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JARNAThe Official Journal of the Australasian Rehabilitation Nurses’ Association

Volume 21 Number 1 April 2018

In this issue:

Guest editorial Reflections on a career in nursing

Nursing bedside clinical handover: a pilot study testing a ward-based education intervention to improve patient outcomes

Women’s experience of traumatic brain injury — a narrative review

Development of a falls risk screening tool in a traumatic brain injury rehabilitation population: a two-phased project

Growing vegetables as part of rehabilitation

Australasian Rehabilitation Outcomes Centre

2 Day Registration... ARNA Members $500Non Members $670

28TH NATIONAL CONFERENCE

REHABILITATION NURSING:

environments practice lives

ENABLING

KEYNOTE SPEAKERSDr Joan OstaszkiewiczRN, GCert Cont Prom, GCertHE, MNurs-Res, PhD

Dr Tracey McDonaldAM, PhD, MSC(Hons), BHA (UNSW), Dip.Ed; RN, RM, GAICD

Tracey McDonald is a clinical gerontologist who, for the past 13 years, has held the research Chair of Ageing with ACU where she further augmented a national and international clinical, management, academic and scholarship career spanning 50 years. Tracey was appointed as a Member of the Order of Australia (AM) in 2012 for her work in nursing, health and aged care. She has also focused her energies on, inter alia, policy

development review in relation to human rights, health and ageing, clinician safety and quality and life quality. She brings experience in clinical care, treatment support and protection of older adults from abuse; all levels of education, social policy and management in not-for profit organisations associated with professional practice, education and services to older adults.

Joan Ostaszkiewicz is a Registered Nurse and an academic in the Deakin University- Barwon Health Partnership, Centre for Quality and Patient Safety Research at Deakin University in Australia. Her clinical and academic expertise is in the management of incontinence in frail older adults and in designing, developing and evaluating workforce models to promote evidence-based nursing

practice to enhance the quality of care for people who are care dependent. Her PhD and postdoctoral work resulted in a new conceptual approach to continence care for people with complex health conditions who are incontinent or who require assistance to maintain continence.

OCTOBER 18 & 19 2018FAIRMONT RESORT LEURA, BLUE MOUNTAINS NSW

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NOW OPEN

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Book before 30 June to be in the running for two nights free accommodation*

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1JARNA Volume 21 Number 1 April 2018

The Official Journal of the Australasian Rehabilitation Nurses’ Association

Volume 21 Number 1 — April 2018

ARNA National Committee

ExecutivePresident: Deidre Widdall (NT)Email: [email protected]

Vice President: Murray Fisher (NSW)Email: [email protected]

Secretary: Kay Stevens (NT)Email: [email protected]

Treasurer: Kerrie Garrad (QLD)Email: [email protected]

Vice Treasurer: Patricia Dobbs (VIC)

Editor-in-Chief JARNA: Julie Pryor (NSW)Email: [email protected]

Committee MembersSandra Lever (NSW)Alison New (QLD)Kylie Wicks (NSW)Sue Andrusiow (NSW)Raewyn Buchanan (VIC)Elizabeth Collins (SA)Erika Schlemmer (WA)

Chapter PresidentsBrendan Bakes — Victorian/Tasmanian ChapterAlison New — Queensland ChapterGail Teal-Sinclair — NSW/ACT ChapterTerry Wells — SA/NT ChapterStephanie Jones — WA Chapter

JARNA Editor-in-ChiefJulie Pryor RN, BA, GradCertRemoteHlthPrac, MN, PhD, FACN

Associate EditorMurray Fisher RN, ICT Cert, DipAppSc (Nursing), BHSc (Nursing), MHPEd, PhD

JARNA Editorial Board MembersMark Baker RN, BN, DipHSM, GradDipNursing (MentalHlth), ProfCertTLHPE, MN

Brendan Bakes RN, BN, PostGrad Diploma in Clinical Nursing (Ortho), MN by Research, MACN

Murray Fisher RN, ICT Cert, DipAppSc (Nursing), BHSc (Nursing), MHPEd, PhD

Sandra Lever RN, BHM, Post-Reg Cert in Rehab Nursing, GradDipHlthSc (Sexual Health), MN (Rehab), MACN

Alison New RN, BHScN, MCR, MHScNCE

Deidre Widdall RN, GradCertStomalTherapyNurs, MClinRehab

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ISSN 1440-3994

©2018 All rights reserved. No part of this publication may be reproduced or copied in any form or by any means without the written permission of the publisher. Unsolicited material is welcomed by the editor but no responsibility is taken for the return of copy or photographs unless special arrangements are made. The opinions expressed in articles, letters and advertisements in JARNA are not necessarily those of the publisher or the Australasian Rehabilitation Nurses’ Association.

PO Box 546, East Melbourne, VIC 3002, AustraliaTel: +61 3 9895 4483 Fax: +61 3 9898 0249Web: www.arna.com.au

Contents

Editorial A few more words on person-centred rehabilitation 2

Letter to the editor 4

Guest editorial Reflections on a career in nursing 5

Nursing bedside clinical handover: a pilot study testing a ward-based education intervention to improve patient outcomes 9

Women’s experience of traumatic brain injury — a narrative review 19

Development of a falls risk screening tool in a traumatic brain injury rehabilitation population: a two-phased project 22

Growing vegetables as part of rehabilitation 24

Australasian Rehabilitation Outcomes Centre 29

Guidelines for submission of manuscripts to JARNA 31


28TH NATIONAL CONFERENCE

REHABILITATION NURSING:

environments practice lives

ENABLING

KEYNOTE SPEAKERSDr Joan OstaszkiewiczRN, GCert Cont Prom, GCertHE, MNurs-Res, PhD

Dr Tracey McDonaldAM, PhD, MSC(Hons), BHA (UNSW), Dip.Ed; RN, RM, GAICD

Tracey McDonald is a clinical gerontologist who, for the past 13 years, has held the research Chair of Ageing with ACU where she further augmented a national and international clinical, management, academic and scholarship career spanning 50 years. Tracey was appointed as a Member of the Order of Australia (AM) in 2012 for her work in nursing, health and aged care. She has also focused her energies on, inter alia, policy

development review in relation to human rights, health and ageing, clinician safety and quality and life quality. She brings experience in clinical care, treatment support and protection of older adults from abuse; all levels of education, social policy and management in not-for profit organisations associated with professional practice, education and services to older adults.

Joan Ostaszkiewicz is a Registered Nurse and an academic in the Deakin University- Barwon Health Partnership, Centre for Quality and Patient Safety Research at Deakin University in Australia. Her clinical and academic expertise is in the management of incontinence in frail older adults and in designing, developing and evaluating workforce models to promote evidence-based nursing

practice to enhance the quality of care for people who are care dependent. Her PhD and postdoctoral work resulted in a new conceptual approach to continence care for people with complex health conditions who are incontinent or who require assistance to maintain continence.

OCTOBER 18 & 19 2018FAIRMONT RESORT LEURA, BLUE MOUNTAINS NSW

EARLY BIRD REGISTRATIONS

NOW OPEN

REGISTER VIA:arna2018.com.au

Undergraduate Nursing Student Discount... $50 off Early Bird and Standard Registration*

Special Conference Accommodation Rate $209/night*at Fairmont Resort for Conference Attendees

Book before 30 June to be in the running for two nights free accommodation*

*Conditions apply, see website for more information.


EARLY BIRD REGISTRATION PRICES

2 Volume 21 Number 1 April 2018 JARNA

EditorialA few more words on person-centred rehabilitation

Julie Pryor RN, BA, GradCertRemoteHlthPrac, MN, PhD, FACN

Editor-in-Chief

Email: [email protected]

With the central tenet of person-centredness being “respect for

and integration of individual differences when delivering patient

care” (Lauver et al., 2002, p. 248), engaging patients individually

in their own care as well as at a system level is now strongly

advocated (Australian Commission on Safety and Quality in

Health Care [ACSQHC], 2011a; Loeffler, Power, Bovaird &

Hine-Hughes, 2013). At the system level, there is increasing

interest in involving consumers in the design and evaluation of

health service delivery (ACSQHC, 2011b), with this sometimes

referred to as experience-based co-design. Some local examples

can be located on these websites:

http://www.healthcodesign.org.nz/about.html;

https://chf.org.au/experience-based-co-design-toolkit; and

https://www.aci.health.nsw.gov.au/__data/assets/

pdf_file/0003/390126/ACI-Experience-Based-Co-design-

Infographic.pdf.

At the individual level, person-centredness means involving

patients in shared decision making and providing support for

self-management (Ahmad, Ellins, Krelle & Lawrie, 2014); it is

about ‘doing with’ rather than ‘doing to’ (Loeffler et al., 2013).

It is a philosophy or way of thinking that informs the way we act.

Only last week I recall myself referring to person-centredness as

the manner in which technically competent health care should

be delivered. But what does this look like in everyday practice?

Thinking about person-centredness at the individual level

requires us to consider the nurse–patient relationship because

this is where nurses enact the notion of person-centredness

as explained by St-Germain, Boivin and Fougeyrollas (2011, p.

2106):

The effort the person in rehabilitation has to expend

on a daily basis to ensure a successful outcome to the

rehabilitation is driven by the power of the day-to-day

relationship between the caregiver and care receiver.

Borg, Karlsson, Tondora and Davidson (2009, p. 84) make the

point that person-centredness may require: “1) reorientation from

patient to personhood; 2) reorientation of what is considered

valued knowledge and expertise; and 3) partnership and

negotiation”. Being person-centred means that nurses engage

in these activities together with patients, with nurses acting as

agents of change in a patient’s rehabilitation (Pryor, 2005; Tyrell

& Pryor, 2016). The nurse and patient come to the interaction

as separate people, with possibly quite different resources

and ‘habitus’ (Oerther & Oerther, 2017), but it is the nurse’s

professional responsibility to engage the person who is the

patient.

Engagement, however, can mean many things and take many

forms, hence further clarity is needed. Following a review of the

healthcare and rehabilitation literature, the following definition

of engagement was proposed by Bright, Kayes, Worrall and

McPherson (2015, p. 650):

Engagement is a co-constructed process and state. It

incorporates a process of gradually connecting with

each other and/or a therapeutic program, which enables

the individual to become an active, committed and

invested collaborator.

In a subsequent study of practitioner engagement and

disengagement in stroke rehabilitation, Bright, Kayes, Cummins,

Worrall and McPherson (2017, p. 1396) found that “when patients

considered practitioners were engaged, this helped engagement.


When they considered practitioners were not engaged, their

engagement was negatively affected”. Similarly, practitioners

were affected by patients; “each party’s engagement influenced

the other, suggesting it was co-constructed” (p. 1396). Bright

et al. (2017) include descriptions of engaged and disengaged

practitioners in their paper that are worth reading. The reader is

also referred to earlier editions of JARNA, where Tyrell and Pryor

(2016) provide guidance about creating effective nurse–patient

relationships and I reviewed the text Rethinking rehabilitation:

Theory and practice (Pryor, 2017), for further reading about this.

Thinking about engagement being co-constructed is in line

with my suggestion, four years ago now, that the principles (i.e.,

determining characteristics or essential qualities) of rehabilitation

are “values-guided, person-centred enablement of person–

environment congruence using goal-directed, strengths-based

co-production” (Pryor, 2014, p. 2). The fit of rehabilitation being

a “co-production between patients, their family and friends, and

the treating clinicians” (Pryor, 2014, p. 3) with co-constructed

engagement as described by Bright et al. (2017) is particularly

strong.

Further to this, in 2014 I explained that:

Rehabilitation is not done by one person to another.

All members of the team have strengths. Clinicians

use their expertise to guide and support patient work

(Pryor & Dean, 2012). Patients share the significance

they assign to their situation with clinicians. Family and

friends are potential sources of a wide range of inputs to

the co-production. Seek and capitalise on the strengths

of each person on the rehabilitation team. Also, capitalise

on the research evidence to guide the co-production of

rehabilitation (Pryor, 2014, p. 3).

While more recently the spotlight has been beginning to shine

on the clinician’s role in co-constructed practitioner–patient

relationships, I think it is vital not to forget that the notions of co-

constructed engagement and co-produced rehabilitation bring

with it expectations of the patient. For many years ARNA has

positioned the maximisation of self-determination as a goal of

rehabilitation. It features in our position statements about scope

of practice and undergraduate nursing curricula as well as our

competency standards for registered nurses, all of which can

be found on our website: www.arna.com.au. However, to my

knowledge we are yet to consider in full what this might mean for

the patient. In relation to this, the following caught my attention

recently in an analysis of the Swedish rehabilitation sector:

The liberal idea of self-determination makes certain

demands on the ‘user’. These demands are categorised

as ‘physical presence’, ‘interpretable voice’, ‘purposeful

voice’, ‘sincere voice’ and ‘realisable voice’ (Karlsson &

Nilholm, 2006, p. 193).

These researchers report on a range of dilemmas encountered

when seeking to enact the ideal of self-determination in everyday

practice which are worthy of our attention. While many may be

familiar to experienced clinicians in pursuit of person-centred

practice, the emphasis on what this means in relation to demands

upon the patient is the take-home message for me. Karlsson

and Nilholm (2006) conclude that given these dilemmas “the

possibility of appreciating interdependence and justifying

paternalistic actions also needs to be acknowledged” (p. 193).

This does not mean they are condoning paternalism, rather

they are acknowledging the complexities of enacting person-

centredness. These are important points in the evolution of our

understanding of effectiveness in relationship to rehabilitation

service delivery that are not unique to nursing. This thinking is

relevant to all clinicians, regardless of their discipline, in their

pursuit of person-centred clinical excellence.

