J Clin Nurs. 2019;00:1–12. wileyonlinelibrary.com/journal/jocn  | 1© 2019 John Wiley & Sons Ltd

Received:31January2019  |  Revised:16March2019  |  Accepted:26May2019DOI: 10.1111/jocn.14958

O R I G I N A L A R T I C L E

Strategies nurses use when caring for patients with moderate‐to‐severe traumatic brain injury who have cognitive impairments

Tolu O. Oyesanya PhD, RN, Assistant Professor1  | Mitchell A. Thomas BA, Research Assistant2

1SchoolofNursing,DukeUniversity,Durham,NorthCarolina2DepartmentofCommunicationSciencesandDisorders,UniversityofWisconsin‐Madison,Madison,Wisconsin

CorrespondenceToluO.Oyesanya,SchoolofNursing,DukeUniversity,307TrentDr.,Room2029,Durham,NC27710.Email:tolu.oyesanya@duke.edu

Funding informationThisresearchwasfundedbytheUniversityofWisconsin–Madison,SchoolofNursingEckburgResearchandEckburgDissertationAward.ThisprojectwassupportedbytheNIH/NIGMSInitiativeforMaximizingStudentDevelopment(PI,M.Carnes)Grant#R25GM083252.ThecontentissolelytheresponsibilityoftheauthorsanddoesnotnecessarilyrepresenttheofficialviewsoftheNIH.Fundingsourceswerenotinvolvedwithstudydesign,datacollection,analysis,interpretationordecisiontosubmitthearticleforpublication.Fundingsourceswerenotinvolvedinconductingtheresearchorpreparationofthisarticle.

AbstractAims and objectives: Adultswithmoderate‐to‐severetraumaticbraininjury(TBI)mayhaveimmediateandchroniccognitiveimpairmentsthatrequireuseofspecificnursingstrategies.Nursesmustbeknowledgeableaboutstrategies touse toaccommodatethese impairments.However,availableclinicalguidelinesandresearch lack informa‐tiontodirectnonacutenursingmanagementofcognition,limitingguidancefornurseswhendevelopingtheircareplans.Thepurposeofthisstudywastoinvestigatestrate‐giesnursesusewhencaringforpatientswithmoderate‐to‐severeTBIwhohavecogni‐tiveimpairments.Design: Cross‐sectional,exploratorystudy.Methods: Atotalof692nursesfromthreehospitalsansweredthefollowingopen‐ended question via electronic survey: “Imagine you are caring for a patient withmoderate‐to‐severe TBIwho has problemswith cognition (e.g., issueswithmem‐ory,attention,andexecutivefunction).Pleasestateyourtypicalnursingroutinetocareforthistypeofpatient.”Datawereanalysedusingsummativecontentanalysis.MethodsarereportedusingCOREQguidelines(SeeFileS1).Results: Mostrespondentswerefemale (89%),middle‐aged (40.3years), staff regis‐terednurses(77%)practicingonaninpatientunit(51%)withpriorexperiencecaringforpatientswithmoderate‐to‐severeTBI(95%).Nursesdescribed189strategiesusedintheircareplanwhencaringforpatientswithTBIwhohavecognitiveimpairments,includingthefollowing:(a)cognitivetechniques;(b)communicationtechniques;(c)pa‐tientsafetytechniques; (d)agitationandbehaviourmanagementtechniques;and(e)educationtechniques.Conclusions: Findingshaveimplicationsforeducationandtrainingofnurses,directionfor future researchaimedatdetermining theeffectivenessofnursingstrategieswiththispatientpopulation,andfordevelopmentofclinicalguidelinesfornonacutenursingmanagementofpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.Relevance to clinical practice: Findingsprovidefoundationalknowledgeonstrate‐giesnursesusewhencaringforpatientswithTBIwhohavecognitiveimpairments,whichcouldbeusedtodirectevidence‐basednursingcareofthispatientpopulation.

2  |     OYESANYA ANd THOMAS

1  | INTRODUC TION

Traumaticbraininjury(TBI),particularlyTBIsthataremoderateorse‐vereinnature,maycauseadultpatientstohaveimmediateandchroniccognitive impairments that influence strategies nurseswhen caringfor these patients. Available research and nursing and interdiscipli‐naryTBIclinicalguidelineslackinformationtodirectnonacutenursingmanagementofcognition,whichlimitsguidancefornursestouseindevelopingtheircareplans.Toaddressthesegapsinknowledge,thepurposeofthisstudywastoinvestigatestrategiesnursesuseintheircare planswhen caring for adult patientswithmoderate‐to‐severeTBIwhohavecognitive impairments.Findingshave implicationsforeducationandtrainingofnursingwhocareforthesepatients,futureresearchaimedatdeterminingtheeffectivenessofnursingstrategieswith this patient population, aswell as development of TBI clinicalguidelines todirectnonacutenursingmanagementofpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.

2  | BACKGROUND

Globally,morethan69millionpeoplesustainaTBIeachyear(Dewanetal.,2018),and2.7millionoftheseindividualsresideintheUnitedStates (Centers forDiseaseControl&Prevention,2017).TBI isde‐finedas“abump,bloworjolttotheheadorapenetratingheadinjurythatdisruptsthenormalfunctionofthebrain” (CentersforDiseaseControl&Prevention,2017).TBIcanbecharacterisedasmild,mod‐erate, or severe,with neurological injury severity being defined byindicatorssuchasGlasgowComaScaleScore,lengthoflossofcon‐sciousness,andpresenceandlengthofpost‐traumaticamnesia(PTA)(Teasdaleetal.,2014).Adultswhosustainamoderate‐to‐severeTBIrequire immediatehospitalisation for critical careand rehabilitationandtypicallyhavemultipleimpairmentsincognition,behaviour,com‐munication,emotionandphysical functioning (Babikian&Asarnow,2009). Patients who have cognitive impairments may experienceproblemswithmemory,attention,executivefunctioning,comprehen‐sionandprocessingspeed(Babikian&Asarnow,2009).Impairmentsin behaviour canmanifest as agitation, aggression, impulsivity andhypo‐/hyper‐activity (Reddy, Rajeswaran, Devi, & Kandavel, 2017).Asbehaviourinvolvescognition,cognitiveandbehaviouralproblemsoften occur together (Reddy et al., 2017). Communication impair‐mentsmayincludedifficultieswithwordfinding,expressingoneself,understandingwhatothersaresayingorpickinguponverbalandnon‐verbalcues(McDonald,Code,&Togher,2016).Similartobehaviour,communicationinvolvescognition,somanyimpairmentsincognitionandcommunicationco‐occur(McDonaldetal.,2016).Commonemo‐tionalimpairmentsincludeanxiety,depression,irritability,motivationandpersonalitychanges.Finally,patientswithphysical impairments

often report headaches and problems with vision, hearing, motorskills,balanceandfatigue(Reddyetal.,2017).

Theabove‐listedimpairmentshavemajornegativeeffectsonadultpatients’lives,includingchronicproblemswithemployment,relation‐ships,independenceandhealthcaremanagement(Jaglaletal.,2014).Thefullrecoverytrajectoryishighlyvariable,andprognosisandre‐sidualeffectsaredifficulttopredict(Kothari,2007;Maas,Marmarou,Murray,Teasdale,&Steyerberg,2007).AsTBIincidenceratesarehighforyoungadults (Centers forDiseaseControl&Prevention,2017),manysurvivorslivewiththeresidualeffectsoftheinjuryovertheirlifespan(Corrigan&Hammond,2013).Whenseekingcareunrelatedto the TBI later in life, the presence of these residual impairmentsrequires that nurses revise their care plans to meet patient needs(Oyesanya,Brown,&Turkstra,2016;Oyesanya&Snedden,2018).

