Conceptualising personhood in nursing care for people with altered consciousness, cognition and behaviours: A discussion paper.

The aim of this discussion paper is to explore factors and contexts that influence how nurses might conceptualise and assign personhood for people with altered consciousness, cognition and behaviours. While a biomedical framing is founded upon a dichotomy between the body and self, such that the body can be subjected to a medical and objectifying gaze, relational theories of self, multiculturalism and technological advances for life-sustaining interventions present new dilemmas which necessitate discussion about what constitutes personhood. The concept of personhood is dynamic and evolving: where historical constructs of rationality, agency, autonomy and a conscious mind once formed the basis for personhood, these ideas have been challenged to encompass embodied, relational, social and cultural paradigms of selfhood. Themes in this discussion include: the right to personhood, mind-body dualism versus the embodied self; personhood as consciousness, rationality and narratives of self; social relational contexts of personhood and cultural contexts of personhood. Patricia Benner's and Christine Tanner's clinical judgement model is then applied to consider the implications for nursing care that seeks to reflexively incorporate personhood. Nurse clinicians are able to move between conceptions of personhood and act to support the body, as well as presumed autonomy and relational, social and cultural personhood. In doing so, they use analytical, intuitive and narrative reasoning which prioritises autonomous constructions of self. They also incorporate relational and social contexts of the person receiving care within the possibilities of technological advances and constraints of contextual resources.

Potential for misinterpretation: An everyday problem male nurses encounter in inpatient rehabilitation.

AIMS: This study aims to report on the everyday concern of the 'potential for misinterpretation', which was the basic social problem revealed in a grounded theory study exploring male nurse practice in inpatient rehabilitation in Australia. BACKGROUND: Male nurses account for approximately 10% of nursing workforce across western countries and they practice in a range of clinical areas; however, how they practice in inpatient rehabilitation remains unexplored. METHODS: Constructivist grounded theory was used in this study and was conducted in two phases: (i) involved semi-structured interviews with 11 male nurses from October 2013 to June 2014 and (ii) observation of practice of 12 male nurses and semi-structured interviews with male nurses and 15 patients from February to April 2015. RESULTS: Nurse participants encountered the intersection of two pervasive patient ideologies about male nurses. Patients perceived nursing to be women's work and that male nurses are sexual threats. These two intersecting ideologies created a concern for male nurses working in inpatient rehabilitation and that concern was labelled 'potential for misinterpretation'. CONCLUSION: Gender stereotypes impacted on the ability of male nurses to practise nursing in inpatient rehabilitation. Male nurses were mindful on a daily basis that misinterpretation could, and did, happen in inpatient rehabilitation.

Problems people with spinal cord injury experience accessing help with bowel care when hospitalised outside a specialist spinal injury service.

AIMS AND OBJECTIVES: To examine the nature of problems experienced by people with spinal cord injury (SCI) when accessing help to maintain recommended bowel regimes while hospitalised outside a specialist spinal injury service. BACKGROUND: Bowel dysfunction is one particularly undesirable aspect of life with a SCI, with constipation and incontinence common. DESIGN: Descriptive qualitative. METHODS: Accounts of problems encountered in hospitals in New South Wales Australia collected during interviews with 11 people living with SCI and 12 responses provided by spinal clinicians via an online survey were subjected to thematic analysis. The COREQ guidelines were followed for reporting. RESULTS: There were similarities across data collected from both sources. Individuals with SCI described instances where their bowel care needs did not fit with the pace and processes in acute hospitals. The clinician data pointed to a failure of healthcare professionals to assist people with SCI to maintain bowel care regimes recommended by specialist spinal services. Both groups described times when bowel care received was unreliable and fragmented, along with reports of staff who were unwilling and/or unable to provide the assistance required. Many and varied physical and psychosocial repercussions for individuals were associated with these system failures. In some instances, rather than restoring health, being admitted to hospital represented a significant health risk. CONCLUSION: A failure of hospital systems to meet the bowel care needs of people with SCI when hospitalised outside a specialist spinal unit was identified. System and individual factors contributed to these problems, hence addressing them requires both system and individual responses. RELEVANCE TO CLINICAL PRACTICE: If this problem is left unaddressed, the health and quality of life of people with SCI will continue to be compromised. Nursing scope of practice needs to be clarified and communicated to nurses outside specialist spinal injury units in relation to their role in maintaining bowel care regimes recommended for their patients by spinal specialists, and nurses need to ensure they possess the skills required. To allocate the time needed to provide this care, individual nurses need the support of the whole nursing team, including managers who are prepared to arrange additional staff when needed.

An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation.

AIM: To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation. DESIGN: A retrospective cohort design. METHODS: Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care. RESULTS: Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N = 38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care. CONCLUSION: Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes. IMPACT: Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.