In this, my final editorial as editor-in-chief of JARNA, I have

included several studies that are worthy of your attention. I

encourage you to track them down then read and discuss with

your colleagues on our journey to co-produce person-centred,

clinically effective and resource-efficient rehabilitation services

that meet the needs of our ever-evolving communities.

ReferencesAhmad, N., Ellins, J., Krelle., H., & Lawrie, M. (2014). Person-centred

care: From ideas to action. London: The Health Fund.

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2011a). Patient-centred care: improving quality and safety through partnerships with patients and consumers. Retrieved 20 February 2018 from http://www.safetyandquality.gov.au/wp-content/uploads/2012/03/person-centred care_Paper_August.pdf.

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2011b). National safety and quality health service standards. Retrieved 6 March 2018 from http://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/.

Borg, M., Karlsson, B., Tondora, J., & Davidson, L. (2009). Implementing person-centred care in psychiatric rehabilitation: what does this involve? Israel Journal of Psychiatry and Related Sciences, 46(2), 84–93.

Bright, F. A. S., Kayes, N. M., Worrall, L., & McPherson, K. (2015). A conceptual review of engagement in healthcare and rehabilitation. Disability and Rehabilitation, 37(8), 643–654.

Bright, F. A. S., Kayes, N. M., Cummins, C., Worrall, L., & McPherson, K. (2017). Co-constructing engagement in stroke rehabilitation: a qualitative study exploring how practitioner engagement can influence patient engagement. Clinical Rehabilitation, 31(10), 1396–1405.


Letter to the editor

“A memo about mentoring”

Jenny Kohlhardt RN, MN, MEd

Clinical Nurse Consultant, Geriatric and Rehabilitation Unit, Princess Alexandra Hospital

[email protected]

Karlsson, K., & Nilholm, C. (2006). Democracy and dilemmas of self-determination. Disability & Society, 21(2), 193–207.

Lauver, D. R., Ward, S. E., Heidrich, S. M., Keller, M. L., Bowers, B. J., Flatley Brennan, P., Kirchhoff, K. T., & Wells, T. J. (2002). Patient-centred interventions. Research in Nursing and Health, 25, 246–255.

Loeffler, E., Power, G., Bovaird, T., & Hine-Hughes, F. (eds). (2013). Co-production of health and wellbeing in Scotland. Governance International.

Oerther, S., & Oerther, D. B. (2017). Pierre Bourdieu’s Theory of Practice offers nurses a framework to uncover embodied knowledge of patients living with disabilities or illness: a discussion paper. Journal of Advanced Nursing, 74, 818–826.

Pryor, J. (2005). A grounded theory of nursing’s contribution to inpatient rehabilitation. Unpublished PhD thesis. Melbourne: Deakin University.

Pryor, J. (2014). Editorial. The principles of rehabilitation. JARNA (Journal

of the Australasian Rehabilitation Nurses Association), 17(1), 2–3.

Pryor, J. (2017). Book review: Rethinking rehabilitation: Theory and

practice. JARNA (Journal of the Australasian Rehabilitation Nurses

Association), 20(1), 19.

St-Germain, D., Boivin, B., & Fougeyrollas, P. (2011). The Caring Disability

Creation Process model: a new way of combining ‘Care’ in nursing

and ‘Rehabilitation’ for better quality of services and patient safety.

Disability and Rehabilitation, 33(21–22), 2105–2113.

Tyrell, E. F., & Pryor, J. (2016). Nurses as agents of change in the

rehabilitation process. JARNA (Journal of the Australasian

Rehabilitation Nurses’ Association), 19(1), 13–20.

How do you write a letter to the editor? Well, to say the least I am

a novice, so it is with this in mind that I ask you to treat me kindly

as I attempt to write in this new forum. My publishing journey

has been a long, slow process, but it would have been longer

and slower and I would have needed more perseverance that

I may have necessarily had the time or the patience, if it hadn’t

been for the help of a mentor. As a result, I’ve realised how a

kind, focused and personal approach to mentoring enhanced my

personal and professional growth and facilitated the publishing

process. I found that last month before publishing to be a

positive, relationship-building and respectful experience which

will encourage me to undertake the process again. Thank you

Julie. Interestingly, the process of writing this letter has prompted

my thoughts towards how mentoring is present in all professional

nursing roles at every level. Taking this idea further, the importance

of the clinical coach role in which mentoring plays an integral

part. As I assess the staff undertaking our clinical rehabilitation

transition program, and as the last group of undergraduates

head out of their “jacaranda coloured glasses” phase of study

(symbolically the end of the study year in Brisbane), I am mindful

of our integral role in spreading the word about what it means to

be a rehabilitation nurse to our current undergraduates who will

eventually teeter on the edge of the decision-making precipice of

“where do I want to work?”. All our interactions, both words and

actions, are being heard and felt, and if we want the “best” to

come and work with us, we need to be the best we can be too,

and to build what we want and what we need. Part of a building

is the theoretical foundation, so why not go the step further and

publish your fantastic thoughts and activities. Spread the seeds

of how fantastic we are as rehabilitation nurses! You never know

where the fertile soil may be.


Guest editorial

Reflections on a career in nursing

Garry FehringEmail: [email protected]

As I approach the 40-year reunion of my own nursing group, I

write for young and mid-career nurses, and perhaps the approval

of my own peers. This article is a brief consideration of the

importance of nursing history, some rehabilitation nursing history

and my thoughts on seeking leadership.

Quickly to introduce myself. I graduated as an RN in 1982

through the hospital program, completed an Oncology Nursing

Certificate in 1985, Rehabilitation Nursing Certificate in 1987,

Bachelor Degree in 1989 and Graduate Diploma in Nursing

Management in 1994. I have worked as a clinician and manager

in public and private patient rehabilitation services for 28 years,

with an additional nine years in other health environments. I

retired from the clinical scene in 2016. I am a life member of

ARNA, a member of both the Australian College of Nursing and

the Melba Opera Trust, and I currently serve as Vice-Chair of the

Board at Castlemaine Health in Victoria.

History

Nurses show their interest in history in many ways. I once met

a Tasmanian nurse who had collected thousands of items of

equipment and paraphernalia from nursing work; this monumental

task was to ensure the preservation and documentation of our

history. Nurses investigate, support and teach our history through

the Australian College of Nursing History Conference (Australian

College of Nursing, 2018).

Each year I attend the Nurses’ Memorial Service in Slater Street,

Melbourne, on the Sunday before 25 April. Usually there are very

few young heads among the silver and grey of older colleagues

at that service. Those who attend are there to honour and recall

nurses who suffered in war time; they are remembering those

who were injured and those who gave everything. At each year’s

event I find it deeply touching to remember the sacrifice nurses

have made in war time. For myself as one of the participants

in the 1985 and 1986 Victoria nurses’ strikes, I have vivid and

compelling memories of those events and the forces that were

opposed to nurses obtaining credible salaries and working

conditions.

Nursing philosophy for practice

I have always been interested in history and professionally in

nursing history, being one of I think the minority of nurses who

seem to want to read and talk about it. My view that history is

useful and relevant may be regarded by many of our colleagues

as an idiosyncrasy and not related to their daily work. I want

to consider: how important is nursing history?; should it be

important to nurses?; and what are the consequences of a lack

of regard for nursing history?

To some people, studying history may mean a tendency to look

backwards. To me it seems essential that to understand the world

and appreciate where we are up to and to anticipate change(s),

it is necessary to understand our past and where we have come

from. This is not to imply that looking backward along a time

line means that things were done better in the past. It means to

remember with affection those brilliant nurses who taught us.

It means to appreciate the efforts of those who went before us

and to understand how change is shaping our practice and our

lived experience as nurses. A nurse working today is dealing with

broad technological, complex care, as well as ethical and legal

issues that are likely to be more complex than was the case in

former years. I fear that to be unaware of our history may have

adverse effects, such as a tendency for disassociation from the

real meaning of nursing work.

My reading periodically indicates that a preoccupation with

history is necessary to understanding the present. There is a

large body of nursing theory and philosophy which I feel is under

acknowledged. It may be that because nursing is a practical

science and art that our philosophy for practice is not always

overtly stated. One could take the view that the generic nursing

degree program of three years has in fact four years of work

packed into it, and that those who develop the curriculum and

our educators are hard-pressed to deal in depth with worthwhile

topics, such as the history of the profession.


One thing that concerns me is how well we are inducting our

students to nursing philosophy and by implication rehabilitation

nursing philosophy. Henderson referred to nurses as

“rehabilitators par excellence” (Henderson, 1980, p. 246). In

saying this, Henderson meant that the philosophy of promoting

human independence is the first order of business for all nurses.

In recent years, in the role of Director Clinical Services, I made

it my practice to meet with the undergraduates who came on

clinical placements in my area of responsibility; I discussed

nursing assessment and ethics with them. Often I found that

the students were not able to identify particular theorists or a

philosophy of practice beyond a general reference to Nightingale

or an intention to help people. I wonder how well we are preparing

students in this regard; should I consider that their education is

fragmented.

Two examples that are historically important and of which the

student may not be aware are the works of Virginia Henderson

and Myra Levine. Virginia Henderson, an American nurse and

academic, is one of my heroes. Her theory and recommendations

for nursing assessment are the basis of many of the assessment

forms used in our rehabilitation hospitals; a practical, structured

process for learning about the patient and getting your

interview and examination data organised for: a) reflection; b)

communication with your colleagues; and c) to meet clinical,

ethical and legal obligations to document the patient’s care.

She called it ‘basic’ nursing care, though I prefer the term

‘fundamental nursing care’.

Henderson made very beautiful statements about the nurse

making his/her nursing assessment internalised, a part of

yourself, to know the patient; “get inside his skin” (Henderson,

1964, p. 64) and the resulting assessment being complete,

competent and made with authority. Perhaps a side issue,

when I was a student the nursing notes were held in separate

folders from the medical record; the purpose of this was so

that other professionals didn’t have to wade through nursing

documentation to find the medical information that they required.

I think it is historically relevant because it relegated nursing work

to the unimportant and inconvenient, and ignored or subjugated

their role to medicine and other professions. My rehabilitation

nursing course placed emphasis on the value of the nursing

assessment and actions to place the nursing view forward in the

discussion of the patient’s care. It was a proud day when, as a

primary nurse, I saw the team scrambling for my notes in order

to prepare for case conference for a patient who had arrived just

two hours earlier.

My second example is Myra Levine (1969) who has the honour

of introducing the concept of holism into the nursing literature

through her seminal statements. This included four principles for

the nurse–patient work:

• energy conservation;

• structural physical integrity;

• social integrity; and

• personal psychological integrity.

All nurses may state that a goal for nursing is to provide ‘holistic

nursing care’; Levine tells us what that should mean.

I would like to advocate for a stronger emphasis on history in our

under- and postgraduate nursing studies.

Rehabilitation nursing education

In 1986, I was recruited into a unique nursing program that was

developed and shared between the Royal Talbot Rehabilitation

Centre in Kew and Fairfield Infectious Diseases Hospital

Victoria. There were eight senior nurses inducted into the first

program: five women, all charge nurses, and three men who

were experienced clinicians. Classes were conducted in the

education centres at the two hospitals, with clinical placements

on the two campuses and visits conducted in other specialist

centres. I wish to acknowledge the nurse leaders who were

instrumental in designing and implementing the program: Dr Bev

Walker at Royal Talbot, Val Seeger at Fairfield; Jane Brennan,

Sandy Roberts and Bronwyn Mace.

This excellent program was designed to inspire general nurses,

which we were, to be rehabilitation specialists. The essential

goals from the course description were to: 1) provide specialist

education; 2) ensure the nursing role is not eroded; 3) provide

holistic nursing; 4) offer a high degree of skill; 5) ensure that

theoretical bases for practice are provided in an environment

where there had been fragmented learning and inconsistent

standards of nursing practice; and 6) meet community

expectations of professional nursing care.

Briefly the one-year course was designed to integrate theoretical

class room education and private reading into the clinical

program of ward assignment. There were case studies and

specialist teaching, including physicians and gerontological

nurses among our teachers; this education is still in my memory.

Assessment included:


• six theoretical student assessments;

• major, individualised negotiated assignment to 6,000 words;

and

• assessments during clinical placements at the two hospitals.

The core modules were: anatomy, physiology and pathophysiology,

microbiology and infection control, pharmacology, sociology,

psychology, human relations, including sexuality and sexual

function, investigative methods, teaching and learning, nursing

theory and models, nursing processes, nursing assessment,

rehabilitation process, disease processes, nursing and

rehabilitation, health care system and rehabilitation, course and

participant evaluation. Total contact hours were 456 hours plus

152 hours for independent study.

Happily, we were on full pay under the Victorian Nurses’ Award.

This course subsequently ran for another six yearly cycles.

What did the course achieve?

I became a primary nurse and led a small group of nurses within

a 55-bed rehabilitation ward with a dedicated caseload between

six and nine patients at any time. The course prepared me to

assist patients to plan a program of care; this sometimes ran

over several months in the case of those who had encountered

major disabilities. I learned to understand and negotiate within

multidisciplinary rehabilitation teams and to provide better

health education to patients and families. The nursing process

(assessment, planning, implementation and evaluation) had

been somewhat begrudgingly taught to me in my undergraduate

program. This straightforward idea, the application of logic to

thinking about patient care was emphasised in the rehabilitation

nursing course; it gave a structure to documentation of care,

communicating our ideas and plans with our colleagues,

negotiating with the patient (‘Is this what we have agreed for

your care?’) and encouraging a reflective approach to nursing

practice.

Notwithstanding my view that the course was excellent

preparation for rehabilitation nursing practice, I am reminded

that I wrote my course case study on a typewriter. The last 30

years have seen massive changes, such as the internet, genome

mapping and national registration for health professionals

through AHPRA — all once vague dreams. I would think that

a modern specialist rehabilitation nursing course would now

require modules on information technology and perhaps even

stronger consideration of ethics and legal issues, given that

through social and other media there is increased awareness

of social ills, such as family violence, elder abuse and sexual

predation. These topics were missing in both my undergraduate

and postgraduate nursing education. These issues may now

present themselves within a comprehensive nursing assessment

and a nurse is mandated to act, given the increasing requirement

for professional accountability over the last three decades.

The patient learning to care for him/herself is the core of rehabilitation nursing

As I am writing for rehabilitation nurses, I will assume that the

practitioner has a professional commitment to the philosophy

of the patient being central to the assessment, that a planned

negotiated care program is in place and that the plan is evaluated

for its effectiveness.

In the Australasian Rehabilitation Nurses’ Association (ARNA)

Competency Standards for Registered Nurses there are seven

domains of practice. Nurses from other clinical specialities

will recognise some of the professional values embedded in

these domains. My favourite is Competency Standard 2: ‘The

Registered Nurse views every interaction with the person as a

teaching/learning opportunity’ (ARNA, 2003, p. 11).

This elegant and beautiful statement asks the nurse to approach

the patient with an open mind, be aware of his or her own

prejudices and to be receptive to the person who is the patient.

Henderson already knew this when ARNA’s membership

described and validated this competency. My view is that nursing

has four distinct roles: patient care, team member, teacher and

learner. I often reflected on these roles when I undertook difficult

discussions, such as the patient who was wary or afraid of his/

her discharge planning meeting, remedying some discord within

a team, listening to a patient complaint or negotiating what and

how a patient or a staff member might learn something.

Leadership: what does a great nurse need?

One of the intriguing things that beginner or novice nurses will

tell you is that they have a preference for a particular clinical area.

My view is that it is at least as important to seek out the nurse

leaders on whom you can learn and model yourself. When I was

a young nurse, I opted for specialist clinical training as many

do and secondarily I wanted to work for a particular director of

nursing. It was not ‘the done thing’ in those days to speak openly

about your ambition and your desire to seek good leaders;


indeed, I hardly had the language to describe my instincts to

work with those nurses who impressed me.

We know leaders emerge in all areas of clinical nursing, for

example, the experienced enrolled nurse on your ward to the

director of clinical services. I hope to encourage younger

nurses to search for the best leaders: those who exemplify

characteristics, such as an open style of communication and

teach as they go; those who aren’t afraid to stretch their staff

and ensure they are constantly stimulated with new material and

challenges; and teach them about the environment in which they

work.

Characteristics that I value in all leaders are:

• clinical competence;

• an ability to communicate the vision for the unit or ward;

• demonstrating actions which support the vision;

• compassion and tolerance of mistakes;

• an active teaching agenda;

• clear and open delegation; and

• a staff recognition and reward system.

If you are a nurse in the early years of practice, your nurse unit

manager and education managers are likely to be very important

to your professional development. These are some of the issues

which these senior nurses are dealing with that you may not be

aware of:

• physical environments wards that are not fit for purpose;

• ageing population and chronic health conditions;

• constrained health budgets;

• organisational politics;

• legal changes such as the forthcoming ‘Duty of Disclosure’

legislation in Victoria;

• new providers entering the rehabilitation field/competition;

• health funds’ requirements;

• effective clinical practice: FIM scores and their significance

in your environment;

• meeting undergraduates’ requirements;

• technological change; and

• reduced inpatient length of stay: more patients and faster

discharge.

Reflection

I was a nurse for seven years before I entered the 1986

rehabilitation nursing course. At that time, I think I knew rather

more about medicine than nursing. I say this to attest to the value

that I place on educational programs similar to the rehabilitation

course which I undertook all those years ago. It was common in my

early nursing years to find TLC (tender loving care) +++ written

in care plans. What that care was, other than the important issue

of being kind and compassionate, was anyone’s guess. Care and

support should be specific to that particular patient. During the

rehabilitation nursing course, I started to develop an appreciation

of nursing models and theory, and to develop a much more formal

nursing assessment framework for my practice. To contrast the

depth which I believe the rehabilitation nursing course gave me, I

can well remember an earlier discussion with a senior colleague,

a domiciliary nurse who told me about the inadequacies of my

discharge summary/plan; it wasn’t a very comfortable moment.

I hadn’t developed the skilled language that I needed to tell my

colleague about the patient’s problems, along with the specifics

of the help and support that the patient would need on her arrival

home.

I encourage nurses to work in a variety of settings prior to their

decision to specialise their clinical practice. This is because

nurses need a strong overview of the patient experience as

he/she moves through the health care system — ambulance to

emergency department or from the consultant’s room to theatre

to the surgical or medical ward to discharge to community

agency or resource. A nurse’s broad knowledge of the health

care system makes him/her more effective in helping the patient

to plan in an environment of constant change.

Like Henderson (1964), I see nursing as an ethical force

worldwide. On these foundations a nurse can be proud of his/

her career and assured of its value to society and the dignity

of being a nurse. In my view, a rehabilitation nurse specialist

positions him/herself well for success if they can include in their

preparation: broad preparation in their discipline; knowledge of

the history of their profession; and access effective leadership.

ReferencesAustralasian Rehabilitation Nurses’ Association. (2003). Rehabilitation

Nursing: Competency Standards for Registered Nurses. Melbourne: Australasian Rehabilitation Nurses’ Association.

Australian College of Nursing History Conference. (2018). https://www.acn.edu.au/acn-history-conference

Henderson, V. A. (1964). The nature of nursing. American Journal of Nursing 64(8), 62–67.

Henderson, V. A. (1980). Preserving the essence of nursing in a technological age. Journal of Advanced Nursing, 5, 245–260.

Levine, M. E. (1969). The pursuit of wholeness. American Journal of Nursing 69(1), 93–98.


Research

Nursing bedside clinical handover: a pilot study testing a ward-based education intervention to improve patient outcomes

Adriana Hada* MN, RNAssistant Director of Nursing, Division of Medicine, Princess Alexandra Hospital, Brisbane, Qld, Australia Email: [email protected]

Fiona Coyer PhD, MScNsg, PGCEA, RNProfessor, School of Nursing, Queensland University of Technology and Intensive Care Services, Royal Brisbane and Women’s Hospital, Qld, Australia Email: [email protected]

Leanne Jack PhD, MNrs (ICU), RNPost Graduate Study Area Coordinator Intensive Care Nursing and Acute Care Nursing, Unit Coordinator NSN721, NSN722, NSN724, NSN726, School of Nursing, Queensland University of Technology, Qld, Australia Email: [email protected]

*Corresponding author

Abstract

ObjectiveTo explore the effectiveness of an education intervention in facilitating the provision of standardised bedside nursing handover communication, and enhancement of patient safety and quality of care in geriatric and rehabilitation wards.

Design

Pilot study using a prospective before and after quasi-experimental design.

Setting

Two geriatric and rehabilitation wards of a major tertiary referral teaching and research hospital in Brisbane, Australia.

Participants

The study population was comprised of registered and enrolled nurses employed in the two wards, and all inpatients and their families present in the two wards at the time of the study.

Main outcome measures

The outcome measures included patient outcomes (patient satisfaction with the bedside handover process, the number of patient adverse events); and staff outcomes (staff satisfaction with the bedside handover process, compliance with best-practice nursing shift-to-shift handover recommendations).

Results

A total of 104 bedside handover audits were completed. Of the 143 patients admitted to the two wards, 125 met the inclusion criteria. Returned satisfaction surveys were received from 105 patients. Of the 58 nursing staff who met the inclusion criteria, 93% returned the satisfaction surveys before implementation and 58.6% returned the satisfaction surveys after implementation. Results showed improved nursing compliance with best practice shift-to-shift handover, and increased patient and nursing staff satisfaction with the bedside handover process. Reduction in the number and severity of patient adverse events was noted: 9.37% decrease in the number of falls without patient harm, 75% decrease in the number of pressure injuries, and 11.1% decrease in medication errors.

Conclusion The results indicate that nursing education had a positive impact on the quality of the communication during bedside nursing clinical handover in the two geriatric and rehabilitation wards.

Keywords: Standardised handover communication, adverse events, rehabilitation patient safety, patient outcomes.


Introduction

Accurate handover of clinical information is essential to the

continuity and safety of care. Consequently, there has been a

strong national and international focus on improving handover

communication over the last decade. In 2008, the Special

Commission of Inquiry into Acute Care Services in New South

Wales Public Hospitals (“The Garling Report”) analysed the

impact that poor communication had on patient safety. Clinical

handover has been identified as one of the most important

communication mechanisms to ensure patient safety and many

individual projects aimed at improving the clinical handover have

been reviewed. Despite the value of these individual projects,

Garling found a paucity of strong evidence demonstrating

system wide improvements to clinical handovers (Garling,

2008). The Garling Report included a recommendation that

hospital policy mandates shift handover with a structured tool,

at least part of which should be conducted at the bedside. The

report also acknowledged appropriate training and coaching

was required (Garling, 2008). Furthermore, current literature,

including a number of systematic reviews (Cohen & Hilligoss,

2010; Reisenberg & Leitzsch, 2010; Smeulers, Lucas &

Vermeulen, 2014), provides significant evidence to suggest

that inappropriate handover practices put patients at risk of

harm through poor communication. Effective and professional

communication is an essential requirement for the provision

of safe nursing care and is mandated by the Registered and

Enrolled Nurses Standards for Practice (Nursing and Midwifery

Board of Australia, 2015) as well as the Rehabilitation Nursing

Competency Standards (Australasian Rehabilitation Nurses’

Association, 2003).

Key functions of the clinical handover include the transfer of

accurate information about a patient’s care, treatment, services,

current condition and any recent or anticipated changes (Gage,

2013; Scovell, 2010; Staggers & Blaz, 2012). In addition, the

Australian Commission on Safety and Quality in Health Care,

(ACSQHC, 2010) recognised that another key function of the

clinical handover is the transfer of professional responsibility and

accountability. Gage (2013) identifies professional accountability

as an obligation of a nurse or any health professional to

account for or justify their actions and provide an explanation

for particular decisions, including situations where responsibility

has been delegated to another person. In this context, Gage

accentuates the importance of effective handover. Several

barriers to effective clinical handover have been identified,

including inconsistent communication, lack of standardisation,

insufficient staff education, unclear work procedures, team

culture, and environmental issues (Halm, 2013; Reisenberg &

Leitzsch, 2010). Enablers of effective handover, such as flexible

standardisation, use of mnemonics, technological support, and

focus on handover education have been suggested (Meissner et

al., 2007; Siemsen et al., 2012).

The SBAR (Situation, Background, Assessment,

Recommendation) communication technique, or variations of it,

such as ISBAR (Identify, Situation, Background, Assessment,

Recommendation), have been supported by the ACSQHC

(2010) as a form of structured communication for the clinical

handover. This technique provides a standardised framework for

communication between members of the health care team, such

as nurses, about a patient’s condition. It is an easy-to-remember,

concrete mechanism useful for framing a conversation and

provides a focused approach to set expectations for content that

will be communicated and how it will be communicated between

members of the team, which is essential for developing teamwork

and fostering a culture of patient safety (ACSQHC, 2010).

Boaro, Fancott, Baker, Velji and Andreoli (2010) described

the results of a pilot study conducted to adapt, implement,

and evaluate the SBAR communication tool in a rehabilitation

setting. The findings of the study identified that the SBAR tool

enhanced communication for urgent and non-urgent patient

care situations (Boaro et al., 2010), highlighting how it can

assist clinical staff to structure their concerns and issues, and

to close the communication loop in terms of recommendations

and accountabilities. The literature also suggests that in addition

to structured verbal handover communication, handover

documentation in either a paper-based or electronic form

should be used to ensure the full maintenance of data, minimise

repetition and reduce the length of handover (ACSQHC, 2010).

Bedside nursing handover has been found to improve patient

satisfaction by keeping patients better informed (Chaboyer et

al., 2009; Maxon, Derby, Wrobleski & Foss, 2012; Sand-Jencklin

& Sherman, 2013), and involving patients more in their care

(Anderson & Mangino, 2006; Maxon et al., 2012; Sand-Jencklin

& Sherman, 2013). Several studies (Chaboyer et al., 2009;

Chapman, 2009; Maxon et al., 2012; Reinbeck & Fitzsimmons

2013) report general increased patient satisfaction with a report

undertaken at their bedside. Chaboyer et al. (2009) found that

patients interviewed following the implementation of the bedside

handover perceived this change to be a positive experience

and that the handover conducted at the bedside was seen by

patients as an opportunity for interaction. Furthermore, Chapman

(2009) reported that the implementation of the bedside handover

increased patients’ involvement in the exchange of information;


comments from the patients’ satisfaction surveys reflected that

this change was positively received and patients valued being

part of the nursing handover.

Results of quantitative and qualitative evaluations regarding

nursing staff satisfaction with the bedside handover have been

frequently described (Athwal, Fields, & Wagnell, 2009; Chaboyer

et al., 2009; Sand-Jecklin & Sherman, 2013). Reasons for

increased nurse satisfaction are attributed to receiving accurate

handover without distractions, assessment of the patient and

environment in real time, and avoiding delays in receiving the

report and asking questions to the nurse providing handover as

well as the patient and their family or significant other (Anderson

& Mangino, 2006; Bradley & Mott, 2012; Jukkala, James, Autry,

Azuero & Miltner, 2012).

Direct patient safety outcomes related to handover improvements

are described by a few authors (Athwal, Field & Wagnell, 2009;

Bradley & Mott, 2012; Sand-Jencklin & Sherman, 2013). These

safety outcomes are reported in the form of decreased frequency

of patient adverse events such as falls, pressure injuries, burns,

skin tears and medication incidents. Anderson and Mangino

(2006) reported patients’ perceptions of safety; however, there

was no evaluation of direct patient outcomes.

In summary, there is a trend of an increased interest in improving

the handover structure and processes with the aim of achieving

better patient outcomes; however, the imperative to build

evidence-based handover processes and practices remains. A

reduction in adverse patient events such as falls, medication

errors and pressure injuries would be the expected outcome of

effective, structured bedside clinical handover.

Aim

The aim of this pilot study was to explore the effectiveness of

bedside nursing handover education in facilitating the provision

of standardised handover communication and enhancement of

patient safety and quality of care.

Research questions

The research questions informing this study were:

1. Does an education intervention improve compliance with

best practice nursing shift-to-shift handover?

2. Do changes in bedside handover communication impact

patient outcomes (falls, pressure injuries and medication

errors)?

3. How do changes in bedside handover communication

impact patients, their families and nursing staff satisfaction

with the bedside handover process?

Method

this study was a pilot study using a prospective before and after

quasi-experimental design that included before-test measures

(observation and surveys), intervention implementation, and

after-test measures (observation and surveys). The timelines are

reflected in Figure 1.

Figure 1: Pilot study timelines

Figure 1: Pilot study timelines

Setting

The research was conducted in two geriatric and rehabilitation

wards of a major tertiary referral teaching and research hospital in

Brisbane, Australia. The Geriatric and Rehabilitation Unit (GARU)

is the largest rehabilitation unit in Queensland, incorporating

three wards totalling 78 inpatient beds. The GARU wards

provide care for inpatients undertaking a rehabilitation program

following a stroke, orthopaedic procedures, amputations, and

other medical or surgical conditions. A total of 58 registered and

enrolled nurses work in full-time or part-time capacities in the

two wards.

Participants

The study population was comprised of registered and enrolled

nurses employed in the two wards (n=58), as well as all

inpatients and their families present in the two wards at the time

of the study.

Inclusion criteria:

- Permanent nursing staff consisting of registered and

enrolled nurses who were employed either full time or part

time in the two wards for at least three months prior to the

commencement of study.

- All inpatients in the two wards at the time of the study and/

or their families if present at the time of bedside handover.


Exclusion criteria:

- Transient nursing staff, such as casual or agency nurses

were excluded as this group was infrequently used to cover

sick or emergency leave and it would have been unlikely to

capture the same nurses in the before and after groups.

- Non-English-speaking patients, unless an interpreter was

present.

- Patients unable to communicate due to a medical condition

(such as aphasia or cognitive deficits); however, the families

of these patients were included in the study if they were

present at the time of handover.

- Handover occasions where patients were not at the bedside

at the time of bedside handover.

Outcome measures

This study had two areas of outcome measures:

1) Patient outcomes included patient satisfaction with the

bedside handover process, and the number of patient

adverse events, including falls, pressure injuries and

medication errors.

2) Staff outcomes included staff satisfaction with the bedside

handover process, and compliance with the best practice

nursing shift-to-shift handover recommendations.

Intervention

The intervention consisted of an education package containing

a video exemplar and written materials: bedside handover

SBAR script, bedside handover flowchart, and SBAR posters

and lanyard cards. The development and implementation of

the education package was supported by relevant research

theoretical frameworks and based on identified teaching and

learning theories and principles (Gordon & Findley, 2011;

McGrail, 2011; Potts & Davis, 2009).

Intervention handover process

The intervention handover process comprised evidence-based,

best-practice recommendations (ACSQHC, 2010; Chaboyer,

2010) and focused on conducting the handover at the patient’s

bedside, with the patient and/or family participating in the

handover process. The handover incorporated a short group

meeting where the outgoing team leader provided a brief overview

of relevant information or identified sensitive aspects of patient

care that could not be discussed at the bedside. The incoming

nurses then moved to their allocated patient’s room where

the outgoing nurse, using the SBAR communication method,

provided concise relevant information to the incoming nurse. The

handover concluded by inviting questions from patients/families

and the incoming nurses and performing a safety environmental

and equipment scan.

Handover process prior to intervention

Prior to the intervention, the nursing shift handover approach in

both wards consisted of a mixed written and verbal handover

model that took place in the staffroom. Each outgoing nurse

handed over their own patients, focusing on what they believed

was relevant information for each patient. Anecdotally, despite

the adoption of the SBAR clinical handover framework within

the organisation, the content of the information provided by the

outgoing nurses was highly variable. The outgoing and incoming

nurses then moved to the patients’ rooms, where they briefly

checked the bedside documentation. The safety environmental

and equipment scan was performed inconsistently.

Instruments

Data collection was comprised of five tools: a bedside handover

audit tool; patient experience survey; family experience survey;

nursing staff experience survey; and an Excel spreadsheet

incorporating the number, type and severity of patient adverse

events (falls, pressure injuries and medication errors). The audit

tool was adapted by the research team utilising the existing

hospital nursing bedside handover audit tool. The survey tools,

developed by the research team, were based on existing valid

and reliable surveys described in the literature, using Likert-type

scale design (O’Connell, Macdonald & Kelly, 2008).

1) The bedside handover observational audit tool addressed

compliance with the bedside handover process and

components recommended by the hospital policy. Items

assessed are illustrated in Table 1.

2) Patient experience with the bedside handover was

determined through an anonymous and voluntary survey.

The survey explored patients’ opinions regarding the extent

to which they were involved in the bedside handover

communication and the opportunity to ask for explanations

and further information regarding their care (Table 2).

3) Family experience with the bedside handover was also

determined through an anonymous, voluntary survey which


explored families’ perceptions of their involvement in the

bedside handover process and incorporated the same

aspects as the patient satisfaction surveys (Table 3).

4) Nurses’ experience with the bedside handover also

comprised an anonymous, voluntary survey (Table 4) which

explored nurses’ perceptions of the bedside handover.

5) Nurse sensitive indicator (NSI) data establishing the

number, type and severity of falls and medication errors,

and the number, location and stage of pressure injuries

were collected from the hospital clinical incident reporting

database and from the quarterly pressure injury prevention

audit reports.

Table 1: Bedside handover audit tool

Handover component Item assessed

Preparation D1: No interruptions occurred during handover that related to patients’ needs

D2: Patient informed that handover is starting immediately

D3: Hand hygiene performed at the bedside prior to patient handover

Patient involvement D4: Patient is greeted by name

D5: Outgoing staff introduce incoming staff by name

D6: Identify patient details including allergies as per policy

D7: Patient invited to be involved in handover

Exchange of clinical information

D8: Situation is stated

D9: Background is stated

D10: Assessment: Review recent observations including pain assessment

D11: Assessment: Review of nursing care plan and rehabilitation goals

D12: Assessment: Review of medication chart

D13: Assessment: Review and discuss any other nursing documentation

D14: Assessment: Review and discuss risks (falls, pressure injury, aspiration)

D15: Recommendations: Discuss plan for next shift

D16: Recommendations: Discuss plan for discharge

Safety check D17: Safety issues at the bedside identified and rectified

Transfer of responsibility D18: Patient asked if any questions

D19: Oncoming staff asked if any questions

D20: Hand hygiene performed after patient handover

Table 2: Patient experience survey

Domain assessed

Scale 1 (strongly disagree) to 5 (strongly agree)

D1: I felt fully involved in all discussions about my care with the nursing staff

D2: I understood everything that was discussed about my care

D3: If I didn’t understand something, it was explained to me

D4: I felt respected during the bedside handover discussions

D5: I had a chance to ask questions during the bedside discussions

Table 3: Family experience

Domain assessed

Scale 1 (strongly disagree) to 5 (strongly agree)

D1: I felt fully involved in the handover discussion about my relative’s care with the nursing staff.

D2: I understood everything that was discussed about my relative’s care

D3: If I didn’t understand something, it was explained to me.

D4: I felt respected during the bedside handover discussions

D5: I had a chance to ask questions during the bedside discussions

Table 4: Nursing staff experience survey

Domain assessed Scale 1 to 5

D1: A standardised process improves safety of the bedside handover

1 (strongly disagree) to 5 (strongly agree)

D2: Please indicate how you rate the quality of handovers in unit

1 (poor) to 5 (outstanding)

D3: Please indicate how you rate the quality of own handover

D4: How do you rate the importance of patient involvement in handover

1 (very unimportant) to 5 (very important)

D5: Please indicate how involved you feel the patients are in handover on the unit

1 (not at all) to 5 (a great deal)

D6: Please indicate how involved you feel the patients’ families are in handover on the unit

D7: I know and understand the key components of the standardised handover process

1 (strongly disagree) to 5 (strongly agree)

D8: I feel confident in using SBAR technique to exchange information


Ethics

Ethical and site-specific assessment approval was sought and

granted through the Metro South Human Research Ethics

Committee (HREC), Centre for Health Research (HREC/16/

QPAH/001), and Queensland University of Technology HREC

(QUT approval number:1600000217).

Data analysis

Data collected was entered and stored electronically using the

Statistical Package for Social Sciences (SPSS Version 20).

Univariate and bivariate analyses were performed to assess

frequencies, means, standard deviations, and the relationship

between the before and after values for each item. Normality of

distribution was checked using descriptive statistics. As the data

were not normally distributed and the sample size was relatively

small, non-parametric tests were used to analyse differences.

Wilcoxon signed-rank test was used to assess each item on the

Likert-type surveys and the McNemar’s test was used to assess

the dichotomous data for the observational audit results (Fields,

2013). Statistical assumptions for both tests were checked and

met. For all statistical tests, significance was set at the a priori

p-value 0.05 level (Field, 2013).

Findings

Participants

During the before and after implementation evaluation periods,

143 patients were admitted to the two wards for various lengths

of stay. Of these patients, 125 met the inclusion criteria and were

invited to participate in the study (61 before and 64 after group).

All patients who were invited consented to the observational

audit. Of the total number of patients included, 85.2% (n=52)

returned the surveys in the before group and 82.8% (n=53)

in the after group. The majority of included patients were over

65 years of age, undertaking a rehabilitation program following

stroke, orthopaedic procedures, amputations, and other medical

or surgical conditions. Over 90% of the included patients had

been assessed at risk of falling.

Family members were present at the bedside handover on nine

occasions during the pre-implementation evaluation and on five

occasions during the post-implementation evaluation. Only one

family satisfaction survey was returned pre-implementation and

three post-implementation; consequently these data were not

analysed.

All nursing staff working in the two wards who met the inclusion

criteria (n=58) were invited to participate in the study. The

nursing staff was comprised of clinical and registered nurses

(n=38, 65.5%) and enrolled nurses (n=20, 34.5%); of these,

8.6% were male and 91.4% female. All nursing staff consented

to the observational audit. Of the total number of nursing staff,

93% (n=54) returned the satisfaction surveys in the before

group and 58.6% (n=34) in the after group.

Compliance with best-practice nursing shift-to-shift handover observational audit

A total of 104 audits were completed (n=52 before group;

n=52 after group). The summary in Table 5 incorporates the

frequency of occasions when compliance was achieved (“yes”

answers on audit tool), the times and percentages by which the

correct compliance increased, if applicable, and the statistical

significance of the change. The results showed an increase in

compliance for each of the 20 assessed items. The compliance

increase varied from 1.02 times (2%) for ‘Discuss plan for next

shift’ (Item 15), to 6.4 times (540%) for ‘Review nursing care

plans and rehabilitation goals’ (Item 11). The McNemar’s test

determined that there was a statistically significant difference

between the before and after groups results in 19 of the 20

tested items (p < 0.05).

Bedside handover communication impact on patients’ outcomes

No harm occurred in 32 falls in the before group and in 29 falls in

the after group, representing a 9.37% decrease in the number of

falls without patient harm. One fall resulted in a patient sustaining

a fractured neck of femur in the before group and there were

no falls with harm in the after group. Twelve stage 2 pressure

injuries were reported in the before group and only three in the

after group, representing a 75% decrease in the number of

pressure injuries in the two wards. A minor decrease of 11.1% in

medication errors was also noted.

Bedside handover communication impact on patients, families and nursing staff satisfaction

The analysis of patient satisfaction was based on 52 patient

satisfaction surveys received in the before group and 53 surveys

in the after group. As illustrated in Table 6, the mean score

percentages increased in each domain (D), between 12.1%

(D2 — patients understood everything that was discussed

about their care) and 23.6% (D1 — patients felt fully involved

in all discussions about their care). The Wilcoxon signed-rank

test indicated that for patient satisfaction, after-test scores were


Table 5: Summary of observational audit results

Item assessedBefore group occasions of correct compliance

Number (%)

After group occasions of correct compliance

Number (%)

Times (%)increase

Statistical significanceMcNemar’s sig (2-tailed)

p value

1 13 (25%) 26 (50%) 2 (100%) 0.021*

2 20 (38.5%) 34 (65.4%) 1.7 (70%) 0.018*

3 11 (21.2%) 28 (53.8%) 2.5 (155%) 0.000*

4 34 (65.4%) 51 (98%) 1.5 (50%) 0.000*

5 26 (50%) 45 (86.5%) 1.7 (73%) 0.000*

6 22 (42.3%) 39 (75%) 1.8 (77%) 0.001*

7 24 (46%) 40 (77%) 1.6 (67%) 0.005*

8 42 (80.8%) 52 (100%) 1.2 (24%) 0.001*

9 27 (52%) 50 (96%) 1.8 (85%) 0.000*

10 14 (27%) 45 (86.5%) 3.2 (221%) 0.000*

11 5 (9.6%) 32 (61.5%) 6.4 (540%) 0.000*

12 31 (31%) 43 (82.6%) 1.4 (38.7%) 0.004*

13 12 (23%) 42 (80.8%) 3.5 (250%) 0.000*

14 24 (46%) 47 (90%) 1.9 (95.8%) 0.000*

15 48 (92.3%) 49 (94.2%) 1.02 (2%) 1.000

16 16 (30.7%) 37 (71.2%) 2.3 (131.2%) 0.000*

17 19 (36.5%) 34 (65.4%) 1.7 (79%) 0.018*

18 18 (34.6%) 43 (82.7%) 2.4 (139%) 0.000*

19 16 (30.7%) 37 (71.1%) 2.3 (131%) 0.000*

20 11 (21.2%) 29 (55.8%) 2.6 (164%) 0.005*

*Significance set at p=0.05

Before group: 52 audits; After group: 52 audits

statistically significantly higher that the before-test scores for all

five domains assessed (p < 0.05).