Nursesplayamulti‐facetedroleinthecareofadultpatientswithmoderate‐to‐severeTBIthroughoutthehospitalstay,withnumerousrolesandvaryingresponsibilitiesas interdisciplinary teammembers(LeCroy&McMahon,2015;McNett&Gianakis,2010).Anursemust(a)assesspatientneeds, (b)monitorandmaintainthepatient'scon‐dition, (c)coordinatethepatient'scare, (d)communicatewithotherinterdisciplinaryproviders about thepatient's condition, (e) providenursingcare, (f)prevent further injury, (g) integrate therapy recom‐mendationsinthenursingcareplan,(h)educatethepatientandfamily,(i)provideemotionalsupporttothepatientandfamilyand(j)advo‐cate for thepatient (Long,Kneafsey,Ryan,&Berry, 2002;McNett&Gianakis,2010;Villanueva,1999).Thechoiceofnursingstrategiesinterventions (i.e., the characteristics of the intervention) is solely

K E Y W O R D S

careplan,cognitiveimpairments,nursing,strategies,traumaticbraininjury

What does this paper contribute to the wider global clinical community?• Wesampled692nursesatthreehospitalsintheUnitedStateson thestrategiesused in theircareplanswhenproviding care to adult patients withmoderate‐to‐se‐vereTBIwhohavecognitiveimpairments.

• Findingsshownursesuse189strategiesspreadacross5majorcategories,includingcognitive,communication,patient safety, agitation and behaviour management,andeducationtechniques.

• Findings have implications for education and trainingofnurses,directionforfutureresearchaimedatdeter‐miningtheeffectivenessofnursingstrategieswiththispatientpopulation,andfordevelopmentofTBIclinicalguidelines for nonacute nursing management of pa‐tientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.

     |  3OYESANYA ANd THOMAS

basedonthepatient'scurrentconditionandthepatient'sandfamily'scurrentneeds,whichrequiresthatnursesrevisetheircareplansonaregularbasis(LeCroy&McMahon,2015).Inparticular,addressingthepatient'simmediateandresidualcognitiveimpairmentscausedbytheTBImayrequirethemostrevisionstothenursingcareplan(Oyesanya,Thomas,Brown,&Turkstra,2016).Thesecognitive impairments in‐fluencethepatient'shealthcareexperience,suchasprovider–patientcommunication,(i.e.,thepatient'sabilitytoconversewithandcom‐prehendinformationfromtheprovider)andthepatient'sabilitytore‐ceiveandretaineducationalinformation(Babikian&Asarnow,2009).

Given the high prevalence of cognitive impairments among in‐dividualswithTBI (Babikian&Asarnow,2009;Reddy et al., 2017),adapting care plans to accommodate cognitive limitations is partic‐ularlyimportantfornursingcare;however,thereisadearthofliter‐ature on strategies nurses usewhen caring for adult patientswithmoderate‐to‐severeTBIwhohavecognitive impairments.Similartothe limitedresearchonthistopic, therearegaps inevidence‐basedclinicalguidelinesfornursingmanagementofadultpatientswithmod‐erate‐to‐severeTBIwhohavecognitiveimpairments.Whiletherearenursing (American Association of Neuroscience Nurses, 2008) andinterdisciplinaryclinicalguidelinesoncareofpersonswithmoderate‐to‐severeTBI(Carney,Totten,&O’Reilly,C.,Ullman,J.S.,Hawryluk,G.W.,Bell,M.J.,…Kissoon,N.,2017;DepartmentofVeteransAffairs,2013;JointTraumaSystem,2017),fewsufficientlyinformnonacutenursing care andmanagementof patientswithmoderate‐to‐severeTBI who have cognitive impairments. In addition, limited researchhas been conducted to determinewhether nurses adhere to avail‐ableclinicalguidelines;however,interdisciplinaryresearchhasshownvariationsinprovideradherencetoTBIclinicalguidelines(Brolliaretal.,2016).The lackof clinicalguidelines to informnursingcareandmanagementofthispatientpopulationsuggestsnursesmaynothavenecessaryinformationtoguidedevelopmentofcareplansforpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.

Asevidence‐basedcareisthestandardfornursingcare(Melnyk& Fineout‐Overholt, 2011), this study seeks to address the lack ofresearchandevidence‐basedclinicalguidelinesfornursestousetodirectdevelopmentoftheircareplanswhencaringforpatientswithmoderate‐to‐severe TBI who have cognitive impairments. Our aimwastoshed lightonthetopic inanefforttodirectfutureresearchfocusedonidentifyingandtestingeffectivenursinginterventionsforthispatientpopulation,which is foundational research fordevelop‐mentofevidence‐basedclinicalguidelines.Toachieveouraims,wesoughttotheanswertothefollowingresearchquestion:Whatstrat‐egiesdonursesuseintheircareplanswhencaringforadultpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments?

3  | METHODS

3.1 | Design

Weconductedacross‐sectional,exploratoryqualitativestudy.Themethods of this study are reported in accordance with COREQguidelines(SeeFileS1)(Tong,Sainsbury,&Craig,2007).

3.2 | Ethical considerations

We obtained approval from the participating institutional reviewboards, including approval for awaiver ofwritten consent (Lentz,Kennett,Perlmutter,&Forrest,2016).Thefirstpageofthesurveylistedthestudyinformationsheet,containinginformationaboutthestudy team,purposeandactivities, aswell as risk andbenefitsofparticipating.Participantswerenotifiedthattheirparticipationwasvoluntary,confidentialandanonymousandthatcompletionofthesurveyimpliedconsenttoparticipateinthestudy.

3.3 | Sample

WerecruitednursesfromthreelargehospitalsintheMidwest:onehospital within a large academicmedical centre hospital and twoVeterans’hospitals.Nurseswereeligibletobeinthisstudyiftheywereemployedbyoneoftheparticipatinghospitals.

3.4 | Data collection

Data were collected electronically through a purposive sample.Hospitaladministratorssentanemailtoallnursesemployedbytheirfacilities(n=3,904)invitingthemtoparticipatebyclickingaweblinktocompleteanelectronicsurvey.Withintheemail,nurseswereno‐tifiedthatanurseresearcherwasconductingastudytolearnmoreaboutnursingcareofpatientswithTBIandthattheirparticipationwasvoluntary,confidentialandanonymous.

We asked nurses to anonymously answer the following open‐endedquestion:“Imagineyouarecaringforapatientwithmoder‐ate‐to‐severeTBIwhohasproblemswithcognition(e.g.,issueswithmemory,attention,andexecutivefunction).Pleasestateyourtypi‐calnursingroutinetocareforthistypeofpatient.”Theopen‐endedquestionwaspilottestedwiththenursingpracticecouncilofapar‐ticipatinghospitalbeforeuse.Nursestypedtheir responses intoatextboxthathadnolimitonthenumberofwordsorcharacters.Wealsoaskednurses toanswerdemographicquestions, includingthefollowing:age,sex,highestnursingdegree,yearsofactivenursingpractice,yearsatcurrentposition,primaryrole,primaryworkset‐ting,ageofpatients seenandpriorexperiencecaring forpatientswithTBI.

3.5 | Data analysis

Weusedsummativecontentanalysistoanalyseourdata,whichin‐cludes interpreting the content and determining the frequency ofcontent (Hsieh&Shannon,2005).Summativecontentanalysis isasuitablemethodologytoanswerourresearchquestionbecauseweaimedtodeterminethestrategiesnursesusedtocareforpatientswith TBI who have cognitive impairments. This methodology notonlyallowedus toanswerour researchquestionof thestrategiesused but provided additional information on the frequency of re‐portofthevariousstrategies.Weanalysednurses’responsestoanopen‐endedquestion about their typical plan of care for patients

4  |     OYESANYA ANd THOMAS

withmoderate‐to‐severe TBIwho have cognitive impairments. Atthetimeofdataanalysis,thefirstauthorwasaPhD‐preparednurseresearcherwith5yearsofexperienceinqualitativemethodsandthesecondauthorwasaresearchassistantwithoneyearofexperienceinqualitativemethods.