Predictors of unplanned readmission to acute care from inpatient brain injury rehabilitation.

AIMS AND OBJECTIVES: To identify the predictors of unplanned readmission to acute care (RTAC) from inpatient brain injury rehabilitation and to develop a risk prediction model. BACKGROUND: RTAC from inpatient rehabilitation is not uncommon. Individual rehabilitation patient populations require their own body of evidence regarding predictors of RTAC. DESIGN: Retrospective cohort study. METHODS: Adult patients with new onset acquired brain injury admitted to a stand-alone rehabilitation facility between 1 January 2012-31 December 2018 were included in the study. The main measures were RTAC, sensitivity, specificity, the C-statistic and Youden's index. This paper is reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: Of 383 patients admitted for rehabilitation, 83 (22%) experienced a RTAC; 69 (18%) patients had at least one unplanned RTAC episode. Patients requiring unplanned RTAC were more likely to have lower Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) scores on rehabilitation admission, a higher burden of care on rehabilitation discharge and be discharged to a nonhome residence. Rehabilitation admission GCS and motor FIM were identified as the independent RTAC predictors in multivariate regression modelling. The combined C-statistic was 0.86. A GCS cut-off score of ≤14 and motor FIM cut-off score of ≤40 were identified as optimal, yielding a combined Youden's index of 0.56 (sensitivity = 0.72; specificity = 0.83). CONCLUSION: Patients requiring an unplanned RTAC had a lower functional status on rehabilitation admission. A prediction model for unplanned RTAC has been developed using validated and readily available clinical measures. RELEVANCE TO CLINICAL PRACTICE: The developed RTAC risk prediction model is the first step in preventing unplanned RTAC from inpatient brain injury rehabilitation. Future research should focus on discrete interventions for preventing unplanned RTAC from inpatient brain injury rehabilitation.

Spirituality and its relationship with positive adjustment following traumatic brain injury: a scoping review.

OBJECTIVE: To identify the extent of research which has investigated spirituality or closely related meaning-making constructs after traumatic brain injury (TBI). DESIGN: A scoping review was employed to capture the broadest possible range of studies. METHODS: Search terms 'spirituality', 'religion', 'beliefs', 'faith', 'hope', 'meaning', 'purpose in life', 'sense of coherence' and 'posttraumatic growth' were combined with search terms related to TBI. Findings were restricted to empirical studies published in English, in peer-reviewed journals and conducted over a 20-year period between 1997 and 2016. RESULTS: Nine studies were identified, conducted in the USA, Canada and the UK. These included eight quantitative studies and one qualitative study. Definitions and measurement of spirituality varied widely among the studies. Findings revealed that spirituality was closely related to a number of positive outcomes following TBI including psychological coping, physical health, mental health, productivity, life satisfaction, functional independence and posttraumatic growth. CONCLUSIONS: The limited research conducted into spirituality following TBI suggests it can play an important role in the recovery process. Further research is necessary to identify the particular spiritual needs of this population, and how clinical staff may be supported to address such needs.

Development of the Sydney Falls Risk Screening Tool in brain injury rehabilitation: A multisite prospective cohort study.

AIMS AND OBJECTIVES: To develop a falls risk screening tool (FRST) sensitive to the traumatic brain injury rehabilitation population. BACKGROUND: Falls are the most frequently recorded patient safety incident within the hospital context. The inpatient traumatic brain injury rehabilitation population is one particular population that has been identified as at high risk of falls. However, no FRST has been developed for this patient population. Consequently in the traumatic brain injury rehabilitation population, there is the real possibility that nurses are using falls risk screening tools that have a poor clinical utility. DESIGN: Multisite prospective cohort study. METHODS: Univariate and multiple logistic regression modelling techniques (backward elimination, elastic net and hierarchical) were used to examine each variable's association with patients who fell. The resulting FRST's clinical validity was examined. RESULTS: Of the 140 patients in the study, 41 (29%) fell. Through multiple logistic regression modelling, 11 variables were identified as predictors for falls. Using hierarchical logistic regression, five of these were identified for inclusion in the resulting falls risk screening tool: 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 FRST has good clinical validity (sensitivity = 0.9; specificity = 0.62; area under the curve = 0.87; Youden index = 0.54). The tool was significantly more accurate (p = .037 on DeLong test) in discriminating fallers from nonfallers than the Ontario Modified STRATIFY FRST. CONCLUSION: A FRST has been developed using a comprehensive statistical framework, and evidence has been provided of this tool's clinical validity. RELEVANCE TO CLINICAL PRACTICE: The developed tool, the Sydney Falls Risk Screening Tool, should be considered for use in brain injury rehabilitation populations.

A Case-control Study Examining the Characteristics of Patients who Fall in an Inpatient Traumatic Brain Injury Rehabilitation Setting.

OBJECTIVE: The purpose of the study was to describe the characteristics of patients who fall in the inpatient traumatic brain injury (TBI) rehabilitation setting. SETTING: Specialized inpatient TBI rehabilitation unit. PARTICIPANTS: Fifty-four patients with history of falls and 55 nonequivalent patients without history of falls. DESIGN: Retrospective nonequivalent case-control study. MAIN MEASURES: The Functional Independence Measure, Glasgow Coma Scale, Westmead Post-traumatic Amnesia Scale, demographic and functional characteristics, and behavior and medication variables. RESULTS: No significant difference between patients with and without history of falls for age, sex, medication class or total number of medications administered on admission, and median admission Westmead Post-traumatic Amnesia Scale score was observed. Patients with history of falls had a significantly longer duration of post-traumatic amnesia, rehabilitation length of stay, and lower mean total admission Functional Independence Measure score and median Glasgow Coma Scale score at the time of injury. Patients with history of falls were more than 10 times more likely than patients without history of falls to require assistance on admission for activities of daily living, transfers, and continence/toileting. Neurobehaviors including noncompliance and anosognosia were significantly associated with patients with history of falls. CONCLUSIONS: A patient in the rehabilitation setting with a more severe TBI characterized by multisystem impairments is at an increased risk of falling, whereas some traditional fall risk factors were not associated with patients who fall. Rehabilitation settings should consider cohort-specific fall risk profiling. The Ontario STRATIFY Falls Risk Screening Tool is perhaps not the best tool to screen for falls in this inpatient population.

Predicting falls: considerations for screening tool selection vs. screening tool development.

AIMS: This paper discusses considerations for falls risk screening tool selection vs. the need to develop new tools. BACKGROUND: Inpatient falls are a complex patient safety issue that represent a significant burden for the healthcare system. In the inpatient context, falls risk screening tools are most often used for predicting falls, but in some populations assessment tools are more suited, however in others, a clinician's clinical judgment may be just as effective. Limited external validity is a central issue with falls risk screening tools when used in different populations than the original study. There is clinical need for guidance regarding screening tool selection vs. the need to development new tools and how to effect change in relation to the prediction of falls. DESIGN: Discussion paper. DATA SOURCES: This discussion paper is based on our own experiences and research and is supported by literature. IMPLICATIONS FOR NURSING: This paper provides clinicians with a better understanding of considerations for falls risk screening tool selection vs. the need to develop new tools. In doing so, it provides clinicians guidance on how to critique the efficacy and utility of their falls risk screening tool. This paper equips clinicians for effecting change in relation to the prediction of falls. CONCLUSION: Falls risk prediction is a particularly complex patient safety issue. Clinicians need to be aware of the limitations of their tool used to predict falls.

The characteristics of falls in an inpatient traumatic brain injury rehabilitation setting.

AIMS AND OBJECTIVES: To describe the nature of falls in an inpatient traumatic brain injury rehabilitation setting. BACKGROUND: Falls are the most frequently recorded patient safety incident in the inpatient context. However, higher rates of falls are reported in rehabilitation settings compared to acute care settings. In the rehabilitation setting, patients with a traumatic brain injury have been identified as at a high risk of falling. However to date, research into the nature of falls involving this patient population is limited. DESIGN: Five-year retrospective cohort study design. METHODS: Falls data from an inpatient traumatic brain injury rehabilitation unit were retrieved from the NSW Ministry of Health Incident Information Management System and patient clinical notes; nursing shift data were retrieved from the local rostering system. RESULTS: The fall rate was 5·18 per 1000 patient bed days. Over a 24-hour period falls (n = 103) occurred in a trimodal pattern. The median fall free period after admission was 14 days and 22% of traumatic brain injury patients had at least one fall. 53% of falls occurred in the patient's bedroom and 57% were attributed to loss of balance. At time of fall, 93% of fallers had impaired mobility and 85% required assistance for transfers. CONCLUSION: Falls within inpatient traumatic brain injury rehabilitation are a significant and complex clinical issue. While many patients continued to be at risk of falling several months after admission, a repeat faller's first fall occurred earlier in their admission than a single faller's. RELEVANCE TO CLINICAL PRACTICE: Generic falls prevention measures are insufficient for preventing falls in the brain injury rehabilitation population. Falls prevention initiatives should target times of high patient activity and situations where there is decreased nursing capacity to observe patients. Rehabilitation clinicians need to be mindful that a patient's risk of falling is not static and in fact, may increase over time.