The analysis of nurses’ satisfaction surveys was based on

54 surveys received in the before group and 34 in the after

group (Table 7). The mean score percentages for each domain

increased between 2.7% (D1 — nurses felt that a standardised

process improved safety of bedside handover) to 16.3% (D2 —

nurses’ rating of the quality of handovers in the unit); however, the

Wilcoxon signed-rank test indicated that for nurses’ satisfaction,

after-test scores were statistically significantly higher that the

before-test scores for only three of the eight domains (p < 0.05).

This demonstrated that, from the nurses’ perspective, statistically

significant improvements after implementation were achieved in

relation to the quality of handovers in the unit (D2) (p=0.002),

the level of patient involvement in the bedside handover (D5)

(p=0.004), and the level of nurses’ agreement that they knew

the key components of standardised handover process (D7)

(p=0.001).

Discussion

The implementation of a nursing education package to facilitate

the provision of effective handover communication resulted in

several significant outcomes, including improved compliance

with best-practice nursing shift-to-shift handover, and an

increase in patient and nursing staff satisfaction with the bedside

handover process. Some reduction in the number and severity

of patient adverse events, including falls, pressure injuries and

medication errors was noted, although the changes were not

statistically significant, and were most likely due to the small

number of reported incidents.

There is little evidence in the literature describing changes in

compliance with best-practice nursing handover evaluated


through direct observation of the handover process. Chaboyer,

McMurray and Wallis (2010) reported the results of a descriptive

case study conducted in six Australian hospitals. Data were

collected using a semi-structured observation of the bedside

handover that assessed compliance utilising the SBAR

communication technique and patient involvement. Findings

from a total of 532 observations undertaken showed that the

SBAR was only used at one hospital in varying degrees, from

45% to 65% of the handovers. Patients were actively involved in

approximately one-third to slightly over half of handovers across

the six hospitals. Several studies have described the results of

interventions aimed at improving the handover process; however,

the evaluation method was comprised of surveys exploring nurses’

perceptions of compliance with the new practice (Chung, Davis,

Mougharabi & Gawlinski, 2011; Jukkala et al., 2012; Maxon et

al., 2012). Results of these studies indicate that following various

interventions to standardise nursing handover, nurses perceived

an increased accuracy of information exchanged, improvements

in handover communication, nurse-to-nurse accountability, and

medication reconciliation.

In this study, the comparative observational audit results

indicated that nursing education had a positive impact on the

delivery of the nursing bedside handover. Whilst these results

are encouraging, consideration must be given to the possibility

of the Hawthorne effect, which produces an improvement in

research participants’ performance as a result of being observed

(McCambridge, Witton, & Elbourne, 2014). Longitudinal data

obtained through periodic re-auditing over an extended period of

time would be required to assess the sustainability of improved

compliance.

Standardisation of the bedside handover content and process

following the implementation of the nursing handover education

resulted in an overall decrease in the frequency of patient adverse

events. Benefits experienced with changes in the handover

process, particularly with the introduction of the bedside

handover, are associated with a reduction in errors and improved

patient safety (Athwal et al., 2009; Bradley & Mott, 2012; Sand-

Jecklin, 2013). Congruent with this study’s findings, Athwal et al.

(2009) reported that following the introduction of the bedside

handover in a 34-bed cardiac medical unit, the frequency of falls

occurring during the night to morning shift nursing handover

decreased from one to two patient falls each month to only one

patient fall in six months. The findings of a study conducted by

Bradley and Mott (2012) indicated a trend in the reduction of the

frequency of incidents after the implementation of the bedside

handover process.

Table 6: Patient satisfaction survey results.

Domain assessedBefore group

n=52Mean (SD)

After groupn=53

Mean (SD)

Percentage increase mean

Wilcoxon signed-rankz and p

D1 3.73 (1.34) 4.61 (0.59) 23.6% –4.003, 0 .000*

D2 4.13 (1.02) 4.63 (0.62) 12.1% –2.911, 0.004*

D3 4.09 (0.97) 4.69 (0.64) 14.7% –3.342, 0.001*

D4 4.07 (1.18) 4.76 (0.54) 16.9% –3.661, 0.000*

D5 4.23 (1.07) 4.82 (0.51) 13.9% –3.497, 0.000*

*Significance set at p=0.05

Table 7: Nurses satisfaction survey results

Domain assessedBefore group

n=54Mean (SD)

After groupn=34

Mean (SD)

Percentage increased mean

Wilcoxon signed-rankz and p

D1 4.35 (0.61) 4.47 (0.50) 2.7% –1.091, 0.275

D2 3.18 (0.97) 3.70 (0.79) 16.3% –3.172, 0.002*

D3 3.20 (0.87) 3.38 (0.77) 5.6% –1.411, 0.158

D4 3.87 (1.31) 4.08 (1.02) 5.4% –0.420, 0.674

D5 4.05 (5.47) 4.17 (0.83) 2.9% –2.903, 0.004*

D6 3.14 (1.10) 3.41 (0.92) 8.6% 1.818, 0.069

D7 3.96 (0.77) 4.32 (0.47) 9.1% –3.274, 0.001*

D8 3.96 (0.75) 4.17 (0.57) 5.3% –1.669, 0.095

* Significance set at p=0.05


The overall reduction in adverse events, whilst not statistically

significant, is of clinical significance. It is well documented that

adverse events have a significant impact on patient outcomes,

potentially leading to in-hospital complications, extended length

of stay, increased disability, morbidity, and mortality (Joint

Commission, 2011). The association between standardised

communication during bedside handover and the reduction in

the frequency of adverse events must be interpreted with caution

due to numerous confounders, such as concurrent prevention

strategies aimed at reducing risk, as well as patient acuity and

complexity, shift nursing skill mix, and patient understanding and

participation in risk-mitigation strategies (Chaboyer et al., 2009;

Velji et al., 2008).

The findings of this study indicate that the changes in bedside

handover communication had a positive impact on patients’

and nurses’ satisfaction with the bedside handover process.

In the before group, patients’ comments included “I feel I am

unable to interact with nurses at handover as they are talking

about me and not to me”, “I do not have the opportunity to ask

questions or participate”, whilst in the after group, patients

commented “It was nice to know what my rehabilitation goals

were”, “Nurses answered my questions”, and “Enjoyed being part

of the conversation”. These comments reinforced the importance

of bedside communication in which patients are viewed as

active participants. Similarly, in the before group, nursing staff

comments included “I would like to see a more structured

approach to the handover”, “need more patient input”; while in

the after group nurses noted that “all information I need is there”,

“very positive initiative, very happy with the new process”.

These findings were consistent with previous work in this

area. Anderson and Mangino (2006) found that after the

implementation of the bedside handover patients were more

satisfied with the way they were kept informed, being included in

the decision making, and having better control of pain. Similarly,

Chapman (2009), Chaboyer et al. (2009), and Maxon et al.

(2012) reported increased overall patient satisfaction with the

introduction of a bedside handover report. Patient involvement in

the handover discussions aligns with the rehabilitation principles

of the Rehabilitation Nursing Competency Standards, which

require nurses to facilitate effective communication and work

with the patients and their significant others to support the

achievement of the person’s goals (Australasian Rehabilitation

Nurses’ Association, 2003). A systematic review conducted by

Rosewilliam, Roskell and Pandyan (2011) found that increased

patient participation and information sharing led to better

rehabilitation outcomes.

Furthermore, in regard to nurse satisfaction, Chaboyer et al.

(2009) reported increased nursing staff satisfaction with the

bedside handover implementation, particularly in relation to

patient safety, discharge planning and teamwork. Other features

of a standardised nursing handover, such as exchange of accurate

information, more efficient use of time (Bradley & Mott, 2012;

Chung et al., 2011), patient involvement, timely assessment

of the patient and effective communication (Chaboyer et al.,

2010; Sand-Jencklin & Sherman, 2013) were associated with

increased nursing staff satisfaction with the newly implemented

handover practices.

Limitations

The limitations of this study include the use of a relatively small

sample of patients and nursing staff in a single setting; this

sample may not be representative of acute inpatient wards,

as the local context may have influenced the project. Pilot

studies, however, are conducted with intended small sample

sizes. As suggested by Moore, Carter, Nietert and Stewart

(2011), small samples may be appropriate when testing the

acceptability and adherence to a new intervention; in this

case the bedside handover education package. Furthermore,

the Hawthorne effect may have influenced findings; bedside

handover communication may have improved solely because it

was being evaluated (McCambridge, Witton, & Elbourne, 2014).

More detailed information about the nursing staff profile would

be recommended for future research to strengthen the study.

In addition, other improvements occurring at the same time

may have influenced the findings. For example, during the after

implementation evaluation period, the hospital-wide pressure

injury prevention audit was conducted; in preparation for this

audit, a strong focus was placed on identifying and addressing

risk factors for pressure injuries across the organisation.

Conclusion

Ensuring effective communication during nursing shift-to-

shift bedside handover is essential for ensuring patient safety

and continuity of care. The changes in bedside handover

communication were associated with minimal impact on the

reduction of reported patient adverse events; these changes had

a significant impact on patient and nursing staff satisfaction with

the standardised bedside handover structure and processes.

The handover education package utilised as the intervention in

this study could be tailored and made context-specific to any

clinical area in the hospital. Undertaking further study in a larger

context within the organisation would be beneficial to improve

the generalisation of these findings.


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After working as a clinician in brain injury rehabilitation for many

years, it was evident that more men than women who sustained

traumatic brain injury (TBI) were engaged in rehabilitation

programs. Much of the published literature exploring TBI is

presented in a generic way, suggesting men’s and women’s

experiences do not differ. After discussions with clinicians,

brain injury advocacy organisations and the notable absence

of gendered experience of TBI within the literature, the PhD

project, titled “I AM WOMAN — What are the gendered issues

for Australian women following traumatic brain injury?” was

born. Consequently, this poster, which was displayed at the

Nepean Blue Mountains local health district 4th Nursing and

Midwifery Research and Practice Development Conference in

2017, and was incorporated into a presentation for the 27th

Annual Australasian Rehabilitation Nurses Association National

Conference in 2017, presents a published narrative review of the

literature. The review explored what was available in regard to

the health, activity and participation issues for women following

TBI and revealed that the limited research that was available was

predominantly from Canada. It highlighted that without a focused

Research in brief

Women’s experience of traumatic brain injury — a narrative review

Kate O’ReillyAssociate Lecturer, School of Nursing & Midwifery, Western Sydney University, NSW, Australia [email protected]

exploration of Australian women’s experience of TBI, a generic

discussion which was informed by more male participants in

research would continue to take place. Without adding women’s

voices to the discourse there is the danger that rehabilitation,

health and disability services asexualise people who sustain TBI.

For a detailed discussion of the issues noted above, you are

invited to access the following publication, which was published

in Disability and Rehabilitation.

O’Reilly, K., Wilson, N.J., & Peters, K. (2017) Narrative literature

review: Health, activity and participation issues for women

following traumatic brain injury. Disability and Rehabilitation.

1–12. DOI:10.1080/09638288.2017.1334838.

For more information about this research, please contact:

Kate O’Reilly

Tel: (02) 4620 3362

Email: [email protected]


A NARRATIVE REVIEW Women’s Experience of Traumatic Brain Injury

Kate O’Reilly, Kath Peters & Nathan Wilson

SEARCHED & FOUND

KEY TERMS Brain injury, women,

participation, concussion, outcomes

CINAHL; MEDLINE; SCOPUS; PSYCHInfo

PERCEPTION OF SELF & BODY IMAGE

Scarring Depression Spasticity

¼ of those who sustain TBI are women

RELATIONSHIPS & LIFE SATISFACTION

Isolation Anxiety

Separation

MEANINGFUL OCCUPATION

Underemployment Parenting roles

Financial Burden

PHYSICAL FUNCTION Hemiplegia Headaches Body Pain

SEXUALITY & SEXUAL HEALTH

Hormonal Imbalance Amenorrhea

Fatigue

431 Papers Screened

395 Papers Excluded

36 Papers Included

THEMES 5

Survival rate following TBI has increased due to improvements

in medical technology and resuscitation procedures

TBI is injury to the brain caused by an external force, such as from a motor

vehicle accident, a fall or an assault

57 million people worldwide hospitalised due to TBI


Development of a falls risk screening tool in a traumatic brain injury rehabilitation population: a two-phased project

Duncan McKechnie RN, BN(Hons), DipPublicSafety, GradCertRehabNurse, PhDClinical Nurse Consultant, Brain Injury Unit, Royal Rehab, PO Box 6, Ryde, NSW 1680, Australia Email: [email protected]

This research was conducted for the award of Doctor of

Philosophy at the University of Sydney, under the supervision of

Associate Professor Murray Fisher and Associate Professor Julie

Pryor.

Thesis abstract

Background

With higher rates of falls reported in sub-acute than acute

care inpatient populations, patients in rehabilitation settings

are generally described as at an increased risk of falling. This

is especially the case for patients with cognitive impairment. In

mixed inpatient rehabilitation cohorts, traumatic brain injury (TBI)

is one diagnosis-related group with cognitive impairment that

has been identified as at an increased risk for falls. However,

despite the number of falls studies involving many patient

populations, falls in the inpatient TBI rehabilitation population is

under-researched. There has also been no falls risk screening

tool (FRST) developed for, or validated in, this patient population.

Consequently, there is the real possibility that frontline clinicians

are using FRSTs that have poor clinical utility. This is likely to

have implications for falls prevention. In order to prevent falls, it

is essential to accurately identify those individuals who are most

likely to fall and why. There is a need for research into the nature

of falls and factors that contribute to falls in the inpatient TBI

rehabilitation population, and for a validated FRST sensitive to

this patient population to be developed.

Aim

This project aimed to:

A. develop a falls risk patient profile for the inpatient TBI

rehabilitation population (phase 1); and

Research in brief

B. develop an FRST sensitive to the inpatient TBI rehabilitation

population (phase 2).

Design

A two-phase research design was used that consisted of four

discrete studies undertaken sequentially.

Methods

The four studies comprised: a retrospective cohort study

(Chapter Four) to describe the nature of falls in the inpatient TBI

rehabilitation population; a retrospective nonequivalent case-

control study (Chapter Five) to describe the characteristics of

patients who fall; a modified Delphi study to gain consensus from

a panel of experts on patient characteristics that contribute to

falls (Chapter Six); and an 18-month prospective cohort study

(Chapter Seven) to develop an FRST sensitive to the inpatient

TBI rehabilitation population. With the exception of the modified

Delphi study which involved experts from a wide range of settings,

the studies were undertaken in short-stay inpatient rehabilitation

units specialising in rehabilitating individuals following a TBI.

These units service the state of New South Wales, Australia.

Before the studies commenced, an integrative review of the

research literature was conducted (Chapter Three). The aim of

this review was to critically appraise the research literature on the

nature of falls and characteristics of fallers in TBI rehabilitation

settings (inpatient and community). This review, the cohort study,

case-control study and modified Delphi study were used to

develop a falls risk profile which was tested in the prospective

cohort study and formed the basis for the development of an

FRST.


Results

In the retrospective cohort study the fall incident rate was 5.18

per 1000 patient bed days; as a proportion of admitted patients,

22% fell. Over a 24-hour period falls occurred in a trimodal

pattern, represented by peak fall periods 0900–0959 hours,

1500–1559 hours and 1700–1759 hours. At these times in

this setting, patients were undertaking their morning routine,

engaging in morning and afternoon therapy sessions and

having their evening meal (often requiring one-to-one nursing

assistance). Forty-three per cent of first falls occurred in the

first week of inpatient rehabilitation and 35% occurred after one

month.

In contrast to several studies identified in the literature, the

retrospective nonequivalent case-control study revealed that

age, sex, medication class and total number of medications

administered on admission to rehabilitation were not associated

with falls in the inpatient TBI rehabilitation population. Impaired

mobility and cognition, bladder and/or bowel dysfunction

(incontinence) and Functional Independence MeasureTM total

and subscale scores were associated with patients who fell.

In the case-control study, fallers were over 10 times more

likely than non-fallers to require assistance with activities of

daily living, transfers and continence/toileting on admission.

Neurobehaviours, including noncompliance and anosognosia,

were associated with patients who fell.

In the three-round modified Delphi study, the predictive efficacy

of 38 falls risk factor items in the TBI rehabilitation population

were considered by a panel of experts. In round three, five items

were rejected (such as, male gender and certain medication

classes), five were rated as undecided (such as, antecedent

falls and polypharmacy) and expert consensus was reached for

28 items. The panel of experts identified that some risk factors

for falls, such as outdoor mobility, are more relevant at particular

times during a patient’s rehabilitation.

From results of the integrative review, retrospective cohort

study, case-control study and modified Delphi study, a

21-falls risk variable dataset was identified for inclusion in

the prospective cohort study. Twenty of these variables were

significantly associated with patients who fell. Through multiple

logistic regression modelling, 11 variables were identified as

predictors for falls. Using hierarchical regression, five of these

were identified for inclusion in the resulting FRST: a 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 tool, the Sydney Falls

Risk Screening Tool (SFRST), was found to have good clinical

validity (sensitivity = 0.9; specificity = 0.64; area under the curve

= 0.87; Youden index = 0.54). The SFRST was significantly

more accurate (p = .037 on DeLong test) in discriminating fallers

from non-fallers than the Ontario Modified STRATIFY FRST.

Conclusion

TBI rehabilitation patients with a severe brain injury characterised

by multisystem impairments are at an increased risk of falling;

however, some common falls risk factors such as age, sex,

antecedent falls, medication class and medication quantity

were not associated with falls in this population. Some falls risk

factors are more prominent at different times over a 24-hour day

and at particular times during a patient’s rehabilitation. Some

situations where a patient’s risk of falling may increase include

the commencement of high-level mobility activities, outdoor

mobility or weekend leave and when a patient has improved

mobility but is not yet independent. Consequently, rehabilitation

clinicians need to be mindful that a patient’s risk of falling is

not linear but may increase over time. Rehabilitation settings

should, therefore, consider cohort-specific falls risk profiling

and periodic falls risk screening. In the TBI rehabilitation setting,

generic falls prevention measures are insufficient for preventing

falls and falls prevention initiatives should target times of high

patient activity and situations where there is decreased nursing

capacity to observe all patients concurrently (such as, during a

patient’s morning routine and their evening meal). The Ontario

Modified STRATIFY FRST has limited clinical utility in this patient

population.

An FRST has been developed using a comprehensive

methodological framework and evidence has been provided of

this tool’s clinical validity. The developed tool, the SFRST, should

be considered for use in inpatient brain injury rehabilitation

populations.

Publications from this thesisMcKechnie, D., Pryor, J., & Fisher, M. J. (2014). Falls in inpatient TBI

rehabilitation. Journal of the Australasian Rehabilitation Nurses’ Association, 17(1), 14–18.

McKechnie, D. (2015). The lived experience and lessons learned about publishing by an early career nursing researcher. Journal of the Australasian Rehabilitation Nurses’ Association, 18(2), 18–22.

McKechnie, D., Pryor, J., & Fisher, M. J. (2015). Falls and fallers in traumatic brain injury (TBI) rehabilitation settings: an integrative review. Disability and Rehabilitation, 37(24), 2291–2299. doi: 10.3109/09638288.2014.1002578

McKechnie, D., Pryor, J., & Fisher, M. J. (2016). Predicting falls: considerations for screening tool selection vs. screening tool


development. Journal of Advanced Nursing, 72(9), 2238–2250. doi: 10.1111/jan.12977

McKechnie, D., Fisher, M. J., & Pryor, J. (2016). The characteristics of falls in an inpatient traumatic brain injury rehabilitation setting. Journal of Clinical Nursing, 25, 213–222. doi: 10.1111/jocn.13087

McKechnie, D., Fisher, M. J., & Pryor, J. (2016). A Case-control study examining the characteristics of patients who fall in an inpatient traumatic brain injury rehabilitation setting. Journal of Head Trauma Rehabilitation, 31(2), 59–70. doi: 10.1097/HTR.0000000000000146

McKechnie, D., Pryor, J., & Fisher, M. J. (2017). An examination of patient characteristics that contribute to falls in the inpatient traumatic brain injury rehabilitation setting. Disability and Rehabilitation, 39(18),

Growing vegetables as part of rehabilitation

Julie Pryor RN, BA, GradCertRemoteHlthPrac, MN, PhD, FACNRoyal Rehab, Sydney, NSW, Australia Faculty of Nursing & Midwifery, Sydney University, NSW, Australia

Claire L Boyle* Horticulture Cert III, B. Ed SpecEd, MOT (Hons)Royal Rehab, Sydney, Australia Email: [email protected]

*Corresponding author

Abstract

This article tells the story of the Royal Rehab Productive Garden Project. We explore the reasons behind using vegetable growing in

rehabilitation; describe the strategy employed to get rehabilitation patients and their treating clinicians involved in vegetable growing;

and outline the steps involved in implementing the project with comment on future directions.

Introduction

In 2015 something happened at Royal Rehab. Garden beds were

designed, built and filled with soil, the theoretical underpinnings

of a Productive Garden initiative were identified, a project brief

written, and funding sourced for a project officer. The primary

activity of this initiative was to introduce vegetable growing as

part of patient rehabilitation on the main campus of Royal Rehab

in suburban Sydney, Australia.

The garden, which grows edibles and their companion plants, is

tended by patients during their therapy sessions and overseen

by a Project Officer. Produce from the garden is also used by

patients in meal preparation sessions. This article will tell the

Clinical commentary

1864–1871. doi: 10.1080/09638288.2016.1212112

McKechnie, D., Fisher, M. J., Pryor, J., De Jesus, J., & Bonser, M. (2017).

Development of a neurorehabilitation-specific falls risk screening

tool [Abstract]. Brain Injury, 31(6–7), 719–1017.

McKechnie, D., Pryor, J., & Fisher, M. J. (2017). Predicting falls in the

inpatient setting. Journal of the Australasian Rehabilitation Nurses’

Association, 20(3), 14–19.

McKechnie, D., Fisher, M. J., Pryor, J., Bonser, M., & De Jesus, J. (2018).

Development of the Sydney Falls Risk Screening Tool in brain

injury rehabilitation: a multisite prospective cohort study. Journal of

Clinical Nursing, 1–11. doi: 10.1111/jocn.14048


story of the Royal Rehab Productive Garden Project, explaining

why and how vegetable growing was introduced.

Why vegetable growing?

Rehabilitation is about individuals regaining control over their

bodies and their lives (Ozer, 1999) and for some this may

require “the holistic reconstruction of the self”’ (Siegert, Ward,

Levack & McPherson, 2007, p. 1609). Efforts to regain control

over the body are commonly guided by clinicians with a range of

specialist knowledge and skills during therapy sessions in clinical

settings. Commonly, these clinical settings lack any resemblance

to a patient’s usual life, which has the potential to complicate the

transfer of skills learned to everyday life activities.

Regaining control over a life is often a complex and drawn-out

process. A person’s awareness of their rehabilitation needs can

take some time to evolve. Furthermore, each person’s journey is

unique, with the experience of injury or illness being assigned

personal significance in accordance with the individual’s

personal context (Donnelly, Donnelly & Grohman, 2005).

To facilitate individuals regaining control over their bodies and

their lives, the Royal Rehab Productive Garden Project sought

to:

• increase the options available to clinicians for enabling

rehabilitation activities in everyday, real-life contexts;

• foster two-way learning between patients/families and

clinicians; and

• provide clinicians with support in using the Productive

Garden to facilitate the rehabilitation and wellbeing of their

patient.

This thinking was informed by the participate to learn model

(Carlson et al., 2006), which advocates for rehabilitation in

real-life settings doing real-life activities, where learning is

experiential. This is in contrast to the learn to participate model,

where rehabilitation happens in controlled environments with

more formal teaching.

Outdoors, especially in the garden, is an important context of

functional performance for many people, but gardens are seldom

the setting for contemporary rehabilitation practice. Awareness

of the health and economic benefits associated with biophilia,

the innate attraction humans have to nature, is growing (Terrapin

Bright Green, 2012). A report conducted by Deakin University

for BeyondBlue outlined the benefits of green space and nature-

based activities on the mental health and wellbeing of a range

of populations (Townsend & Weerasuriya, 2010). Specifically

relating to gardening and horticulture activities as therapy, they

reported that these improve physical functioning, communication

skills and relieve stress, among other benefits (Townsend &

Weerasuriya 2010, p. 56). In rehabilitation and hospital settings,

each of these benefits can contribute positively to patient

outcomes. After a long absence, gardens in hospitals and care

facilities are making a comeback as reported by Burton (2014)

in The Lancet.

Within the context of health, two types of gardens are emerging

as beneficial: healing gardens, which are designed to relieve

psychological distress, and therapeutic gardens, which seek

to assist in bringing about a measurable change and functional

goal achievement (Mitrione, 2008). The Royal Rehab Productive

Garden was conceptualised to have the potential to be both

a healing and a therapeutic garden, as reflected in the original

underpinning beliefs informing the initiative:

1. Productive gardening is a mechanism for enriching the

environment of inpatient rehabilitation.

2. Being in a productive garden can facilitate healing and

wellbeing for rehabilitation inpatients.

3. Undertaking rehabilitation activities in a productive

garden can facilitate improved functional performance for

rehabilitation inpatients.

4. A productive garden provides activities that rehabilitation

inpatients can do with their families and friends.

5. Inclusion of productive gardening activities in an inpatient

rehabilitation program speeds up resumption or uptake of

gardening activities after discharge.

The strategy to get rehabilitation patients involved in growing vegetables

The Productive Garden Project didn’t seek to introduce a new

clinical discipline to Royal Rehab, nor did we seek to enable one

discipline to take ownership of the Productive Garden. Instead,

the garden works on the principle that growing vegetables is

everybody’s business. This means that patients may garden

during therapy sessions with any member of their treating

team, including occupational therapists, speech pathologists,

recreation therapists and psychologists. Produce from the


garden can be used by patients in meal preparation sessions in

the ADL kitchen. In this way, we ensure the Productive Garden

is seen as a context and mechanism for rehabilitation and not a

separate therapy in and of itself. In short, the Productive Garden

can be used by any clinician in any unit from any discipline.

How was the Productive Garden Project implemented?

