people with traumatic brain injury (TBI) of working age. The review aimed to identify the output, impact and quality of publications authored by social workers on this topic. Study quality was evaluated through assessment frameworks drawn from the United Kingdom National Service Framework for Long-Term Conditions. In the 40-year period from 1975 to 2014, 115 items were published that met the search criteria (intervention studies, n = 10; observational studies, n = 52; literature reviews, n = 6; expert opinion or policy analysis, n = 39; and others, n = 8). The publications could be grouped into five major fields of practice: families, social inclusion, military, inequalities and psychological adjustment. There was a significant increase in the number of publications over each decade. Impact was demonstrated in that the great majority of publications had been cited at least once (80.6%, 103/115). Articles published in rehabilitation journals were cited significantly more often than articles published in social work journals. A significant improvement in publication quality was observed across the four decades, with the majority of studies in the last decade rated as high quality.

Council of Australian Governments' (COAG) Initiative for Young People With Disability in Residential Aged Care: What Are the Issues for Acquired Brain Injury?

People surviving severe acquired brain injury (ABI) may potentially benefit from the Council of Australian Governments' (COAG) 5-year initiative for young people with disability in residential aged-care facilities. Yet critical examination of this policy initiative for ABI population is warranted for 2 reasons. First, reliance on the disability sector to resolve the complexities of long-term care for people with ABI detracts attention from systemic failures at the health/disability sector interface, and notably, debate concerning the role of, and right to rehabilitation. Second, the COAG initiative is being pursued within an extraordinarily complex and variable contemporary care environment, involving multiple services and sectors, and historically, high unmet need. This raises questions as to the adequacy and sustainability of care provided under the responsibility of state-based disability services. In this article, it is argued that long-term care for young people with severe ABI is better served by incorporating a health and rehabilitation perspective alongside a disability support approach. Although the effectiveness of rehabilitation may be contested in some instances of very severe ABI, nevertheless the role of rehabilitation in seeking to reduce the number of young people at risk of entering residential aged care needs to be addressed in policy solutions. It is also suggested that provision of long time care in the contemporary care environment involves a number of challenges due to the complex and changing patterns of need, diverse funding arrangements and mix of government and nongovernment services, and the increasing demand for care.

Professional Claims, Uncertainty and the Politics of Care: Impact on Referral and Equitable Care in Traumatic Brain Injury

Rising healthcare expenditure and more explicit rationing of healthcare resources is a central feature of healthcare systems globally. In Australia, reform efforts have targeted the high cost areas such as the public hospital system. This has increased the demands on professionals to reduce length of stay and complicated post-hospital referral of people with complex and severe injury. In the area of traumatic brain injury (TBI), pressures on existing rehabilitation resources and a changing healthcare environment, with greater emphasis on efficiency and evidence-based practice, confront professionals' efforts to provide equitable care. In this paper, some of the key issues important in understanding patterns of referral in TBI are presented. It is argued that referral decisions exemplify a negotiation of professional claims and value judgements that not only conceal the uncertainty in decision-making, but also more notably, reflect the lack of attention to equity in the broader politics of care. Case studies are used to illustrate these issues and to discuss the implications for equitable care in the contemporary healthcare environment in Australia. The paper concludes by outlining the challenges and opportunities in applying evidence-based decision-making in TBI and some future directions for attaining more equitable patterns of referral.

Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral.