| ObjectiveTo construct the early rehabilitation nursing plan for limb function of patients with traumatic brain injury,to conduct transformation and application based on clinical situations,promote the clinical transformation of evidence,and improve the efficacy of clinical rehabilitation nursing.MethodsBased on the Knowledge to action framework,this study provides basis for the early rehabilitation and nursing of limbs after traumatic brain injury through four parts: analysis of early rehabilitation nursing of the limbs function of patients with traumatic brain injury,summary of evidence,preparation before clinical transformation of evidence,clinical transformation of evidence and effect evaluation,to provide basis for early rehabilitation nursing of limb function after traumatic brain injury.1.Investigation on the implementation of early rehabilitation nursing of limb function in traumatic brain injury patientsField research was conducted in two third-class hospitals in China to understand the current status of early rehabilitation nursing for the limb function of clinical traumatic brain injury patients and the problems that exist.2 Summary of evidence of early rehabilitation nursing for patients with traumatic brain injuryBased on problems identified in clinical field studies,PIPOST questions were constructed,literature related to limb function rehabilitation nursing of traumatic brain injury patients was systematically searched from domestic and foreign databases,literature quality was screened and evaluated,evidence was extracted from the included literature and summarized into the best evidence summary.3.Research on barriers and facilitators of clinical transformation of evidenceClinical specialist are selected to conduct evidence availability evaluation research based on FAME framework,evaluate the feasibility,suitability,clinical significance and validity of each piece of evidence in the evidence summary,and modify the evidence content.Based on the comprehensive framework of implementation research,qualitative interview research was conducted in clinical practice to evaluate the barriers and facilitators affecting the clinical transformation of evidence from five areas: intervention characteristics,internal environment,individual characteristics,external environment and implementation process,so as to provide a basis for the formulation of intervention programs.According to the barriers and facilitators,the corresponding clinical reform and training should be carried out respectively to form the suitable clinical intervention program.4.Clinical application and evaluation of intervention programsAccording to the content of evidence summary,formulate the corresponding clinical review indicators,and review the evidence before and after clinical intervention;Clinical application and evaluation of evidence were carried out.Traumatic brain injury patients with limb dysfunction admitted to the neurosurgery department of two Grade A hospitals in Guilin and Jinan were selected as research objects,and a stepped wedge cluster randomized trial including three stages and two steps was carried out.In the first stage,the two hospitals did not enter the step,and the intervention was still carried out according to conventional nursing intervention methods.One of the hospitals entered the step and began to apply the intervention protocol of this study,and the third stage,the other hospital entered.The control group received routine rehabilitation nursing,mainly including routine education and nursing,and the experimental group received early rehabilitation nursing program for limb function summarized based on evidence.Data collection and analysis were conducted on corresponding process indicators and outcome indicators to verify the effectiveness and clinical implementability of the intervention program.Results1.Investigation on the implementation of early rehabilitation nursing of limb function in traumatic brain injury patientsThrough the participation observation in two fields,the current situation of the department and the responsibilities of rehabilitation related personnel were understood,and the deficiencies in the rehabilitation nursing practice of TBI limb function were found,the degree of attention to the rehabilitation nursing of patients with limb function is not enough,and the clinical lack of early rehabilitation nursing standards for patients with limb function,further analyzed the need for clinical transformation of evidence and the factors that may affect the clinical transformation of evidence.2.Summary of evidence of early rehabilitation nursing for patients with traumatic brain injuryThirteen literatures were included in this study,including 5 guidelines,5 expert consensus,2 systematic reviews and 1 technical report.A total of 19 pieces of evidence were extracted from 6 aspects,including: Assess,develop intervention plan,intervention initiation/suspension timing,acute phase intervention,recovery phase intervention,discharge and follow-up.3.Research on barriers and facilitators of clinical transformation of evidenceFirstly,FAME evaluation of evidence was conducted.A total of 16 clinical specialist were included in the two hospitals to evaluate 19 pieces of evidence respectively.There were 15 evidences with the approval rate of 80% or above,and 13 evidences with the adoption rate of 90% or above,indicating that the evidence was of good clinical applicability.Then,based on the implementation of scientific CFIR framework,5 clinical nursing staff were interviewed qualitatively,and 5 barriers,15 facilitators and 1 factor were both barrier and facilitator.Finally,clinical reform and training were carried out based on the barriers and facilitators,and an intervention program suitable for clinical practice was formed.The program mainly includes assessment,position management,passive movement,active movement,daily living ability training,health education,and the timing of assessment and intervention as well as relevant assessment tools and intervention methods were defined.4.Clinical application and evaluation of intervention programsFirstly,clinical review studies were conducted based on evidence.The results of clinical review before intervention and one month after intervention found that the clinical compliance rate of review indicators of neurosurgery in hospital A increased by 26.3%compared with baseline,and hospital B increased by 36.8% compared with baseline.A stepped cluster-randomized trial was conducted in the neurosurgery departments of two hospitals from September 2022 to February 2023.The sample size of each stage in each hospital in the step was 30 cases,and each hospital were 90 cases,a total of 180 cases.