The first step in implementing the Productive Garden Project

was to write and implement a policy/guideline around gardening

during therapy sessions. This was done in consultation with the

infection control nurse to ensure compliance with any NSW

Health policies.

Whilst the Productive Garden Project was designed for any

clinician from any discipline working in any unit to use with their

patients, we acknowledged that not all clinicians know about

growing vegetables and to have a garden run smoothly, someone

needed to have oversight of it. A Project Officer was appointed to

work with all clinicians, to help them to use the garden with their

patients through the rehabilitation process. It was considered

essential for the Productive Garden Project Officer: 1) to be a

clinician with understanding of the rehabilitation process and the

Royal Rehab patient base; and 2) for the person to have some

horticultural knowledge and skills. It is important to reiterate that

in recruiting for the Project Officer we were not looking for a

horticultural therapist as the Productive Garden Project aims to

enable all clinicians to use the garden with patients rather than

introduce an additional discipline.

A summary of the key activities undertaken by the Project Officer

in the first six months can be seen in Table 1.

Establishing structures and processes

As the Project Officer role is a part-time position, the first

task was to develop a system to enable clinicians to use the

Productive Garden with patients when the Project Officer isn’t

on site. This was the catalyst for the “jobs board”. Each garden

bed in the Productive Garden was allocated a number. We

placed a repurposed whiteboard in the Productive Garden shed

and divided it into rows, with each garden bed being allocated its

own row. Three columns were added: 1) water (where patients

and volunteers date and tick off the beds they have watered); 2)

notes (where the Project Officer marks any special instructions

or clinicians can make a note when they have started a job but

not finished); and 3) jobs (where the Project Officer writes any

current gardening jobs).

The Project Officer keeps records of specific tasks that should

be done at certain times of the year, such as fertilising the citrus

Table 1: Summary of activities undertaken by the Project Officer during the first six months

Activity name Description

Establishing structures and processes

Plan equipment storage and set up garden shed

Set up an online booking system for using the Productive Garden

Jobs board and seed board in the shed

Design data collection sheets and data collection processes

Staff education Staff sessions: Introduction to the Productive Garden Project

Staff sessions: Orientation to the Productive Garden

All staff Productive Garden updates via email

One-to-one, hands-on staff education: Working alongside clinicians with patients in the Productive Garden

Support clinicians with data entry

Enabling patient ownership of the Productive Garden

Opportunistic conversations with patients and their families

Establish processes for patients to take responsibility for a garden bed

Engaging volunteers Liaising with Volunteer Services

Engaging with individual volunteers and community organisations

Engaging with corporate volunteers

Participating in the City of Ryde Spring Garden Competition

Raising awareness and increasing engagement

Opportunistic conversations with staff

Use awareness days (e.g. April Falls) and other opportunities to engage the whole hospital in the Productive Garden


trees, and adds these to the jobs board at the appropriate time.

If these aren’t completed when needed by patients, the Project

Officer steps in and does these tasks. Seasonal planting guides

are on display for patients and clinicians to refer to.

In addition to the jobs board, we placed a corkboard in the shed

that was divided into columns representing the seasons. On this

we pinned packets of seeds, donated and purchased, according

to the season they could be planted in Sydney. This provides a

clear visual guide for patients and clinicians who want to plant

seeds but are unsure what could be planted at that time. We

developed instruction cards for seed planting, seedling planting

and mulching, which are hung up for any patients or clinicians

who are unsure how to do these tasks.

Staff education

We ran information sessions on different days during lunch and

invited all staff, clinical and non-clinical, to learn about the project.

We also ran orientation sessions in the Productive Garden itself,

which were designed to familiarise staff with the Productive

Garden layout, the jobs board, the equipment available and the

processes we had set up to book time in the Productive Garden

and record usage.

In early July 2015 we began sending all Royal Rehab staff

weekly Productive Garden updates complete with pictures of

the garden, ideas for activities clinicians could do in the garden

with patients and gardening tips. These proved popular with staff

and raised awareness of the Productive Garden amongst clinical

and non-clinical staff.

Enabling patient ownership of the Productive Garden

Many patients who attend Royal Rehab originate from country

areas and have worked as farmers. These patients often have

suggestions about what the Productive Garden needs to

become more productive. One practice adopted has been to

always implement these suggestions where appropriate, even if

only for a trial. This approach has not only enabled the two-way

learning from the garden’s aims, but it has also benefited the

garden and enhanced staff knowledge and skills.

We have also invited patients who are keen gardeners to

take responsibility for one of the garden beds during their

time as inpatients at Royal Rehab. This has been taken up

enthusiastically and the practice has continued. Some crops

have been introduced by patients and their families in this way.

Engaging volunteers

Volunteers have played a vital role in the Productive Garden. The

nature of raised beds means that water drains quickly, making

hand watering essential. With water rules meaning patients

could not use a hose between 10 am and 4 pm, optimal therapy

session times, a strategy was needed to ensure the garden

beds received adequate water on a regular basis. Royal Rehab

Volunteer Services provides a link between willing and skilled

volunteers and the Productive Garden to ensure the garden is

watered most days of the week. We have also used corporate

volunteers to assist in activities such as planting citrus trees and

moving soil.

Raising awareness and increasing engagement

One way to raise awareness of and increase engagement in the

Productive Garden around the hospital has been to get involved

in whole-hospital events. In July 2016 we had an abundance of

sweet potatoes growing in the garden and patients used these

to run a hospital-wide ‘Soup Day’. All patients and clinicians in

all units were invited to participate. The day was divided into

The “Jobs board”

The Seeds board


time slots for different activities: harvesting, washing and cutting,

cooking and eating. Clinicians could sign up with their patients

for as many activities as they wished. At the end of the day, 50

cups of soup were served to patients and staff. The day was so

well received that it has become an annual event at Royal Rehab.

Another initiative has been to install noticeboards on each

inpatient unit and outside the ADL kitchen. On these noticeboards

we display pictures of those crops which are ready for harvest as

well as any other news we want to inform our patients of.

Where to next?

The Royal Rehab Productive Garden continues to develop in

response to the needs of Royal Rehab patients and clinicians.

We continually seek opportunities to connect with the wider

community, especially the therapeutic horticulture community

around Australia.

Our next step is to conduct a review of the literature about the

use of gardening and gardens in inpatient hospital settings

and use this to inform the way forward. We are also planning

to conduct research about the contribution of our Productive

Garden to patient rehabilitation and wellbeing.

One of the garden beds being looked after by an individual patient

Soup Day

One of the Productive Garden noticeboards

ReferencesBurton, A. (2014). Gardens that take care of us. The Lancet, 13, 447-

448.

Carlson PM et al. (2006). ‘Participate to learn’: a promising practice for community ABI rehabilitation, Brain Injury, 20(11), pp. 1111–7.

Donnelly, J. P., Donnelly, K., & Grohman, K. K. (2005). A multi-perspective concept mapping study of problems associated with traumatic brain injury. Brain Injury, 19(13), 1077–1085.

Mitrione, S. & Larson, J. (2008). Healing by design: Healing gardens and landscapes. Implications, 2(10), 1-4.

Ozer, M. N. (1999). Patient participation in the management of stroke rehabilitation. Topics in Stroke Rehabilitation, 6(1), 43–59.

Siegert, R. L., Ward, T., Levack, W. M., McPherson, K. M. (2007). A Good Lives Model of clinical and community rehabilitation. Disability and Rehabilitation, 29(20–21):1604–15.

Terrapin Bright Green. (2012). The economics of biophilia. Vancouver: Terrapin Bright Green.

Townsend, M., & Weerasuriya, R. (2010). Beyond Blue to Green: The benefits of contact with nature for mental health and well-being. BeyondBlue Limited: Melbourne, Australia.


Australasian Rehabilitation Outcomes CentreMeasuring the rehabilitation client’s experience: The Australian Modified Client-Centred Rehabilitation Questionnaire (AM-CCRQ)

Australasian Rehabilitation Outcomes Centre (AROC) University of Wollongong, NSW, AustraliaWeb: http://chsd.uow.edu.au Tel: +61 2 4221 4411 Email: [email protected]

As health care moves towards embracing client-centred care,

an important component of this process and ongoing quality

improvement is to evaluate patient experience in the context

of their care (Browne, Roseman, Shaller & Edgman-Levitan,

2010). Across different care settings, demographic groups and

age ranges, a positive association has been found between

the patient experience, patient safety and clinical effectiveness

(Anhang Price et al., 2014; Doyle, Lennox & Bell, 2013).

Specifically within a rehabilitation setting, researchers found the

patient experience is positively associated with adherence to

treatment and medication regimes (Doyle et al., 2013). Client-

centred practice also results in increased participation, with

more favourable outcomes for the rehabilitation client, including

improved function (Law, Baptiste & Mills, 1995).

In order to assess client perceptions, seven domains of client-

centred care have been identified as relevant in the rehabilitation

context. These include: i) client participation in decision-making

and goal-setting; ii) client-centred education; iii) evaluation of

outcomes from the client’s perspective; iv) family involvement;

v) emotional support; vi) co-ordination/continuity of care; and

vii) physical comfort (Cott, 2004). Standardised measures are

needed in order to assess and review service quality and patients

perceptions about their rehabilitation experience (as opposed to

just client satisfaction).

The Australian Modified Client-Centred Rehabilitation

Questionnaire (AM-CCRQ) (Capell, Pryor, Fisher, Alexander &

Simmonds, 2016) is a self-report measure designed to evaluate

the components of patient-centred care relating to inpatient

rehabilitation. The measure has been found to have sound

psychometric properties with good reliability and validity (Capell

et al., 2016). The AM-CCRQ asks clients questions about what

did or did not occur during their episode of care in rehabilitation

around the seven identified domains of client-centred care (Cott,

2004). It has been adapted for use with an Australian population

from an earlier version developed in Canada, the Patient-

Centred Rehabilitation Questionnaire (Cott, Teare, McGilton &

Lineker, 2006), which has also received further evaluation and

modification in a rehabilitation sample from Germany (Körner,

Dangel, Plewnia, Haller & Wirtz, 2017).

Description of the AM-CCRQ

The AM-CCRQ comprises of 31 items scored on a five-point

Likert scale, ranging from ‘strongly agree’ (1) to ‘strongly

disagree’ (5). Seven items also have a ‘does not apply’ (DNA)

response. The 31 items can be grouped into 7 subscales:

1. Decision-making (6 items: Q1, 6, 8, 13, 17, 20). The

patient’s perceived level of participation in decision-making

and goal setting in their rehabilitation program.

2. Education (4 items: Q2, 18, 21, 27). The patient’s

perception of the education they have received with regard

to their health condition and rehabilitation treatment.

3. Outcome evaluation (4 items: Q3, 9, 14, 29). The patient’s

perception of how well they were informed of their progress

and outcomes during their rehabilitation program.

4. Family involvement (5 items: Q4, 10, 19, 22, 28). The

patient’s perception of how family or significant others were

engaged and informed during the patient’s rehabilitation

program.


5. Emotional support (4 items: Q5, 11, 23, 25). The degree

of emotional support the patient perceived they received

during their rehabilitation program.

6. Continuity/coordination (4 items: Q15, 26, 30, 31). The

patient’s perception of the communication and coordination

during their rehabilitation program.

7. Physical comfort (4 items: Q7, 12, 16, 24). The patient’s

perception of the management of their pain and physical

comfort during their rehabilitation program.

Administration

The AM-CCRQ should be administered in its entirety as

published and not changed in any way. It is recommended the

AM-CCRQ is administered at the completion of the rehabilitation

program, at or after discharge. Confidential completion of the

AM-CCRQ will enable an unbiased response from patients

about your rehabilitation service. To administer the AM-CCRQ:

• Read the instructions with the patient and demonstrate

how the AM-CCRQ should be completed, that is to say, by

circling the correct answer.

• Issue the AM-CCRQ to the patient to complete in private,

or at home. Note: A family member may provide assistance

with completing the AM-CCRQ, but only if the responses

reflect the patient’s opinion.

• Reinforce to the patient that the AM-CCRQ is completed

anonymously and therefore once completed should be:

• returned within the facility’s mail system in a sealed

envelope provided by the facility, addressed, for example

to ‘The Quality Manager’ (or appropriate officer), OR

• returned to the facility in an unidentified reply-paid

envelope (provided by the facility).

Scoring and interpretation

From a service evaluation perspective, individual items are

reviewed for low scores to target/facilitate service improvement.

The AM-CCRQ also enables subscale analysis to review trends in

service delivery and patient care. A single score is not meaningful

or valid for determining overall patient experience. AROC has

developed a scoring template with embedded calculations and

graphical representation at both an item and subscale level.

Conclusions

The AM-CCRQ is designed to use as a quality measure to

evaluate service delivery according to the rehabilitation client’s

experiences. It is recommended that the measure is used regularly

to assist rehabilitation services to evaluate their programs in the

context of patient-centred care in order to improve the client’s

experience and subsequently their rehabilitation outcomes.

Accessing the AM-CCRQ

The AM-CCRQ and scoring template are available by accessing

a link on the AROC website (www.AROC.org.au). The link

will take you to an email form addressed to AROC for you to

complete. Upon receipt of a completed form, AROC will send

you a copy of the AM-CCRQ and scoring template. AROC will

hold your details in a register of users, which will be used to

provide you with updates on any further development made to

either the AM-CCRQ or the scoring template.

ReferencesAnhang Price, R., Elliott, M. N., Zaslavsky, A. M., Hays, R. D., Lehrman,

W. G., Rybowski, L., . . . Cleary, P. D. (2014). Examining the role of patient experience surveys in measuring health care quality. Medical Care Research and Review, 71(5), 522–554.

