A nursing perspective on the relationship between nursing and allied health in inpatient rehabilitation

The development of a research-based interprofessional communication behaviors repository in healthcare education: A systematic review

Interprofessional communication is crucial for patient care, yet there is a dearth of comprehensive assessment tools essential to train and assess healthcare students. While the Interprofessional Educational Collaborative framework (IPEC) outlines eight sub-competencies, it lacks detailed behavioral indicators. This study aimed to create a repository of interprofessional communication behaviors to complement the IPEC sub-competencies. From 12,448 articles, 55 were selected and thematically analyzed with NVivo18®. We identified 230 interprofessional communication behaviors, organized into 10 themes and 61 sub-themes, aligning with the IPEC sub-competencies. This comprehensive repository could be foundational for developing interprofessional communication assessment tools in healthcare education and aiding healthcare institutions in improving interprofessional communication practices.

The role of nurses in inpatient geriatric rehabilitation units: A scoping review

AIMS

(1) To review and synthesize research on the contributions of nurses to rehabilitation in inpatient geriatric rehabilitation units (GRUs), and (2) to compare these reported contributions to the domains of international rehabilitation nursing competency models. The roles and contributions of nurses (e.g. Registered Practical Nurses, Registered Nurses and Licensed Practical Nurses) in GRUs are non-specific, undervalued, undocumented and unrecognized as part of the formal Canadian rehabilitation process.

DESIGN

Arksey and O'Malley's methodological framework for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used.

METHODS

Six databases were searched for relevant literature: MEDLINE, PsychINFO, CINAHL, EMBASE, SCOPUS and Nursing and Allied Health. English articles were included if they examined nursing roles or contributions to inpatient geriatric rehabilitation. Integrated synthesis was used to combine the qualitative and quantitative data, and thematic analysis was used for coding. Three sets of international competency models were amalgamated to explore how different nurse roles in geriatric rehabilitation were portrayed in the included literature.

RESULTS

Eight studies published between 1991 and 2020 were included in the review. Five main geriatric rehabilitation nursing roles were generated from synthesis of the domains of international rehabilitation nursing competency models: conserver, supporter, interpreter, coach and advocate.

CONCLUSIONS

Nurses working in inpatient geriatric rehabilitation are recognized more for their role in conserving the body than their roles in supporting, interpreting, coaching and advocacy. Interprofessional team members appear to be less sure of the nurses' role in the rehabilitation unit. Nurses themselves do not acknowledge the unique rehabilitation aspects of care for older adults. Enhancing formal education, or adding continuing education courses, to facilitate role clarity for nurses in geriatric rehabilitation could improve nurses' and interprofessional healthcare team members' understandings of the possible contributions of nurses working in rehabilitation settings.

Dynamic and distributed exchanges: an interview study of interprofessional communication in rehabilitation

PURPOSE

Interprofessional communication (IPC) in rehabilitation is important for patient care yet it has been shown to be variable and challenging. Existing research does not address the complexity of IPC in this setting. Understanding the influence of contextual factors on IPC may guide improvements to increase the effectiveness of communication within interprofessional teams.

METHODS

From July 2020 to February 2021 semi-structured interviews were conducted with 24 healthcare professionals across Australia and New Zealand. Cultural Historical Activity Theory provided a guiding theoretical and analytical framework for this qualitative study.

RESULTS

Participants described engaging in IPC through evolving interactions, piecing together information that underpinned patient care. Meetings occurred frequently, however communication extended well beyond formalised interactions, often requiring individuals to balance clinical workload with communication tasks. IPC reportedly relied on communication tools, however navigating information from multiple sources was demanding.

CONCLUSIONS

Our results indicate that IPC contributes significantly to the workload of healthcare professionals in rehabilitation. IPC was integral in the provision of cohesive patient care, however it proved time consuming, effortful and at times frustrating and potentially erroneous. Our findings promote the need for rigorous examination of communication practices to ensure they are meeting the needs of an increasingly interprofessional workforce. IMPLICATIONS FOR REHABILITATIONHealthcare professionals should recognise that time spent communicating within their team is a legitimate and important part of patient care.Rehabilitation teams should consider how they allocate resources for communication tasks.Teams should reconsider how they can use communication more effectively to save time by reducing repetition and errors.

Exploring Determinants of Interdisciplinary Collaboration within a Geriatric Oncology Setting: A Mixed-Method Study

Simple Summary

Collaboration between oncologists and geriatricians has been shown to improve the quality of elderly cancer patient care. However, previous research has revealed how interpersonal factors might hinder this interdisciplinary work. This study aims to assess sprocessual and contextual determinants of the collaboration between these two disciplines, including shared time and routines, medical decision criteria and perceptions of age and needs of elderly patients. These aspects are important to develop a more efficient patient-centered approach in oncogeriatric care and improve collaboration between the different disciplines involved.

Abstract

Therapeutic challenges regarding the population of elderly cancer patients and their heterogeneity lead to the need to implement person-centered approaches in order to optimize care strategies and adapt oncology treatments to each pattern of aging. The International Society of Geriatric Oncology recommends a multidisciplinary evaluation of these patients and the use of screening tools prior to the initiation of treatments. However, previous research shows a poor implementation of these recommendations in geriatric oncology. Although some studies have identified how different perceptions of geriatric oncology might hinder routine teamwork, little is known about the impact of other factors on promoting the collaboration between the two specialties. This mixed-method exploratory study used an online questionnaire to assess the perception of a group of 22 geriatricians and oncology physicians on different determinants of oncology care and teamwork. In this sample, older oncology patients benefited from geriatric care. However, there was a variability regarding age criteria and a limited use of screening tools. The multidimensional framework for interprofessional teamwork by Reeves has been used to analyze some of the determinants of the collaboration between oncology physicians and geriatricians. This study has identified systematic issues to consider when promoting communication and common values between the two disciplines, including available resources in terms of shared time, space and routine actions.

Learning self-care skills after spinal cord injury: a qualitative study

BACKGROUND

People with a recent spinal cord injury (SCI) often follow intensive rehabilitation. Learning appropriate self-care, deal with their impairments and prevent secondary health conditions (SHCs), is highly important during rehabilitation. To date it is not clear how self-care skills are taught to people with SCI. The objective of this study was to understand how people with SCI experienced the learning of appropriate self-care skills during inpatient rehabilitation, including the role of the rehabilitation team.

METHODS

Individual semi-structured interviews were conducted with 15 people with SCI, recently discharged from initial inpatient rehabilitation. Interviews were audio-taped, transcribed and analyzed thematically.

RESULTS

Two main themes and seven sub-themes were identified. Participants stated that the contribution of the rehabilitation team to learning self-care, including prevention of SHCs, was mostly made by optimizing opportunities to learn through experience. For preventing SHCs, education and lessons learned from the professionals during therapy and the formal educational program, was experienced as especially important. Further, the motivational attitude of the professionals which participants found stimulating and was based on respect, combined with their positive contribution as one team, were seen as essentials elements for learning appropriate self-care. However participants did not recognize the contribution of the nursing staff as part of their rehabilitation, although it was seen as very important. An important aspect of the participants' own contribution was challenging oneself to learn self-care. This was done in different ways by the participants. Further, their own mental adjustment was considered important in the learning process. The gaining of confidence was by most participants seen as personal characteristic, although they also recognized the importance of the team effort and the experiences they underwent.

CONCLUSIONS

Learning appropriate self-care was mostly done through experience, by challenging themselves, and making use of the opportunities given by the members of the rehabilitation team. The same strategies used by the rehabilitation team to teach people with SCI to perform appropriate self-care, were also helpful for the participants to gain confidence. Explicit attention for self-care training as an important goal in SCI rehabilitation may strengthen the nursing staff's role and stimulate interdisciplinary working.

Impacts of tailored, rehabilitation nursing care on functional ability and quality of life in hospitalized elderly patients after rib fractures

OBJECTIVES

We aimed to analyze the effects of a tailored rehabilitation nursing care program on functional ability and quality of life in patients with conservative treatment for rib fractures.

DESIGN

Randomized controlled trial.

SETTING

Inpatient rehabilitation hospital.

SUBJECTS

Rib fracture patients treated conservatively were randomized into two groups (experimental and control group).

INTERVENTIONS

Patients in control group received Treatment as Usual (TAU) and patients included in experimental group received TAU and an added tailored rehabilitation nursing care program (RNT).

MAIN MEASURES

At baseline, and end of hospitalization treatment, the functional ability was assessed with the Barthel Index, and the quality of life was evaluated with the EuroQol-5D. Additionally, the outcomes were assessed at six-month follow-up.

RESULTS

A total of 80 patients were included in the study, whose mean age was 77.19 SD 7.71 in the RNT group and 75.55 SD 9.46 in the TAU group. Our data showed a significant difference in the post-treatment gains in overall quality of life (74.25 SD 20.62 vs 60.28 SD 20.54), and functional ability (71.79 SD 23.85 vs 69.41 SD 24.30) between the RNT group and the TAU group (P < 0.05). Compared to the TAU group, the RNT group also showed a significant improvement in functional ability and quality of life at six-month follow-up.

CONCLUSIONS

A tailored rehabilitation nursing care program added to the conservative treatment during hospitalization can improve the functional ability and quality of life of patients after rib fractures at discharge and at six-month follow-up.

TRIAL REGISTRATION

ClinicalTrial.gov Identifier: NCT04168996.

Context matters when implementing patient centred rehabilitation models for persons with cognitive impairment: a case study

Background

There is a growing number of older adults with cognitive impairment (CI) that require inpatient rehabilitation, and as such patient centred rehabilitation models have been developed. However, implementing evidence-based models without attending to the fit of the model to the new context could lead to an unsuccessful outcome. Researchers collaborated with administrators and staff in one rural site to adapt a patient centred rehabilitation model of care in the Canadian province of Ontario. This paper reports on the contextual factors that influenced the implementation of the model of care.

Methods

The study takes a case study approach. One rural facility was purposefully selected for its interest in offering rehabilitation to persons with CI. Four focus group discussions were conducted to explore healthcare professionals’ perceptions on the contextual factors that could affect the implementation of the rehabilitation model of care in the facility. Twenty-seven professionals with various backgrounds were purposively sampled using a maximum diversity sampling strategy. A hybrid inductive-deductive approach was used to analyze the data using the Context and Implementation of Complex Interventions (CICI) Framework.

Results

Across the domains of the CICI framework, three domains (political, epidemiological, and geographical) and seven corresponding sub-domains of the context were found to have a major influence on the implementation process. Key elements within the political domain included effective teamwork, facilitation, adequate resources, effective communication strategies, and a vision for change. Within the epidemiological domain, a key element was knowing how to tailor rehabilitation approaches for persons with CI. Infrastructure, an aspect of the geographical domain, focused on the facility’s physical layout that required attention.

Conclusions

The CICI framework was a useful guide to identify key factors within the context that existed and were required to fully support the implementation of the model of care in a new environment. The findings suggest that when implementing a new program of care, strong consideration should be paid to the political, epidemiological, and geographical domains of the context and how they interact and influence one another.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06206-9.

When interactions are interruptions: an ethnographic study of information-sharing by speech and language therapists and nurses on stroke units

PURPOSE

To explore how the information-sharing context influences how speech and language therapy (SLT) and nursing staff interact on stroke units and what they discuss.

METHODS

Ethnographic methodology was used, with data collected during 40 weeks of fieldwork across three inner city stroke units in the UK. Data comprised field notes collected during 357 h of participant observation and 43 interviews. Interviews were conducted with 14 SLTs, 1 SLT assistant, 24 registered nurses and 4 nursing assistants.

RESULTS

This paper is focused on informal information-sharing. SLTs and nurses had different experiences of time and space (the temporal-spatial context) with respect to ward presence and proximity to patients, influencing how they interacted, the content of their talk and their relationships. Most interactions had the quality of interruptions, in which SLTs seized moments in between nursing tasks. Conditions were less suited to sharing information about communication than swallowing and SLTs felt more allied to other therapists than nurses.

CONCLUSION

The temporal-spatial context impeded information-sharing, particularly about patients' communication needs. Consideration should be given to developing relationships between SLTs and nurses as key partners for patient care and raising the profile of communication information in ways that are relevant and useful to nursing work.Implications for rehabilitationStrategic waiting for opportunities to interrupt nurses and gain their attention is central to how speech and language therapists manage their need to share information informally with nurses.The small "windows in time" available for interaction influence information-sharing, with a limiting effect on information about patients' communication.There is potential to improve information-sharing between speech and language therapists and nurses by considering how the relevance of information for patient care could be made clearer.

Communication in interprofessional rehabilitation teams: a scoping review

PURPOSE

Effective communication in interprofessional rehabilitation teams is essential for optimal patient care. Despite the established importance, it remains unclear how interprofessional communication (IPC) within teams contributes to rehabilitation service delivery. The aim of this scoping review was to investigate how IPC has been described in rehabilitation literature.

METHODS

Databases (Medline, CINAHL, ERIC, Embase, PsychInfo, and Academic Search Complete) were searched for studies including rehabilitation interprofessional communication. Inclusion and exclusion criteria were identified and applied, data were charted, and thematic analysis conducted.

RESULTS

Twenty-nine papers were identified, and analysis revealed interrelated themes: communication processes, and inputs and effects. Formal communication processes were most prevalent, portraying variability in professional participation and a lack of patient involvement in dialogue and decision making. Inputs and effects were described at an organisational, team and individual level, highlighting the importance of communication throughout the healthcare hierarchy.

CONCLUSIONS

IPC in rehabilitation is central to effective team function and patient care. To further our understanding, empirical studies examining everyday informal IPC, as well as formal ritualised encounters are needed. Additionally, conceptualisations of IPC would benefit from including the patients' perspective and by using theoretical framing to attend to places, spaces, and artefacts identified in this review.

Clinicians' perceptions of rounding processes and effectiveness of clinical communication

RATIONALE, AIMS, AND OBJECTIVES

Ward rounds present opportunities for medical officers, nurses, allied health clinicians, and patients to interact and plan patient care. A recent literature review found eight types of rounding processes. Different purposes, varying levels of representation from clinical professions, and understanding of each others' roles revealed a complex activity. A shared understanding of rounding processes facilitates positive teamwork and improves patient care. We examined how clinicians perceive the nature of rounding processes they undertake within their practice, multidisciplinary team attendance at rounds, and the effectiveness of team communication.

METHODS

We surveyed frontline professionals in two acute care and two rehabilitation wards from a metropolitan teaching hospital. There were 77 participants representing medical officers, nurses, and allied health clinicians. Participants selected the type of rounding processes undertaken on their ward from a list of six defined types, then answered questions about who participated in the rounds and their perceptions of the effectiveness of multidisciplinary communication. Survey findings were analysed using descriptive statistics and comparison.

RESULTS

Overall, professionals were inconsistent in the identification of number and types of rounds. Participants nominated processes more consistently within individual clinical disciplines than by clinical speciality. Medical officers identified rounds most consistently, while some nurses were unable to identify any rounding processes undertaken. The perceptions clinicians had of their own attendance at rounds differed from that of their colleagues. Despite variation in perceptions about rounds, professionals reported effective multidisciplinary communication patterns overall.

CONCLUSION

Rounds are a common yet complex activity. Rounds are revealed to be a taken-for-granted organizational activity with diversity in function, attendance, and participation, yet rounding processes are perceived and experienced differently between health professions. These differences impact on multidisciplinary attendance at rounds amongst peers. Making and communicating explicit round expectations and roles for clinicians supports coordinated teamwork and care planning.

Examining subacute nurses' roles in a changing healthcare context

AIMS AND OBJECTIVES

To explore and describe nurses' role in the rehabilitation and care of patients in one subacute care facility in Melbourne, Australia.

BACKGROUND

The role of nurses in subacute care and within the rehabilitation team is evolving and remains unclear.

DESIGN

Mixed methods.

METHODS

Fourteen nurses from seven rehabilitation and geriatric evaluation and management wards in one subacute facility in Melbourne, Australia, were observed in practice for two hours and then interviewed. Activities were recorded electronically. Interviews were audio-recorded and transcribed. Data were analysed using content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

RESULTS

Three main themes are as follows: (a) Nurses as rehabilitators; (b) Teamwork in rehabilitation; and (c) The changing context of subacute care. Nurses prioritised patient personal and clinical care above other responsibilities. They were largely excluded from team decision-making because clinical responsibilities precluded them from attending team meetings. Unsuitable buildings, increased patient acuity and time constraints were further challenges.

CONCLUSIONS

Nurses have a multifaceted role in patient rehabilitation that is poorly understood. An evaluation of the nursing role within the interdisciplinary team, skills and processes of care may increase understanding, and improve communication and relationships between disciplines potentially benefiting patients. Role clarity and differentiation in nursing skills are required within the nursing workforce.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a unique role in both clinical care and rehabilitation of patients, and as part of the interdisciplinary team. Respectful professional relationships need fostering within the interdisciplinary team to achieve optimal patient outcomes. The way that team meetings and decision-making occur in the subacute wards requires adjustment to ensure that the valuable contribution of nurses, both to the interdisciplinary team and to the rehabilitation of patients, is used and acknowledged to improve patient care.

Development of a participatory, tailored behaviour change intervention to increase active practice during inpatient stroke rehabilitation

Purpose: An evidence-practice gap exists between the amount of active practice recommended and the amount completed by stroke inpatients. The aim of this paper is to describe steps in the design of a participatory, theoretically tailored staff behaviour change intervention to help staff use strategies to increase active practice by stroke inpatients.Methods: A staff behaviour change intervention was developed in one rehabilitation unit in Queensland, Australia using a six-step process guided by the Behaviour Change Wheel framework. Mixed methods were used including direct observation (behavioural mapping), and focus groups to identify barriers and facilitators to implementation. Barriers and facilitators were mapped to the behaviour change techniques, and a behaviour change intervention developed in participation with rehabilitation staff.Results: Staff chose to implement ward-based practice books. Barriers included patient factors (including low motivation and severity of stroke), environmental segregation and limited skills for motivating patients. Staff belief in increasing active practice was a facilitator to implementation. The staff intervention included a training programme about motivation, environmental restructuring, audit, and feedback.Conclusions: This example of collaborative implementation research can be used and adapted by clinicians and researchers in other rehabilitation services.IMPLICATIONS FOR REHABILITATIONRehabilitation staff can be actively involved in designing behaviour change interventions.Behaviour change interventions should target local barriers to increase activity levels and practice completed by stroke inpatients.The process of co-designing behaviour change interventions has the potential to improve the uptake of a strategy such as ward-based practice books, by more precisely identifying local barriers and possible solutions.

Communication between therapists and nurses working in inpatient interprofessional teams: systematic review and meta-ethnography

Purpose: The aim of the synthesis was to develop a new understanding about the influences on communication in interprofessional teams from therapist and nurse perspectives.Methods: Six electronic databases were searched, combined with citation tracking and hand searching, yielded 3994 papers. Three researchers were involved in screening and quality appraisal, resulting in 18 papers for synthesis, using the process of meta-ethnography. Concepts were identified, compared and translated under five category headings. Two researchers mapped interpretative summaries and a line of argument was created.Results: The line of argument is that four inter-related contingences underpin effective communication between therapists and nurses. Effective communication depends on there being a genuine need to give and receive information for patient care, the capacity to attend to, hold, and use information, and opportunities to share space to enable communication to occur. The fourth contingency is good quality relationships and this is the glue that holds the contingencies together.Conclusion: This synthesis has provided an opportunity to illuminate how therapists and nurses accomplish interprofessional work through communication. The contingencies of need, capacity, opportunity, and quality of relationships create a new structure for understanding what underpins communication between these two groups.Implications for RehabilitationNeed, capacity and opportunity should be understood as contingencies that underpin effective communication about patients, strongly centered on the fourth contingency, quality of relationships between professionals.Therapists and nurses should examine what information they genuinely need from each other to effectively conduct integrated care, from the perspective of both giving and receiving information.Consideration should be given to whether a culture of reciprocity might expand the capacity of professionals to attend to, hold and use the information they share about patients.Therapists and nurses should examine how the way they share space on the ward creates or limits their opportunities to communicate about patients and develop relationships.

Understanding nursing practice in stroke units: a Q-methodological study

PURPOSE

Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses' involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses' practice in stroke rehabilitation.

METHOD

Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members.

RESULTS

Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role.

CONCLUSIONS

The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills. Implications for Rehabilitation Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care. Views of stroke unit team members on nurses' involvement in rehabilitation have not been reported previously. Nurses can routinely incorporate rehabilitation principles in their care. Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

Perception From Barrier and Facilitator for Providing Early Rehabilitation Care for RTI Victims

Background:

Road traffic injuries (RTIs) are a major public health problem and the most important cause of disability, morbidity and mortality worldwide. Early rehabilitation can play a significant role in minimizing complications, morbidity and mortality.

Objectives:

The aim of this study was to describe perceptions of barriers precluding provision of early rehabilitation care for RTI victims.

Patients and Methods:

A qualitative content analysis was carried out on 15 nurses with at least one year experience caring for RTI victims. The nurses were selected from various wards (emergency, orthopedic, neurosurgery, and clinic) of Sina and Imam Khomeini Hospitals via targeted sampling. Data were collected through semi-structured interviews and targeted sampling until data saturation. Data were analyzed and assessed.

Results:

After continuous analysis and comparison of data, major causes precluding nurses from early rehabilitation of RTI patients were retrieved. These barriers included: (a) lack of insight, (b) lack of comprehensive care (c) excessive costs; facilitating factors included (d) training for cooperation and (e) support for coping.

Conclusions:

The findings of this study show that the need for early rehabilitation in the hospital phase of care for RTI victims is needed. Knowledge about the barriers precluding nurses from early rehabiltiation of RTI patients and facilitators that can help health care workers and policy makers eliminate the barriers precluding early rehabilitation can help health care workers, especially nurses enable patients get over their disability and gain social and family support.

Evidence of a shared purpose, critical reflection, innovation and leadership in interprofessional healthcare teams: a realist synthesis

Realist synthesis is a theory-driven approach for evaluating complex interventions using empirical evidence, which seeks an explanatory analysis of who a complex intervention works for, how, why, and in what circumstances. Interprofessional teamworking in healthcare is one such complex intervention, as teams are influenced by social and organizational factors, which makes them highly variable and context dependent. This article concludes a series of four articles that report on a realist synthesis of interprofessional teamworking. The synthesis identified 13 mechanisms that are reported in the literature to be the underlying processes through which interprofessional teamworking produces its effects. This article explores four of these mechanisms: a shared purpose; critical reflection; innovation; and leadership. These mechanisms together explain how a team sets and maintains its focus and direction. This article highlights that whilst many assumptions are made within the healthcare literature about how these mechanisms operate within teams, these assumptions are not always founded upon strong empirical evidence.

Nursing practice in stroke rehabilitation: systematic review and meta-ethnography

AIMS AND OBJECTIVES

To identify and synthesise the available research evidence in order to generate an explanatory framework for nursing practice in stroke rehabilitation.

BACKGROUND

Although nurses are the largest professional group working with stroke survivors, there is limited understanding of nursing practice in stroke units. In particular, there is currently very little evidence in respect of nurses' involvement in poststroke rehabilitation.

DESIGN

Meta-ethnography.

METHOD

A systematic review was undertaken. The review question was: 'What is the nature of nursing practice in the care and rehabilitation of inpatient stroke survivors?' Searches of 12 electronic databases identified 14,655 publications, and after screening, 778 remained; 137 papers were obtained and 54 retained for mapping. Sixteen qualitative studies were included in the meta-ethnography.

RESULTS

Nurses' involvement in poststroke rehabilitation was limited. Contextual factors impacted on nurses' perceptions and practice. Nurses' integration of rehabilitation skills was perceived to be contingent on adequate nurse staffing levels and management of demands on nurses' time. Team working practices and use of the built environment indicated separation of nursing and therapy work. Physical care and monitoring were prioritised. Stroke-specific education and training was evident, but not consistent in content or approach. Stroke survivors and families needed help to understand nurses' role in rehabilitation.

CONCLUSION

The review provides compelling evidence that there is an need to re-examine the role of nurses in contributing to poststroke rehabilitation, including clarifying when this process can safely begin and specifying the techniques that can be integrated in nurses' practice.