(1)Process evaluation: The results showed that the intervention implementation rate of the interventionists in one hospital was all greater than 60%,and in the other hospital,84% of interventions had an intervention rate greater than 60%;(2)Outcome evaluation:(1)For the primary outcome measure,the FMA of the patients,the generalized linear mixed model was used for multivariate analysis.The modified model had statistical significance(F=15.237,P < 0.001),and the grouping *before and after measurement had statistical significance(P < 0.001),indicating the interaction between grouping and time.Further analysis of outcome variables between the two groups before and after intervention showed that the FMA difference of motor function between the two groups was not statistically significant before intervention(P=0.357 > 0.05),but statistically significant after intervention(P=0.010 < 0.05),and the FMA score of the intervention group was higher than that of the control group after intervention.(2)For the secondary outcome measure,the patient’s self-care ability BI,the generalized linear mixed model was first used for multivariate analysis.The modified model had statistical significance(F=25.286,P < 0.001),and the grouping * before and after measurement had statistical significance(P < 0.001),indicating that grouping had an interaction with time.Further analysis of the difference of outcome variables between the two groups before and after intervention showed that the difference of self-care ability BI between the two groups was not statistically significant before intervention(P=0.251 >0.05),but statistically significant after intervention(P < 0.001),and the BI score of the intervention group was higher than that of the control group after intervention.(3)For the secondary outcome measure,the patient’s mobility,the generalized linear mixed model was first used for multivariate analysis.The modified model had statistical significance(F=12.611,P < 0.001),and the grouping * before and after measurement had statistical significance(P < 0.001),indicating that grouping had an interaction with time.Further analysis of the difference of outcome variables between the two groups before and after intervention showed that the difference of activity ability DE Morton between the two groups was not statistically significant before intervention(P=0.135 > 0.05),but statistically significant after intervention(P=0.002 < 0.05),and after intervention,the DE Morton score of the intervention group was higher than that of the control group.(4)For the secondary outcome measure,the knowledge and behavior level of the nurses,the results showed that with the advance of the intervention period,the knowledge level of the nurses who implemented the intervention on limb function rehabilitation nursing improved significantly,and finally reached full marks,and the improvement of the rehabilitation nursing behavior score before and after the three stages was not obvious;(5)For the secondary outcome measure,the knowledge scores of the patients,the generalized linear mixed model was first used for multivariate analysis,and the modified model had statistical significance(F=18.006,P <0.001).There was no statistical significance(P=0.160> 0.05),indicating that there was no interaction between grouping and time.The main effects of grouping and pre-test and post-test were statistically significant(P <0.001),indicating that the two groups of patients had significant differences in overall knowledge scores,knowledge scores of pre-test and post-test were significantly different;(6)For the secondary outcome measure,the knowledge scores of the caregivers,the generalized linear mixed model was first used for multi-factor analysis.The modified model had statistical significance(F=12.276,P <0.001),and the grouping * before and after measurement had statistical significance(P=0.001<0.05),indicating the interaction between grouping and time.Further analysis of the difference of outcome variables between the two groups before and after intervention showed that there was no statistical significance in the caregiver knowledge score between the two groups before intervention(P=0.849>0.05),but there was statistical significance after intervention(P <0.001),and the caregiver knowledge score in the intervention group was higher than that in the control group after intervention.(3)One month after the intervention,evidence was reviewed again in the neurosurgery department of the two hospitals,and the clinical compliance rate of the reviewed indicators in the neurosurgery department of Hospital A and Hospital B increased by 21% and 36.8% from baseline.ConclusionThis study summarized the best evidence of early rehabilitation nursing for traumatic brain injury patients with limb function and carried out clinical reform by analyzing the barriers and facilitators affecting transformation of clinical evidence,so as to construct a set of intervention programs suitable for rehabilitation nursing for traumatic brain injury patients with limb function.A stepped cluster-randomized trial was conducted at the neurosurgery departments of two hospitals.Through the improvement of motor function,self-care ability and activity ability of patients,as well as the improvement of the knowledge level of interveners,patients and caregivers,the effectiveness of early rehabilitation nursing intervention program of limb function of patients with craniocerebral trauma was verified.The implementation rate of the process indicators and the interviews with interveners after the experiment verified the clinical implementability of the scheme.The clinical review before and after intervention verified the continuity of clinical transformation of evidence. |
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