Browne, K., Roseman, D., Shaller, D., & Edgman-Levitan, S. (2010). Analysis & commentary measuring patient experience as a strategy for improving primary care. Health Affairs, 29(5), 921–925.

Capell, J., Pryor, J., Fisher, M., Alexander, T., & Simmonds, F. (2016). Person-centred rehabilitation: Implementation and evaluation of a rehabilitation specific patient experience survey. Retrieved from The University of Wollongong:

Cott, C. A. (2004). Client-centred rehabilitation: client perspectives. Disability and Rehabilitation, 26(24), 1411.

Cott, C. A., Teare, G., McGilton, K. S., & Lineker, S. (2006). Reliability and construct validity of the client-centred rehabilitation questionnaire. Disability and Rehabilitation, 28(22), 1387–1397.

Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ open, 3(1), e001570.

Körner, M., Dangel, H., Plewnia, A., Haller, J., & Wirtz, M. A. (2017). Psychometric evaluation of the Client-Centered Rehabilitation Questionnaire (CCRQ) in a large sample of German rehabilitation patients. Clinical Rehabilitation, 31(7), 926–935.

Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice: What does it mean and does it make a difference? Canadian Journal of Occupational Therapy, 62(5), 250–257.

31JARNA Volume 21 Number 1 April 201834 Volume 20 Number 1 April 2017 JARNA

31JARNA Volume 19 Number 1 March 2016

Guidelines for submission of manuscripts to JARNA

Aims and scope

Rehabilitation nursing is a recognised specialty area of nursing

within Australia with a broad and expanding knowledge base.

As the offi cial Journal of the Australasian Rehabilitation Nurses’

Association (ARNA), JARNA seeks to enhance this expanding

knowledge base through the publication of information pertaining

to rehabilitation nursing. An equally important purpose of JARNA

is to facilitate the development of ARNA members as writers for

publication by providing constructive feedback to authors.

Prospective authors are asked to follow the following

guidelines when compiling a manuscript they wish to submit for

consideration for publication in JARNA.

Terms of submission

JARNA is published three times a year and manuscripts

pertaining to rehabilitation nursing are invited. The Editor

welcomes manuscripts on research, quality activities, innovative

practice, education, management, case studies and any other

item of interest to rehabilitation nurses. JARNA also invites new

and fi rst-time authors, with mentoring provided by the Editorial

Board to assist in achieving publication standards.

All work will be sub-edited to the journal’s style. The Editor

reserves the right to modify the style and length of any manuscript

submitted, so that it conforms to journal format. Major changes

to a manuscript will be referred to the author for approval prior

to publication.

Once published, the manuscript and its illustrations become

the property of JARNA, unless rights are reserved before the

publication.

Authorship

All authors must make a substantial contribution to the

manuscript and will be required to indicate their contribution.

Participation solely in the acquisition of funding, collection

of data or supervision of such does not justify authorship. All

participating authors must be acknowledged as such: proof of

authorship may be requested by the editors. The fi rst-named

author is responsible for ensuring that any other authors have

seen and approved the manuscript and are fully conversant with

its contents. If the author wishes to reproduce material subject

to copyright, it is the responsibility of that author to obtain written

permission from the copyright holder and to acknowledge this

permission within the manuscript.

Confl ict of interest It is the responsibility of the submitting

author to disclose to the Editor any signifi cant fi nancial interests

they may have in products mentioned in their manuscript before

the references section.

Regulatory requirements

Research protocol Approval of protocol by the appropriate

ethics committee of the institution within which the research was

carried out must be stated within the manuscript.

Human investigations All work must be stated that it

conformed to the “National Statement on Ethical Conduct in

Research involving Humans” by the National Health and Medical

Research Council of Australia, or equivalent in other countries or

the Declaration of Helsinki.

Humane animal care All work involving animals must contain

a statement that it conformed with the “Statement on Animal

Experimentation” by the National Health and Medical Research

Council of Australia or equivalent in other countries.

Manuscript types

Submitted work may take any of the following forms:

Original articles These articles should be 1500–4000 words

in length and, where appropriate, may include photographs or

tables.

Reviews, commentaries and discussion articles These

articles should be 1000–3000 words in length.

JARNA March 2016 GM Final.indd 31 24/03/2016 10:04 am

32 Volume 19 Number 1 March 2016 JARNA

Case reports and opinion pieces These articles should

be 1000–1500 words in length and should ensure patient

confi dentiality is maintained.

Letters to the editor Letters will be no longer than 1000 words

(but mostly shorter) and typically comment on a topic covered

in a recently published edition of JARNA or on matters of key

professional or clinical importance to rehabilitation nursing or

nurses.

Book and fi lm reviews Book or monograph reviews of no

more than 500 words may be included depending on the interest

to the subscribers. Books or monographs to be reviewed can be

sent directly to the Editor. No books will be returned.

Peer-review process

JARNA is a peer-reviewed journal. All manuscripts are initially

reviewed by the Editor or a member of the Editorial Board

and those deemed unsuitable (insuffi cient originality, serious

scientifi c or methodological fl aws, or a message that is of limited

interest to the audience of JARNA) are returned to the author/s,

usually within four weeks. If the manuscript does not conform to

the submission guidelines, the author will be asked to amend

prior to peer-review.

All manuscripts are reviewed by peers with rehabilitation nursing

experience for relevance, accuracy, currency, construction,

fl ow, style and grammar. All reviewers spend considerable time

reviewing manuscripts and providing feedback to authors. The

length of time of the review process can vary and depends on the

quality of the work submitted. Several revisions may be required

to bring the manuscript to a standard acceptable for publication.

Proofs of articles about to be published will be sent to the

corresponding author for review. This requires rapid response; if

such a response is not forthcoming, the article will be published

without the author’s reply. Providing email addresses facilitates

with process. This fi nal decision about publication is made by

the Editor.

The peer-review process is managed online. Decisions are

communicated by email to the corresponding author. Submitted

manuscripts are acknowledged by email.

Preparation of manuscripts

Manuscripts should use double spacing with Times Roman 12

font and margins 2.5 cm.

Title page To include the title of the manuscript, the author’s

or authors’ names, qualifi cations and affi liations, corresponding

author’s details including email address and contact phone

number, total word count and up to fi ve keywords. An indication

if you would like your manuscript peer-reviewed is needed here.

Abstract All manuscripts should include an abstract of no more

than 250 words. Include the title of work on the abstract page.

Main body text For research and quality articles, subheadings

should be utilised as follows:

Introduction Purpose of study and brief overview of background.

Methods Described in detail.

Results/fi ndings Concisely reported in tables and fi gures with

brief descriptions.

Discussion Clear and concise interpretation of results/fi ndings.

Tables and fi gures To be presented in a separate Word fi le.

Tables should be clearly typed, showing columns and lines.

Number tables consecutively in the order of their fi rst citation

in the text and supply a brief title for each. Place explanatory

matter in footnotes, not in the heading. Explain in footnotes all

non-standard abbreviations used in each table. Illustrations and

fi gures must be clear, well-drawn and large enough to be legible

when reproduced.

Photographs These must be submitted in jpeg format. Patients

or other individual subjects should not be identifi able from photos

unless they have given written permission for their identity to be

disclosed. If permission is provided, this must be supplied.

Referencing guidelines

The sources of information from others and ideas that are not your

own must be appropriately acknowledged in your manuscript by

the inclusion of in-text citations and an alphabetical reference list

at the end. Paraphrasing is more preferable than direct quotes

and primary sources must be used wherever possible.

The accuracy of the references is the author’s responsibility.

JARNA uses the APA referencing style, which is similar to a

modifi ed Harvard style. For further information, refer to the

Publication manual of the American Psychological Association

(6th ed, 2009). Citations in the text include the surname(s) of the

author/s and the year of publication (Smith, 2001) which appear in

brackets after the quotation, paraphrase or data cited. If there are

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35JARNA Volume 20 Number 1 April 201731JARNA Volume 19 Number 1 March 2016


Aims and scope












Terms of submission












to publication.



publication.

Authorship






























Manuscript types




tables.












nurses.





Peer-review process





















the Editor.



















brief descriptions.









when reproduced.



















35JARNA Volume 20 Number 1 April 201731JARNA Volume 19 Number 1 March 2016


Aims and scope












Terms of submission












to publication.



publication.

Authorship






























Manuscript types




tables.












nurses.





Peer-review process





















the Editor.



















brief descriptions.









when reproduced.




















JARNA Volume 19 Number 1 March 2016

two authors, both names should be stated, using an ampersand

(Smith & Jones, 2009). In the case of three to fi ve authors, cite all

authors the fi rst time (Terrace, Petitto, Sanders & Bever, 1979),

then in subsequent citations of this work use the surname of

the fi rst author plus et al. For six or more authors, use only the

fi rst author’s surname plus et al. If the author is a government

agency or corporate organisation, name the organisation in the

parenthetical citation (National Health and Medical Research

Council, 2001). If the organisation has a familiar acronym then

use this in subsequent citations (NH&MRC, 2001).

Use quotation marks for quotations of fewer than 40 words.

For quotations of more than 40 words indent the quotation as

a block, without quotation marks and always include the page

number.

Examples of APA referencing style

Journal

Author, A., & Author, B. (year). Title of article. Title of Journal,

volume number(issue number), page numbers.

Antonakos, C. L., & Kazanis, A. S. (2003). Research process in

the health sciences: A focus on methods. Research and Theory

for Nursing Practice, 17, 257–264.

Clay, G. (2003). Assignment writing skills. Nursing Standard,

17(20), 47–52.

Book

Author, A., & Author, B. (year). Title of book (edition if not fi rst).

Location: Publisher.

Shipley, W. C. (1986). Shipley Institute of Living Scale. Los

Angeles, CA: Western Psychological Services.

Edited book chapter

Author, A. A. (Year). Title of chapter. In B. B. Editor (Ed.), Title of

book (pp. xxx–xxx). Location: Publisher.

Chow, T. W., & Cummings, J. L. (2000). The amygdala and

Alzheimer’s disease. In J. P. Aggleton (Ed.), The amygdala: A

functional analysis (pp. 656–680). Oxford, England: Oxford

University Press.

Submissions of manuscripts

JARNA, in conjunction with Cambridge Publishing, now uses the

world’s leading manuscript management system — ScholarOne.

Manuscripts for peer review will only be accepted via this online

program. All tables, fi gures and photographs, as well as the main

document and title page, are to be uploaded separately. Please

ensure image fi les are between 700 kb and 2 MB in size. The

manuscript may be accompanied by a Word document with tables,

fi gures and photographs embedded so as to show preferred

positioning of such. This separate fi le can be uploaded at step 4

as a cover letter.

To submit manuscripts, go to http://mc04.manuscriptcentral.

com/jarna and log into your Author Centre. Links to the login

page can be found on the JARNA home page on Cambridge

Publishing’s website http://www.cambridgepublishing.com.au/

publications/journal-of-the-australasian-rehabilitation-nurses’-

association.aspx (click on ‘Submit an Article’) where a quick

guide can be downloaded in ‘Author Guidelines’. The ARNA

website http://www.arna.com.au/jarna.html also has the links.

To create an account when using the system for the fi rst time,

click on ‘Register here’ under ‘New User?’ in the middle right of

the screen, or on ‘Create Account’ in the top right hand side of

the screen. Please enter as much information as possible when

creating an account.

Once in the system, the steps to submit an article are:

Step 1. Manuscript type, title, running head (abbreviated title)

and abstract.

Step 2. Keywords — at least two are required, up to fi ve allowed.

Step 3. Add co-author and edit your details (if necessary).

Step 4. Manuscript information and questions on funding, ethics,

confl ict of interest and copyright.

Step 5. Upload fi les.

Step 6. Review and submit.

The JARNA ScholarOne website has comprehensive guidelines

and online tutorials to assist in using the system. Click on the

orange ‘Get Help Now’ in the top right hand corner. A PDF of

the Author Quick Start Guide can be downloaded after choosing

‘Author’ as your role.

An email confi rming successful submission of the manuscript is

sent to the author with details about how to track the progress

of the manuscript.


We discovered that fibre dressings could perform even better

Easier removal1 | Superior fluid retention2

Mölnlycke Health Care Pty Ltd, Suite 1.01, 10 Tilley Lane, Frenchs Forest NSW 2086. Phone 1800 005 231. www.molnlycke.com.au New Zealand Orders & Enquiries 0800 005 231, www.molnlycke.co.nz The Mölnlycke Health Care, Exufiber® and Hydrolock trademarks, names and logo types are registered globally to one or more of the Mölnlycke Health Care Group of Companies. © 2016 Mölnlycke Health Care AB. All rights reserved. AUWC0098

REFERENCES: 1. Chadwick P, McCardle J. Exudate management using a gelling fibre dressing. The Diabetic Foot Journal 2015; 18(1): 43-48. 2. Data-on-file report 20140806-001 Mölnlycke Health Care. 3. Mölnlycke Health Care data: Veeva Survey undertaken in UK, Sweden, Denmark, Finland, Norway and Latvia between September 2014 and July 2015.

Absorption

Wet strength

Fluid retention

Conformability

said their currentfibre dressingbroke up duringremoval3More than

1 in 3

said that managingleakage and macerationwere key challenges3

More than half

From speaking with our customers, we understand how much a fibre dressing that can balance four equally important demands can help you and your patients.

The fibre dressingyou would design

Find out more at www.molnlycke.com.au

Exufiber® is the highly absorbent gelling fibre dressing you and your patients

deserve. It is used to manage moderately to highly exuding wounds.

WITH HYDROLOCK® THERAPY

JARNA April 2017 Final.indd 36 30/3/17 8:55 am

JARNA Volume 21 Number 1 April 2018

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