RELEVANCE TO CLINICAL PRACTICE

Integrating stroke-specific rehabilitation skills in nurses' practice could contribute substantially to improving outcomes for stroke survivors. The explanatory framework developed from the review findings identifies issues which will need to be addressed in order to maximise nurses' contribution to the rehabilitation of stroke survivors.

Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change

BACKGROUND

Medical Research Council (MRC) guidance identifies implementation as a key element of the development and evaluation process for complex healthcare interventions. Implementation is itself a complex process involving the mobilization of human, material, and organizational resources to change practice within settings that have pre-existing structures, historical patterns of relationships, and routinized ways of working. Process evaluations enable researchers and clinicians to understand how implementation proceeds and what factors impact on intended program change. A qualitative process evaluation of the pragmatic cluster randomized controlled trial; Training Caregivers after Stroke was conducted to examine how professionals were engaged in the work of delivering training; how they reached and involved caregivers for whom the intervention was most appropriate; how did those on whom training was targeted experience and respond to it. Normalization Process Theory, which focuses attention on implementing and embedding program change, was used as a sensitizing framework to examine selected findings.

RESULTS

Contextual factors including organizational history and team relationships, external policy, and service development initiatives, impinged on implementation of the caregiver training program in unintended ways that could not have been predicted through focus on mechanisms of individual and collective action at unit level. Factors that facilitated or impeded the effectiveness of the cascade training model used, whether and how stroke unit teams made sense of and engaged individually and collectively with a complex caregiver training intervention, and what impact these factors had on embedding the intervention in routine stroke unit practice were identified.

CONCLUSIONS

Where implementation of complex interventions depends on multiple providers, time needs to be invested in reaching agreement on who will take responsibility for delivery of specific components and in determining how implementation and its effectiveness will be monitored. This goes beyond concern with intervention fidelity; explicit consideration also needs to be given to the implementation process in terms of how program change can be effected at organizational, practice, and service delivery levels. Normalization Process Theory's constructs help identify vulnerable features of implementation processes in respect of the work involved in embedding complex interventions.

Improving hospital care and collaborative communications for the 21st century: key recommendations for general internal medicine

Background

Communication and collaboration failures can have negative impacts on the efficiency of both individual clinicians and health care system delivery as well as on the quality of patient care. Recognizing the problems associated with clinical and collaboration communication, health care professionals and organizations alike have begun to look at alternative communication technologies to address some of these inefficiencies and to improve interprofessional collaboration.

Objective

To develop recommendations that assist health care organizations in improving communication and collaboration in order to develop effective methods for evaluation.

Methods

An interprofessional meeting was held in a large urban city in Canada with 19 nationally and internationally renowned experts to discuss suitable recommendations for an ideal communication and collaboration system as well as a research framework for general internal medicine (GIM) environments.

Results

In designing an ideal GIM communication and collaboration system, attendees believed that the new system should possess attributes that aim to: a) improve workflow through prioritization of information and detection of individuals’ contextual situations; b) promote stronger interprofessional relationships with adequate exchange of information; c) enhance patient-centered care by allowing greater patient autonomy over their health care information; d) enable interoperability and scalability between and within institutions; and e) function across different platforms. In terms of evaluating the effects of technology in GIM settings, participants championed the use of rigorous scientific methods that span multiple perspectives and disciplines. Specifically, participants recommended that consistent measures and definitions need to be established so that these impacts can be examined across individual, group, and organizational levels.

Conclusions

Discussions from our meeting demonstrated the complexities of technological implementations in GIM settings. Recommendations on the design principles and research paradigms for an improved communication system are described.