Thepreparationphaseofouranalysisbeganwiththeselectionof the unit of analysis (Elo & Kyngäs, 2008), whichwas the fullresponse fromeachparticipant, ranging from2–85words.Next,weattempted togain a senseof thedata as awholeby readingthrough all responses multiple times (Graneheim & Lundman,2004). In theorganisationphase,wetookan inductiveapproachtodevelopcategories,alsoknownascodes,directlyfromourdata(Graneheim & Lundman, 2004; Hsieh & Shannon, 2005). To doso,wereadthedataandmadenotesaboutimportanttopicsthatthe participants shared. For example, when a participantwrote,“Iwouldrepeatimportantinformationoften,”wenoted,“repeatsinformation.”Thiswasourfirst‐ordercoding(Elo&Kyngäs,2008).Usingournotes,wecreatedacodebookoutliningimportanttopicsdescribedbyparticipants.

Wegenerated383first‐ordercodes,whichcamedirectlyfromthe data andwere spread across 20 categories. First‐order codesfromourcodebookwerethentransferredintoNVivo,aqualitativedata management software program (Bazeley & Jackson, 2013).Next,wegroupedcodestogetherbasedonsimilarities,alsoknownashigher‐ordercoding(Elo&Kyngäs,2008).Ourhigher‐ordercod‐ingledto231codes,whichwerespreadacross11categories.WeusedNVivotomatchourcodeswithcorrespondingquotes.Asweconductedhigher‐ordercoding,weusedNVivotorecordhowfre‐quentlyeachcodewasdescribedtodevelopaweightedcodinglist.Theweightedcodinglistwasinsertedintoatablethatrecordedthefrequencyofthecodeandcorrespondingquotes.Forexample,mul‐tiplenursesdescribedthattheywouldrepeatthemselves;thiswasdemonstratedbythefollowingresponses:

• “Iwouldrepeatinstructionsmoreoften.”• “Iwouldhavetotakethetimetoberepetitive,”• “Communicationwouldbemoredirectandrepetitive.”

Allresponsesofthisnature(N=40)werecodedas“repeating self when talking to the patient”inourweightedcodinglist.

Next, we began the third iteration of data analysis, specificallyabstraction,toonceagaingroupcategoriesbasedonsimilaritiesandgeneratecategorynamesbasedoncontent‐characteristicwords(Elo&Kyngäs,2008).Ourcontinuedgroupingofthecodesbasedonsimi‐laritiesresultedin189finalcodes,whichwerespreadacrossfivemajorcategories.Wecontinuedour analysis until saturationwas reached,wherenoneofourcategoriesorsub‐categoriescancelledeachotherout and all of our datawere appropriately encompassedwithin thefinal categories (Elo&Kyngäs, 2008).Throughout the data analysisprocess,thetwoauthorscodedindependentlyateachphaseofdataanalysisandmettodiscusscoding,developmentofourcodebookandquoteexemplars;wealsodiscusseddiscrepanciesincodinguntilcon‐sensuswasreached.

3.6 | Rigor

Inthisstudy,weusedmultiplestrategiestoincreasetherigorofourqualitativeresearch.First,weanalysedalldatawitharesearchteamwith several years of experience in qualitative methods. Second,wewrotememos throughout our analysis to create an audit trailtodescribehowweconductedouranalysisand theanalyticalde‐cisionswemadethroughtheanalysisprocess.Finally,weselectedcategoriesthatcoveredawiderangeofstrategiesusedbynursesinoursampleandensuredweusedquoteexemplarsthroughoutourfindingstoprovideadditionalevidenceofourresults(Sandelowski,1986,1993).

3.7 | Trustworthiness

Inqualitativeresearch,trustworthinessoffindingsisoftendiscussedintermsoftransferability,credibility,confirmabilityanddependabil‐ity (Eloetal.,2014;Graneheim&Lundman,2004).Transferabilityrefers to the detailed description of the scopeof one's results sothatfindingsmaybeapplicabletoothercontexts (Eloetal.,2014;Graneheim& Lundman, 2004). To ensure our results were trans‐ferable,weprovidedadetaileddescriptionofoursampleanddatacollectionandanalysisprocess inourmethodsectionssothatthereadermaybeable tounderstand thecontext inwhichour studywasconducted.Credibilityreferstorichandaccuratedescriptionsofthetopicorphenomenonofinterest(Eloetal.,2014;Graneheim&Lundman,2004).Similarly,confirmabilityreferstotheneedtoen‐sure interpretations and findingsmatch the data (Elo et al., 2014;Graneheim & Lundman, 2004). We ensured both credibility andconfirmabilitybyprovidingrich,detaileddescriptionsofourfindingswithquoteexemplarsasevidenceofourresultstoclearlydescribethe strategies nurses use when caring for patients with TBI whohave cognitive impairments.Dependability refers to the ability toreproducefindings(Eloetal.,2014;Graneheim&Lundman,2004).Althoughnotyetdeterminedifourfindingscanbereproduced,onewaytoincreasethelikelihoodofreproducibilityistoprovideade‐tailedaudittrailwithacleardescriptionofdatacollectionandanaly‐sisprocedures (Eloetal.,2014;Graneheim&Lundman,2004).Toincreaselikelihoodofdependability,ourmethodssectionservesasouraudittrail,wherewehaveoutlined,indetail,thestepswetooktocollectandanalyseourdata.

4  | RESULTS

Atotalof692nursesfromthethreeMidwesternhospitalsrespondedtooursurvey.Asapproximately3,904nursesreceivedourinitialemail,theoverall response ratewas17.7%,which is typical for electronicsurveys (Shih & Fan, 2009).Most respondentswere from a Level Itraumacentre(65%fromthepublichospital;27%fromtheVeterans’hospitals), andwere female (89%),middle‐aged (40.3 years),with abachelor'sdegrees (67%).Althoughmostnurses identifiedasastaffregistered nurse (77%), nursing roles included advanced practice

     |  5OYESANYA ANd THOMAS

registerednurses (5.6%),chargenurses (5%),nursemanagers (3.8%)andother (8%).Themajorityofnursesworkedonan inpatientunit(51%) followed by an ambulatory clinic (15%), primary care clinic(4.6%), emergency department (4.5%) andmiscellaneous (26%; e.g.,operatingroom,radiology,outpatientsurgery).Approximately95%ofnursessampledreportedthattheirclinicalpracticehaseverincludedpatientswithmoderate‐to‐severeTBI.

Thefinal5categoriesdescribedstrategiesnursesusewhencar‐ing for patients withmoderate‐to‐severe TBI who have cognitiveimpairments, including the following: (a) cognitive techniques, (b)communicationtechniques, (c)patientsafetytechniques, (d)agita‐tionandbehaviourmanagementtechniques,and(e)educationtech‐niques.StrategiesarelistedinrankorderinTable1,andanoverviewisprovidedinFigure1.

4.1 | Cognitive techniques

Nursesmostfrequentlydescribedusingcognitivetechniquesintheircareplanstodirectlyaddressissueswithcognitiveimpairments.Morethan 40% of nurses in our sample described addressing memoryproblems; frequentlyassessing thepatient's cognition; andaddress‐ingproblemswithattention,organisation,andexecutivefunctioning.Nursesdescribedusing frequent reminders, such as “keep a sched‐ulepostedinroom,”“writemycareplanontheboardforthem,”and“providevisualreminderstohelppatientwithmemory,attention,ex‐ecutivefunction(postits,photoswithnamelabels,etc.).”Nursesalsodescribedusingrepetition,asanursestated,“Rightatthestartofeachinteraction,remindthepatientwhoIamandwhereweareandwhatourplanisforthatmoment.”

Whenassessing thepatient's cognition, nursesdescribed theywould assess the patient's cognitive status and orient the patientto“person,time,situation,andplace,andforeshadowingofeventstocome in thefuture.”Whenaddressingproblemswithattention,nursesdescribedgivingsimplifiedinstructions,suchas“anorderedchecklistforthatpersontouseeverytimeheorsheneedstocom‐pleteataskrelatingtoself‐care.”

4.2 | Communication techniques

The next most commonly described strategy was communicationtechniques.Approximately37%ofnurses inoursampledescribedspecific communication techniques they would use with patientsandstaff,includingchangingthewaytheyaskedquestions,assistingthepatientwithcommunication,changingthedeliveryofcommuni‐cation,explainingthingsandcommunicatingwithotherstaffaboutthepatient.Onenurseencompassedseveralofthesestrategies inhis or her statement, “I would bemore repetitivewhen talking; Iwouldstartmysentenceswiththeirnamestokeeptheirattention;Iwouldtrytokeepmyconversationsshortandconcisetonotconfuseoroverwhelmthem.”

When changing the delivery of communication, nurses de‐scribedrepeatingthemselvesandusinglaytermswhenconversingwiththepatient.Onenursestated, “I tendtorepeatmyselfevery

timeIgointotheroomtomakesurethepatientunderstandswhoIamandwhatIamdoing.”Whenattemptingtoensurethepatientunderstood the information that had been communicated, nursesdescribed asking the patient to restatewhat they heard. A nursestated, “Iwouldhave thepatient repeatbackanddemonstrate tome.”Whenexplainingthingstopatients,nursesdescribedthattheywentovertheprocedures,whytheprocedureswerenecessary,andhowtheseprocedureswereapartofthecareplan.Finally,nursesdescribedchangingcommunicationwithotherstaffbylettingthemknow,forexample,“thatIwillneedadditionaluninterruptedtimetoworkwiththispatient.”

4.3 | Patient safety techniques

Almost23%ofnurses inoursampledescribedusingpatientsafetytechniquesasastrategytokeepthepatientwithmoderate‐to‐severeTBIsafe.Manyofthestrategiesnursesdescribedcentredonprotec‐tion of the patient's physical safety as safety riskswere increasedduetothepatient'scognitive,behaviouralandphysicalimpairments.Techniques included the following: changingassessmentof thepa‐tient,reassuringthepatientthatheorsheissafeandimplementingfallpreventionstrategies.Changestopatientassessmentmethodsfo‐cusedonevaluatingthepatientmorefrequently,asonenursestateditwasimportanttoconduct“frequentsafetyroundssincethey[thepatientwithTBI]aremorelikelytohavebehaviourissuesandbalance/gaitissuesmakingthemmoreatriskofharmingthemselves.”Whenimplementing fall prevention techniques, nurses described puttingthepatientonhighfallriskprecautions,suchasusingaconstantvis‐ualobserverorsitter,employingabedorchairalarmandplacingthepatientclosetothenurses’station,evidencedbythisquoteexemplarfromanurse,“Iwouldprobablyhaveapersonalsafetyattendantwiththepatientandattheveryleastbed/chairalarms.”

4.4 | Agitation and behaviour management techniques

Techniquesinthiscategoryfocusedonstrategiesnursesusedtopre‐vent or deal with agitation or behaviour problems of patients withTBI. Approximately 13%of nurses sampled described incorporatingstrategies tomanageagitationandbehaviourproblems in theircareplans.Nursesdidsobyallowingthepatient'sbraintorest,prevent‐ingagitationanddealingwithagitation.Toallowthepatient'sbraintorest,nursesdescribedtheywouldestablishastructureddailyroutine,schedulebreaksintasksandmoveslowly.MultiplenursesstressedtheimportanceofdecreasingstimulationaroundthepatientwithTBI.Afewnursesdescribedspecificstrategiestopreventagitation,suchasonewhostated:“IwouldtrytolimittheamountofstimulationtojustmetalkingatthetimeIwaswiththepatient.(i.e.,trytolimitvisitors,turnofftheTV,mutethesoundoftheTV,etc.).Ifanythingwouldstarttoagitatethepatient,Iwouldimmediatelydiscontinuethetaskandtryagainlater.”Ifagitationoccurred,nursesdescribedtheywouldpreventpatientviolencetowardsstafforfamilycaregivers.However,strate‐giestopreventpatientviolencewereunspecified.

6  |     OYESANYA ANd THOMAS

TA B L E 1  StrategiesnursesuseintheircareplanswhencaringforpatientswithTBIwhohavecognitiveimpairmentsa

Modification Strategies. Frequency of nurse descriptions

Cognitive Techniques 271

Addressingmemoryproblems 136

Usingvisualreminders 69

Writingthingsdown(onpaper,onawhiteboardoringeneral) 52

Postingpicturesoffamilyorhavingfamilybringfamiliarobjects 13

Usingsignstohelppatientrememberthings 4

Usingfrequentverbalremindersorcueing 28

Usingrepetition 26

Reintroducingselftopatientmultipletimes 14

Usingothertoolstohelpwithmemory(e.g.,tactiletools,alarmformeds,personalone‐pagefactsheet,dailycalendarforroutine,memorybook)

23

Talkingtofamilymembersaboutpertinentinformation 2

Addressingproblemswithattentionbygivinginstructions 75

Simplifyinginstructions 36

Givingpatientstep‐by‐stepdirections 17

Redirectingpatientasneeded 10

Askingthepatienttodosimpletasks 7

Havingpatientpracticethingsindependently 3

Keepingpatientoccupied 2

Assessingpatient'scognition 60

Orientingpatientfrequently 47

Reorientingpatienttoperson,place,timeandsituation 47

Assessingpatient'scognitivestatus 13

Communication Techniques 256

Changingdeliveryofcommunication 148

Repeatingselfwhentalkingtothepatient 52

Usinglaytermswhentalkingtothepatient 25

Beingclearanddirectwhentalkingtothepatient 23

Speakingslowlywhentalkingtothepatient 16

Usingshortersentenceswhentalkingtothepatient 13

Talkingtofamilymember 5

Havingshorterconversationswiththepatient 4

Usingpicturestocommunicatewithpatient 3

Makingsurepatientispayingattentionwhennurseistalking 3

Maintainingeyecontactwithpatientwhentalking 2

Listeningtopatient 2

Explainingthings 37

Explainingprocedurestopatientandstatingwhyyouaredoingprocedure 27

Explainingplanofcaretopatient 10

Changingthewayquestionsareasked 11

Keepingquestionsshortorsimple 9

Askingmoreimportantquestionsfirst 2

Ensuringpatientunderstandscommunication 9

Havingpatientdemonstrate 4

Askingpatientwhatheorsheunderstoodfromthecommunication 4

(Continues)

     |  7OYESANYA ANd THOMAS

4.5 | Education techniques

About10%of nurses inour sampledescribed strategies to try toimprovetheeffectivenessoftheireducationwhenteachingpatientswithTBIandtheirfamilymembers.Nursesdescribedusingmultiple

teaching sources; changing the timing, frequency or duration ofteachingsessions;assessingpatients’andfamilymembers’learningstylesorpriorknowledgeofinformationtobedelivered;assessingunderstandingofteaching;andincreasingthepatients’understand‐ingoftheinformationpresented.

Modification Strategies. Frequency of nurse descriptions

Assistingpatientwithcommunication 5

Givingpatientmoretimetorespond 3

Givingpatientoptionsforanswers 2

Communicatingwithotherstaffaboutpatient 1

Patient Safety Techniques 158

Changingassessmentofpatient 94

Assessingpatientfrequently 65

Assessingpatientneeds 29

Implementingfallpreventionstrategies 64

Usingadditionalsafetytechniques(bedalarm,chairalarm,etc.) 19

Placingpatientonhighfallriskprecautions 14

Havingaconstantvisualobservertoensurepatientissafe 14

Puttingpatientclosetonurses’station 13

Communicatingwithotherstaffaboutpatient'ssafetyrisks 2

Keepingpatient'sroomclutterfree 2

Agitation and Behaviour Management Techniques 89

Allowingpatient'sbraintorest 49

Establishingastructureddailyroutine 23

Movingslowly 14

Schedulingbreaks 4

Makingsurepatientisrestingorsleepingasmuchaspossible 3

Puttingsignonthedoor(e.g.,brainrestneeded) 3

Limitingnumberofvisitorsandlengthofstay 2

Preventingagitationinpatient 36

Decreasingtheamountofstimulationaroundpatient 31

Providingnursingcareswithoutincreasingstimulation 5

Dealingwithagitationinpatient 4

Preventingpatientviolencetowardsstafforfamilycaregivers 4

Education Techniques 71

Usingmultipleteachingsources 27

Teachingthefamilyorhavingfamilymemberpresentduringteaching 16

Usingvisualmaterials 11

Usingwritteninformation 8

Usingpictures 3

Changingtiming,frequencyordurationofteachingsessions 16

Holdingshortenedteachingsessions 16

Assessingpatient'sorfamilymember'slearningstyleorpriorknowledgeofinformation 16

Assessingpatient'sorfamilymember'sunderstandingofteaching 13

Increasingpatient'sunderstandingofteaching 9

Repeatingteachingorfrequentlyreferencingteachingatlaterpoints 9

aThefrequenciesarespecifictothecategory,sub‐categoryorlower‐levelstrategyandarenotalwayssummative.

TA B L E 1   (Continued)

8  |     OYESANYA ANd THOMAS

Whenusingmultiple teaching sources, nurses emphasised theimportanceof includingapatient'sfamilymember(s)duringteach‐ing.Onenursewrote,“Iwouldbesuretopullinthefamilyveryearlyand begin educating themonwhat is happening andwhy.”Othernurses described using written or visual materials as a guide fortheeducationtheywereproviding.Whenchangingthetiming,fre‐quencyordurationofteachingsessions,onenursedescribedheorshewould“spreadteachingoutovernumeroussessions.”

Nurses also described the importance of assessing patients’and family members’ learning styles or prior knowledge of theinformation tobedelivered toensure relevant teachingwasde‐livered in an appropriate manner. To assess understanding ofinformation presented, nurses described using the teach‐backmethod,whereby thenurseasked thepatientor familymembertoexplainwhattheyunderstood.Finally,toincreasethepatient'sunderstanding ofwhat the nurse taught, nurses described rein‐forcingteachingsessionsbyrepeatingtheteachingorfrequentlyreferencingitlater.

5  | DISCUSSION

Thepurposeofthisstudywastoinvestigatethestrategiesnursesuseintheircareplanwhencaringforpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.Findingsdescribeap‐proximately189strategiesnursesuseintheircareplans,includingcognitive,communication,patientsafety,agitationandbehaviourmanagement, and education techniques. The three most com‐monlyusedtypesofnursingstrategieswerecognitivetechniques,communication techniques and patient safety techniques. Thisstudy has generated new knowledge on this topic, as few stud‐ies have assessed strategies providers use to care for patientswith cognitive impairments, including patients with moderate‐to‐severeTBI (Alverzo,2004;Collis&Bloch,2012;Oppikofer&Geschwindner,2014).

Approximately 40% of nurses in our sample described theywouldusecognitivetechniquesintheircareplantoaddressprob‐lemswiththepatient'scognition.Focusingonthepatient'scognitionisimportantbecausecognitiveimpairmentscanaffectthepatient'shealthcareexperience (Oyesanya,Thomas,etal.,2016),aswellasthepatient'sabilitytolearnstrategiesthroughoutthehospitalstayto use to independentlymanage their health,wellness and safetyafter discharge (Oyesanya, Thompson, Arulselvam, & Seel, 2019).Researchshowsproviders’efforts toaddresscognitionduring thehospitalstaycanhelpthepatientdevelopcompensatorystrategiestomanagecognitiveproblemsathome(Turkstra,2013),whichcanoccurwithnursesthroughtherapyintegration(McNett&Gianakis,2010).

Similarly,approximately37%ofnursesinoursampledescribedtheyusedanumberofcommunicationstrategies,suchaschang‐ing theway they communicatewith the patientwith TBI, likelybecause cognitive and communication disorders often co‐occur(McDonaldetal.,2016;Turkstra,Politis,&Forsyth,2015).Usingeffective communication techniques is particularly importantbecausepatientswithcommunication impairmentsareathigherrisk forpooreroutcomescompared topatientswithout commu‐nicationimpairmentsascommunicationimpairmentsmaypreventeffective patient–provider communication about patient needs(Pataketal.,2009).Inaddition,communicationisrelatedtoqualityofcare,aseffectivepatient–providercommunicationcanincreasepatient adherence to the treatment regimen (Piette, Schillinger,Potter, & Heisler, 2003). Nursing literature recommends thatnursesuseapatientcommunicationassessmenttooltoallowfora thorough assessment of barriers to effective communicationsuch as those causedby literacy, linguistic, behavioural, culturalor physical barriers (Patak et al., 2009). Subsequently, the toolprovides guidance on nursing interventions that can be imple‐mented to address the patient's communicationneeds (Patak etal.,2009).However,nurses inoursampledidnotdescribestrat‐egiesusedtoassessthepatient'scommunicationimpairmentsor

F I G U R E 1  Strategiesnursesuseintheircareplanswhencaringforpatientswithtraumaticbraininjury(TBI)whohavecognitiveimpairments

     |  9OYESANYA ANd THOMAS

describeuseofcommunicationassessmenttoolsofanykind.Itisunclearwhethernursesareawareoforareusingassessmenttoolsorstrategiesandcorrespondingnursinginterventionstoaddresscommunicationimpairmentsinpatientswithmoderate‐to‐severeTBI.Inaddition,asbothnursesandspeech‐languagepathologistswork closely with patients with cognitive and communicationimpairments, there is an opportunity for speech therapists andnursestocollaboratetoaddressthepatient'sissueswithcognitionandcommunicationtoimprovepatientoutcomes(Dondorf,Fabus,&Ghassemi,2015;Ghassemi&Fabus,2017).

Ourfindingsaddtotheliteraturebydocumentingnonpharmaco‐logicalstrategiesnursesusetomanageagitationandbehaviourprob‐lemsinpatientswithTBIwhohavecognitiveimpairments(Alverzo,2004;Mortimer&Berg,2017).Recentresearchonnursingmanage‐mentofagitationinpatientswithTBIalsorecommendsnursespro‐motepatients'sleep–wakecyclesandusealternativestrategiessuchasaromatherapy,massagetherapyandmusictopreventandaddressagitationinthispatientpopulation(Mortimer&Berg,2017).Asag‐itationisacommonphaseofrecoveryforpatientswithmoderate‐to‐severeTBI(Mortimer&Berg,2017)andcanhaveaninfluenceonshort‐andlong‐termoutcomesforpersonswithmoderate‐to‐severeTBI (Babikian&Asarnow,2009;Bogner,Corrigan, Fugate,Mysiw,&Clinchot, 2001), it is important nurses have appropriate strate‐giestousewhenfacedwiththisissue.However,fewnursesinoursample(12.8%)describedusingstrategiestomanageagitationandbehaviourproblems.Our lowreportsfromnursesonstrategiestoaddressagitationandbehaviourproblemsmaybeduetotheunpre‐dictablenatureofbehaviourafteranindividualsustainsamoderate‐to‐severe TBI (Mortimer & Berg, 2017);management of agitationcanbechallengingforthenurse,especially ifthepatientbecomesphysically aggressive (Oppikofer & Geschwindner, 2014). Low re‐portsofstrategiestomanageagitationandbehaviourproblemsmayalsobedue to limited trainingandeducation focusedonmanage‐mentofpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairmentsinnursingschoolcurriculumandonthejob(Oyesanya,Brown,etal.,2016;Oyesanya,Thomas,etal.,2016).Thesefindingssuggesttheneedforadditionaltrainingfornurseswhocareforpa‐tientswithTBIwhohavecognitiveimpairments,particularlytolearneffectivestrategiestouseinmanagementofagitationandbehaviourproblems.

Thelistofstrategiesdescribedbynursesinoursampleisbynomeansexhaustive.For instance,nursesdidnotdescribestrategiesusedtoaddressnutritioninpatientswithTBIwhohavecognitiveim‐pairments,eventhoughresearchshowsthispatientpopulationmayhave nutritional deficits (Cook, Peppard, &Magnuson, 2008) andthatadequatenutritionisneededtopromotecognitivefunctioning(Bistrian,Askew,ErdmanJr,&Oria,2011;Schmitt,2010).Althoughdevelopmentand implementationof aperson‐and family‐centrednursingcareplanisagoldstandardinnursingcare(Lor,Crooks,&Tluczek,2016),nursesinoursampledidnotdescribemanystrategiesthatcouldbeusedtomakecaremoreperson‐andfamily‐centred.Inaddition,nursesinoursampledidnotdescribeuseofassessmenttools thatmay be useful in communicating the patients’ status to

otherproviders,suchastheRanchosLosAmigosLevelofCognitiveFunctioningScale,AgitatedBehaviorScale,GalvestonOrientationandAmnesiaTest,DisabilityRatingScale,FunctionalIndependenceMeasureandFunctionalAssessmentMeasure.Althoughnursesmayrequire training before use of these tools, these tools could helpnurseswitheffectivecareplandevelopmentandeffectivecommu‐nicationofthepatient'sstatustotheinterdisciplinaryteam.

5.1 | Strengths and limitations

Strengthsofthisstudyincludealargesamplesizewithnursesfromthree hospitals. However, this study is not without limitations.First,weaskednursestostatetheirtypicalcareplanwhencaringforpatientswithmoderate‐to‐severeTBIwhohaveproblemswithcognition (e.g., issueswithmemory, attention andexecutive func‐tion).Nursesrespondedwithoneormorestrategiestheywoulduse,whetherornotthesestrategieswereeffective.Nursesmayhavenothaveprioritisedtheirresponsesandmayhavewrittenonlyonestrat‐egy,eventhoughmultiplestrategiesmaybenecessarytoadequatelycareforthispatientpopulation.However,morethan50%ofnursesinoursampledescribedtwoormorestrategies,whichwereusefulinourfindings.Second,wedidnotanalysenurses’responsesbasedontheirhospitalunitorfrequencyofcaringforpatientswithmoderate‐to‐severeTBI;strategiesnursesdescribedmighthavedifferedbasedon thesevariables. Instead,weelected to count the frequencyofreport,ifoneassumesfrequencyofreportisonewayofdeterminingrelevance.Third,wedidnotasknursestospecifywhetherthestrat‐egiestheydescribedwererelevanttocareofpatientsintheacuteorchronicphaseofTBIrecovery.Althoughmorestrategiesmaybeneededforpatientswithmoderate‐to‐severeTBIintheacutephaseof recovery, these findings still contribute to the limited literatureonthistopicandprovideafoundationforfutureresearchfocusedonnursingcareofpatientswithTBI.Finally,althoughourresponserateof17.7%isconsideredtypicalofelectronicsurveys(Shih&Fan,2009), the results of our studymay not be representative of thestrategiesusedbyallnurseswhocareforpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairmentsintheUnitedStatesoracrosstheworld.However,ourlargesamplesizeofnursesfromthreehospitalsandsimilarities(basedontypeoftechnique)amongstrategiesreportedbyournurseparticipantsimplythatthestrate‐giesdescribedinourresultsmaybecommonlyusedbynurseswhocareforthepatientpopulation.

6  | FUTURE RESE ARCH

Futureresearchersmaywishtocompareourfindingstothestrate‐giesrecommendedbyTBInursingpracticeexperts,perhapsusingtheDelphimethodtocometoconsensusonnursingstrategies(Hsu& Sandford, 2010). In addition, research is needed to determinewhichnursingstrategiesaremosteffectivefornursestousewhencaringforpatientswithmoderate‐to‐severeTBIwhohavecogni‐tiveimpairments;thisresearchisnecessarybecauseitisimportant

10  |     OYESANYA ANd THOMAS

tobasepracticeonevidenceratherthantypicalityofpracticeorexpertrecommendations.Otherresearchersmaywishto investi‐gate differences in strategies nurses use based onwork setting,asnurseswhopracticeonhospitalunitswherepatientswithTBIregularlyreceivecare(suchastheemergencyroom,intensivecareunit,orinpatientrehabilitation)mayusedifferentstrategiescom‐paredwithnurseswhopracticeonunitswherepatientswithTBIareseenlessfrequently.

7  | CONCLUSION

Inoursample,692nursesfromthreehospitalsdescribedstrategiestheyuseintheircareplansforpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.Approximately189strategiesweredescribed,mostcommonlyaddressingimpairmentsinpatients’cog‐nitive abilities, various means of patient–provider communicationandpatientsafetytechniques,aswellasstrategiesforeducationandmanagingagitationandbehaviour.Resultsdemonstratetheneedforfurtherresearchontheeffectivenessofthesenursingstrategiestoprovideguidancefornursestousewhencaringforthesepatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments.Ourfindingsalsoprovidedirectionfordevelopmentofnursingeducationandtrainingandfordevelopmentofclinicalguidelinesonnonacutenursingmanagementofcognitiveimpairmentswhencaringforpa‐tientswithmoderate‐to‐severeTBI.

8  | RELE VANCE TO CLINIC AL PR AC TICE

Althoughourlistofnursingstrategiesisnotexhaustive,ourfindingsprovidearesourcefornursestousewhencaringforpatientswithmoderate‐to‐severeTBIwhohavecognitive impairments;whetherthenurseisanovice,experiencedorswitchingpatientpopulations,he or shemay find strategies to use in their care planwithin ourfindings.Disseminationofthesefindingstonurseswhocareforpa‐tientswithTBIwhohavecognitive impairmentscouldoccuratanindividual‐,unit‐orhospital‐levelviamultipleavenues,suchasinde‐pendent,onlinemodules;smallgrouptrainingswithaclinicalnursespecialistornurseeducator;andlunchandlearnpresentationsfromaTBIexpertfor individualhospitalunitsorduringahospital‐wideseminar. Finally,with limited clinical guidelines to direct nonacutenursingmanagementofpatientswithmoderate‐to‐severeTBIwhohavecognitiveimpairments,thesefindingscanprovideafoundationfortestingtheeffectivenessofthesenursingstrategies,whichcanguideclinicaldecision‐makinganddevelopmentofclinicalguidelinesthatcanbeusedtoinformnursingpractice.

The usefulness of our findings is demonstrated in the state‐ment, “nurses’ clinical reasoning incorporates experiential, formal,and informal knowledge and uses both inductive and deductivecognitive skills to solveproblems” (Rice,Bennett,Clesi,& Linville,2014,p.137).Ourfindingsdescribeacombinationofexperiential,formalandinformalknowledgenurseshavegainedwhilecaringfor

patients withmoderate‐to‐severe TBI who have cognitive impair‐ments, which can be used to facilitate education and training ofothernurses.Aspeer‐to‐peereducation,suchasaskingacolleagueaquestion,ispreferredbynurses(Oyesanya,Thomas,etal.,2016;Secomb,2008),our findingssummarise relevantknowledgeaboutcareofpatientswithmoderate‐to‐severeTBI,describedbynurses,suitablefornurses.

ACKNOWLEDG EMENTS

SpecialthankstoLynTurkstra,PhD,CCC‐SLP,forguidanceincon‐ceptualdevelopment,studydesignandmanuscriptrevision.

CONFLIC TS OF INTERE S T

Theauthorsreportnoconflictsofinterest.

DATA AVAIL ABILIT Y

Pleasecontactthefirstauthorforaccesstothedatasetusedinthisstudy.

ORCID

Tolu O. Oyesanya https://orcid.org/0000‐0001‐8821‐4510

R E FE R E N C E S

Alverzo,J.(2004).Theuseofaestheticknowledgeinthemanagementofbraininjurypatients.Rehabilitation Nursing,29(3),85–89.https://doi.org/10.1002/j.2048‐7940.2004.tb00316.x

American Association of Neuroscience Nurses (2008). Nursing man‐agement of adults with severe traumatic brain injury. Retrieved fromhttp://www.aann.org/pdf/cpg/aanntraumaticbraininjury.pdf

Babikian, T., & Asarnow, R. (2009). Neurocognitive outcomes and re‐covery after pediatric TBI: Meta‐analytic review of the literature.Neuropsychology,23(3),283.https://doi.org/10.1037/a0015268

Bazeley, P., & Jackson, K. (2013).Qualitative data analysis with NVivo. London,UK:SagePublicationsLimited.

Bistrian,B.R.,Askew,W.,Erdman,J.W.Jr,&Oria,M.P.(2011).Nutritionand traumatic brain injury: A perspective from the Institute ofMedicine report. Journal of Parenteral and Enteral Nutrition, 35(5),556–559.https://doi.org/10.1177/0148607111416122

Bogner,J.A.,Corrigan,J.D.,Fugate,L.,Mysiw,W.J.,&Clinchot,D.(2001).Role of agitation in prediction of outcomes after traumatic braininjury. American Journal of Physical Medicine & Rehabilitation,80(9),636–644.https://doi.org/10.1097/00002060‐200109000‐00002

Brolliar, S.M.,Moore,M., Thompson,H. J.,Whiteside, L.K.,Mink, R.B.,Wainwright,M. S.,…Vavilala,M. S. (2016).Aqualitative studyexploringfactorsassociatedwithprovideradherencetoseverepedi‐atrictraumaticbraininjuryguidelines.Journal of Neurotrauma,33(16),1554–1560.https://doi.org/10.1089/neu.2015.4183

Carney,N.,Totten,A.M.,O’Reilly,C.,Ullman,J.S.,Hawryluk,G.W.,Bell,M.J.,…Kissoon,N.(2017).Guidelinesforthemanagementofseveretraumaticbraininjury.Neurosurgery,80(1),6–15.

Centers for Disease Control and Prevention (2017). TBI data and sta‐tistics. Retrieved from https://www.cdc.gov/traumaticbraininjury/data/index.html

     |  11OYESANYA ANd THOMAS

Collis,J.,&Bloch,S.(2012).SurveyofUKspeechandlanguagetherapists’assessmentandtreatmentpracticesforpeoplewithprogressivedys‐arthria.International Journal of Language & Communication Disorders,47(6),725–737.https://doi.org/10.1111/j.1460‐6984.2012.00183.x

Cook,A.M., Peppard, A.,&Magnuson, B. (2008).Nutrition consider‐ations in traumatic brain injury.Nutrition in Clinical Practice,23(6),608–620.https://doi.org/10.1177/0884533608326060

Corrigan,J.D.,&Hammond,F.M.(2013).Traumaticbraininjuryasachronichealthcondition.Archives of Physical Medicine and Rehabilitation,94(6),1199–1201.https://doi.org/10.1016/j.apmr.2013.01.023

Department of Veterans Affairs (2013). Polytrauma systems of care. In VHA Handbook 1172.01. Washington, DC: Veterans HealthAdministration.

Dewan, M. C., Rattani, A., Gupta, S., Baticulon, R. E., Hung, Y.‐C.,Punchak,M.,…Park,K.B. (2018). Estimating theglobal incidenceoftraumaticbraininjury.Journal of Neurosurgery,130(4),1080–1097,https://doi.org/10.3171/2017.10.JNS17352

Dondorf,K.,Fabus,R.,&Ghassemi,A.E. (2015).The interprofessionalcollaboration between nurses and speech‐language pathologistsworkingwithpatientsdiagnosedwithdysphagiainskillednursingfa‐cilities.Journal of Nursing Education and Practice,6(4),17.https://doi.org/10.5430/jnep.v6n4p17

Elo,S.,Kääriäinen,M.,Kanste,O.,Pölkki,T.,Utriainen,K.,&Kyngäs,H.(2014).Qualitativecontentanalysis:Afocusontrustworthiness.SAGE Open, 4(1), 2158244014522633. https://doi.org/10.1177/2158244014522633

Elo, S., & Kyngäs, H. (2008). The qualitative content analysis pro‐cess. Journal of Advanced Nursing, 62(1), 107–115. https://doi.org/10.1111/j.1365‐2648.2007.04569.x

Ghassemi,A.E.,&Fabus,R.(2017).Aninterprofessionaleducationpilotstudy fornursing and speech‐languagepathology students. Iranian Journal of Nursing and Midwifery Research,22(6),497–498.https://doi.org/10.4103/ijnmr.IJNMR_4_17

Graneheim,U.H., & Lundman, B. (2004).Qualitative content analysisinnursingresearch:Concepts,proceduresandmeasurestoachievetrustworthiness.Nurse Education Today,24(2),105–112.https://doi.org/10.1016/j.nedt.2003.10.001

Hsieh,H.‐F.,&Shannon, S. E. (2005). Three approaches toqualitativecontent analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/1049732305276687

Hsu,C.‐C.,&Sandford,B.A. (2010).Delphitechnique. InN.J.Salkind(Ed.),Encyclopedia of research design(pp.344–347).ThousandOaks,CA:SAGEPublications,Inc.

Jaglal,S.B.,Guilcher,S.J.T.,Bereket,T.,Kwan,M.,Munce,S.,Conklin,J.,…Riopelle,R.(2014).Developmentofachroniccaremodelforneu‐rologicalconditions(CCM‐NC).BMC Health Services Research,14(1),1.https://doi.org/10.1186/1472‐6963‐14‐409

JointTraumaSystem(2017).Clinical practice guideline ‐ Neurosurgery and severe head injury (CPG ID:30).Retrievedfromhttp://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs

Kothari, S. (2007). Prognosis after severe TBI: A practical, evidencebased approach. InN.D. Zasler,D. I. Katz,&R.D. Zafonte (Eds.),Brain injury medicine: Principles and practice(pp.169–199).NewYork,NY:DemosMedicalPublishing,LLC.

LeCroy,T.,&McMahon,J.(2015).Traumaticinjuries:Traumaticbraininjuryandspinalcordinjury.InAssociationofRehabilitationNurses(Ed.),The specialty practice of rehabilitation nursing: A core curriculum(7thed.,pp.511–551).Chicago,IL:AssociationofRehabilitationNurses.