Achieving teamwork in stroke units: the contribution of opportunistic dialogue

Collaborative interdisciplinary working is central to contemporary health policy. The specialized and co-ordinated multidisciplinary care provided in stroke units is considered to contribute to improved patient outcomes in such units. However, how stroke unit teams co-ordinate their work is not clearly understood. This paper reports on a grounded theory study which explains how health professionals in two stroke units in northern England achieved teamwork. Data were generated through 220 hours of participant observation and 34 semi-structured interviews. Interviews were undertaken during and following participant observations. A basic social process common to teamworking in both units was identified; this was termed "opportunistic dialogue". The division of labour in respect of rehabilitation activities was negotiated through this interactional process. Co-location of most team members led to repeated engagement in sharing patient information and in exploring different perspectives. Opportunistic dialoguing contributed to mutual learning and explained the shift in thinking and team culture as team members moved from concern with discrete disciplinary actions to dialogue and negotiations focused on meeting patients' needs. The findings indicate that routinely incorporating periods of joint working in which team members articulate the reasoning for their decisions and interventions, contributes to achieving interdisciplinary teamworking in rehabilitation settings.

Enhancing inpatient rehabilitation through the engagement of patients and nurses

AIM

This paper is a report of a study conducted to describe nurses' knowledge, experiences and perceptions of a rehabilitation nursing practice development project conducted in their workplace.

BACKGROUND

Several studies over the past two decades have led to increasing clarity about the nursing role in rehabilitation. Practice development is a useful vehicle for using the findings of such studies to enhance person-centred practice in rehabilitation settings.

METHOD

This qualitative study, in which grounded theory informed data collection and analysis, involved interviews with 21 nurses working in an inpatient rehabilitation unit in Australia about their knowledge, experiences and perceptions of a rehabilitation nursing practice development project conducted in their workplace. The three rounds of interviews were conducted as follows: 1) December 2005-January 2006; 2) June-July 2006; and 3) October 2006.

FINDINGS

Practice development was an effective vehicle for developing rehabilitation nursing practice. While collaboration and leadership were critical to the effectiveness of the project, the use of a clinically credible practice development facilitator and a focus on the development of collective nursing practice also seem to have been important. Through the introduction of new activities, both patient and nurse engagement in rehabilitation was enhanced and, as a consequence, the nurses developed a deeper appreciation of their role in rehabilitation.

CONCLUSION

Carefully and collaboratively designed and sensitively implemented work-based practice development initiatives can change the context and culture of inpatient care. The use of a facilitator with relevant clinical nursing expertise to engage staff individually and collectively with research findings and to reflect on their practice and skill development is worth exploring in similar initiatives.

Opting in and opting out: a grounded theory of nursing’s contribution to inpatient rehabilitation

Aim: To develop a grounded theory of nursing’s contribution to patient rehabilitation from the perspective of nurses working in inpatient rehabilitation.

Design: Grounded theory method, informed by the theoretical perspective of symbolic interactionism, was used to guide data collection and analysis, and the development of a grounded theory.

Setting: Five inpatient rehabilitation units in Australia.

Participants: Thirty-five registered and 18 enrolled nurses participated in audio-taped interviews and/or were observed during periods of their everyday practice.

Findings: The analysis revealed a situation whereby nurses made decisions about when to ‘opt in’ and when to ‘opt out’ of inpatient rehabilitation. This occurred on two levels: with their interaction with patients and allied health professionals, and when faced with negative system issues that impacted on their ability to contribute to patient rehabilitation. The primary contribution nurses made to inpatient rehabilitation was working directly with patients, enabling them to self-care. Nurses coached patients when their decisions about ‘opting in’ and ‘opting out’ were based on assessment of the person in their particular context. In contrast, the nurses mostly distanced themselves from system-based problems, ‘opting out’ of addressing them. They did this not to make their working lives easier, but more manageable.

Conclusion: System-based problems impacted negatively on the nurses’ ability to deliver comprehensive rehabilitation care. As a consequence, some nurses felt unable to influence the care and they withdrew professionally to make their work lives more manageable.

Talking about stroke rehabilitation can improve team processes

Stroke is an international health concern. The World Health Organization (WHO, 2004) estimates that 15 million people will suffer a stroke every year. Thus stroke represents one of the most common causes of death and disability throughout the world. However, as numerous risk factors for stroke are modifiable, many countries have developed national strategies to prevent strokes, e.g. through better recognition and control of hypertension. In Canada, the United States, Australia and the United Kingdom (UK) these strategies also focus on early intervention and treatment in reducing death and disability, and recognize the key role played by rehabilitation professionals in assisting individuals to adjust and adapt their lives following a stroke.