Lentz,J.,Kennett,M.,Perlmutter,J.,&Forrest,A.(2016).Pavingthewayto a more effective informed consent process: Recommendationsfrom the Clinical Trials Transformation Initiative. Contemporary Clinical Trials,49,65–69.https://doi.org/10.1016/j.cct.2016.06.005

Long,A.F.,Kneafsey,R.,Ryan,J.,&Berry,J.(2002).Theroleofthenursewithinthemulti‐professionalrehabilitationteam.Journal of Advanced Nursing,37(1),70–78.https://doi.org/10.1046/j.1365‐2648.2002.02059.x

Lor,M.,Crooks,N.,&Tluczek,A.(2016).Aproposedmodelofperson‐,fam‐ily‐,andculture‐centerednursingcare.Nursing Outlook,64,352–366.https://doi.org/10.1016/j.outlook.2016.02.006

Maas,A.I.,Marmarou,A.,Murray,G.D.,Teasdale,S.G.M.,&Steyerberg,E.W. (2007). Prognosis and clinical trial design in traumatic braininjury:The IMPACTstudy.Journal of Neurotrauma,24(2),232–238.https://doi.org/10.1089/neu.2006.0024

McDonald,S.,Code,C.,&Togher,L.(2016).Communication disorders fol‐lowing traumatic brain injury.Hove,UK:PsychologyPress.

McNett,M.M.,&Gianakis,A.(2010).Nursinginterventionsforcriticallyill traumatic brain injury patients. Journal of Neuroscience Nursing,42(2),71–77.https://doi.org/10.1097/JNN.0b013e3181ce5b8a

Melnyk, B. M., & Fineout‐Overholt, E. (2011). Evidence‐based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA:LippincottWilliams&Wilkins.

Mortimer,D.S.,&Berg,W.(2017).Agitationinpatientsrecoveringfromtraumatic brain injury:Nursingmanagement. Journal of Neuroscience Nursing, 49(1), 25–30. https://doi.org/10.1097/JNN.0000000000000253

Oppikofer,S.,&Geschwindner,H.(2014).Nursinginterventionsincasesof agitation and dementia. Dementia, 13(3), 306–317. https://doi.org/10.1177/1471301212461110

Oyesanya, T. O., Thompson, N., Arulselvam, K., & Seel, R. T. (2019).Technology and TBI: Perspectives of persons with TBI and theirfamily caregivers on technology solutions to address health,well‐ness, and safety concerns. Assistive Technology, 1–11, https://doi.org/10.1111/jocn.14958

Oyesanya,T.O.,Brown,R.L.,&Turkstra,L.S.(2016).Caringforpatientswithtraumaticbraininjury:Asurveyofnurses’perceptions.Journal of Clinical Nursing,11–12,1562–1574.https://doi.org/10.1111/jocn.13457

Oyesanya, T. O., & Snedden, T. R. (2018). Pediatric nurses’ perceivedknowledgeandbeliefsofevidence‐basedpracticeinthecareofchil‐drenandadolescentswithmoderate‐to‐severetraumaticbraininjury.Journal of Specialists in Pediatric Nursing,23(2), e12209. https://doi.org/10.1111/jspn.12209

Oyesanya,T.O.,Thomas,M.A.,Brown,R.L.,&Turkstra,L.S. (2016).Nurses’beliefsaboutcaringforpatientswithtraumaticbraininjury.Western Journal of Nursing Research,38(9), 1114–1138. https://doi.org/10.1177/0193945916636629

Patak,L.,Wilson‐Stronks,A.,Costello,J.,Kleinpell,R.M.,Henneman,E.A.,Person,C.,&Happ,M.B.(2009).Improvingpatient‐providercom‐munication:Acall toaction.The Journal of Nursing Administration,39(9),372–376.https://doi.org/10.1097/NNA.0b013e3181b414ca

Piette,J.D.,Schillinger,D.,Potter,M.B.,&Heisler,M.(2003).Dimensionsofpatient‐providercommunicationanddiabetesself‐careinaneth‐nicallydiversepopulation.Journal of General Internal Medicine,18(8),624–633.https://doi.org/10.1046/j.1525‐1497.2003.31968.x

Reddy,R.P.,Rajeswaran,J.,Devi,B.I.,&Kandavel,T.(2017).Cascadeoftraumaticbrain injury:Acorrelational studyofcognition,postcon‐cussionsymptoms,andqualityoflife.Indian Journal of Psychological Medicine,39(1),32–39.https://doi.org/10.4103/0253‐7176.198940

Rice, K. L., Bennett,M. J., Clesi, T., & Linville, L. (2014).Mixed‐meth‐odsapproach tounderstandingnurses’ clinical reasoning in recog‐nizingdeliriuminhospitalizedolderadults.The Journal of Continuing Education in Nursing,45(3),136–148.https://doi.org/10.3928/00220124‐20140219‐02

Sandelowski, M. (1986). The problem of rigor in qualitative re‐search. Advances in Nursing Science, 8(3), 27–37. https://doi.org/10.1097/00012272‐198604000‐00005

Sandelowski,M. (1993). Rigor or rigormortis: The problemof rigor inqualitativeresearchrevisited.ANS. Advances in Nursing Science,16(2),1–8.https://doi.org/10.1097/00012272‐199312000‐00002

Schmitt,J.A.(2010).Nutritionandcognition:Meetingthechallengetoob‐taincredibleandevidence‐basedfacts.Nutrition Reviews,68(suppl_1),S2–S5.https://doi.org/10.1111/j.1753‐4887.2010.00329.x

12  |     OYESANYA ANd THOMAS

Secomb, J. (2008).A systematic reviewof peer teaching and learning inclinicaleducation.Journal of Clinical Nursing,17(6),703–716.https://doi.org/10.1111/j.1365‐2702.2007.01954.x

Shih, T.‐H., & Fan, X. (2009). Comparing response rates in e‐mail andpaper surveys: A meta‐analysis. Educational Research Review, 4(1),26–40.https://doi.org/10.1016/j.edurev.2008.01.003

Teasdale,G.,Maas,A., Lecky,F.,Manley,G., Stocchetti,N.,&Murray,G.(2014).TheGlasgowComaScaleat40years:Standingthetestoftime.The Lancet Neurology,13(8),844–854.https://doi.org/10.1016/S1474‐4422(14)70120‐6

Tong,A., Sainsbury,P.,&Craig, J. (2007).Consolidatedcriteria for re‐porting qualitative research (COREQ): A 32‐item checklist for in‐terviewsandfocusgroups.International Journal for Quality in Health Care,19(6),349–357.https://doi.org/10.1093/intqhc/mzm042

Turkstra,L.S. (2013). Inpatientcognitive rehabilitation: Is it time forachange?The Journal of Head Trauma Rehabilitation,28(4),332–336.https://doi.org/10.1097/HTR.0b013e31828b4f3f

Turkstra,L.S.,Politis,A.M.,&Forsyth,R.(2015).Cognitive–communica‐tiondisordersinchildrenwithtraumaticbraininjury.Developmental Medicine & Child Neurology,57(3),217–222.https://doi.org/10.1111/dmcn.12600

Villanueva,N. E. (1999). Experiences of critical care nurses caring forunresponsive patients. Journal of Neuroscience Nursing, 31(4), 216. https://doi.org/10.1097/01376517‐199908000‐00003

SUPPORTING INFORMATION

Additional supporting information may be found online in theSupportingInformationsectionattheendofthearticle.

How to cite this article:OyesanyaTO,ThomasMA.Strategiesnursesusewhencaringforpatientswithmoderate‐to‐severetraumaticbraininjurywhohavecognitiveimpairments.J Clin Nurs. 2019;00:1–12. https://doi.org/10.1111/jocn.14958