Association of Metal Cations with the Anti-PF4/Heparin Antibody Response in Heparin-Induced Thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against complexes of heparin and platelet factor 4 (PF4). The electrostatic interaction between heparin and PF4 is critical for the anti-PF4/heparin antibody response seen in HIT. The binding of metal cations to heparin induces conformational changes and charge neutralization of the heparin molecule, and cation-heparin binding can modulate the specificity and affinity for heparin-binding partners. However, the effects of metal cation binding to heparin in the context of anti-PF4/heparin antibody response have not been determined. Here, we utilized inductively coupled plasma mass spectrometry (ICP-MS) to quantify 16 metal cations in patient plasma and tested for correlation with anti-PF4/heparin IgG levels and platelet count after clinical suspicion of HIT in a cohort of heparin-treated patients. The average age of the cohort (n = 32) was 60.53 (SD = 14.31) years old, had a mean anti-PF4/heparin antibody optical density [OD405] of 0.93 (SD = 1.21) units, and was primarily female (n = 23). Patients with positive anti-PF4/heparin antibody test results (OD405 ≥ 0.5 units) were younger, had increased weight and BMI, and were more likely to have a positive serotonin release assay (SRA) result compared to antibody-negative patients. We observed statistical differences between antibody-positive and -negative groups for sodium and aluminum and significant correlations of anti-PF4/heparin antibody levels with sodium and silver. While differences in sodium concentrations were associated with antibody-positive status and correlated with antibody levels, no replication was performed. Additional studies are warranted to confirm our observed association, including in vitro binding studies and larger observational cohorts.

Association of Metal Cations with the Anti-PF4/Heparin Antibody Response in Heparin-Induced Thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against complexes of heparin and platelet factor 4 (PF4). The electrostatic interaction between heparin and PF4 is critical for the anti-PF4/heparin antibody response seen in HIT. The binding of metal cations to heparin induces conformational changes and charge neutralization of the heparin molecule, and cation-heparin binding can modulate the specificity and affinity for heparin-binding partners. However, the effects of metal cation binding to heparin in the context of anti-PF4/heparin antibody response have not been determined. Here, we utilized inductively coupled plasma mass spectrometry (ICP-MS) to quantify 16 metal cations in patient plasma and tested for correlation with anti-PF4/heparin IgG levels and platelet count after clinical suspicion of HIT in a cohort of heparin-treated patients. The average age of the cohort (n = 32) was 60.53 (SD = 14.31) years old, had a mean anti-PF4/heparin antibody optical density [OD405] of 0.93 (SD = 1.21) units and was primarily female (n = 23). Patients with positive anti-PF4/heparin antibody test results (OD405 ≥ 0.5 units) were younger, had increased weight and BMI, and were more likely to have a positive serotonin release assay (SRA) result compared to antibody negative patients. We observed statistical differences between antibody positive and negative groups for sodium and aluminum and significant correlations of anti-PF4/heparin antibody levels with sodium and silver. While differences in sodium concentrations were associated with antibody positive status and correlated with antibody levels, no replication was performed. Additional studies are warranted to confirm our observed association, including in vitro binding studies and larger observational cohorts.

Male nurse practice in inpatient rehabilitation. Finding a safe way: a grounded theory.

BACKGROUND: Research interest in nursing's contribution to inpatient rehabilitation is growing. Nurses contribute to rehabilitation specifically by teaching patients how to care for themselves. This contribution is largely reported from a female or genderneutral perspective. Despite the work of male nurses being examined in a range of other specialities, their work within inpatient rehabilitation remains underexplored. OBJECTIVE: To report on a grounded theory study to identify and make visible male nurse practice in inpatient rehabilitation in Australia. DESIGN: Constructivist grounded theory informed by symbolic interactionism. SETTING(S): Stage 1 data were collected in locations of participants choosing throughout Australia. Stage 2 data collection centred on seven data collection sites across two specialist rehabilitation hospitals in two states of Australia. PARTICIPANTS: Twenty-three male nurses and 15 patients participated in the study. METHODS: Stage 1 (October 2013 to June 2014) consisted of semi-structured interviews with 11 male nurses. Stage 2 (February to April 2015) consisted of semi-structured interviews and 63.5 h of non-participant observation with 12 male nurses. Fifteen interviews with patients as recipients of male nurse care were also conducted. Data analysis included initial coding, focused coding, and theoretical coding using constant comparative methods, memo writing and diagramming. RESULTS: Nurse participants were aware of patient perceptions about nursing being an occupation for women and male nurses being perceived as sexual threats, which led to an everyday concern of potential for misinterpretation. To address this concern, male nurses engaged in a three-phase process known as assessing and managing risk in order to minimise risk and to keep themselves safe in practice. However, two contextual conditions, type of care and urgency of care, influenced engagement in assessing and managing risk. The core category and substantive grounded theory to explain these results is finding a safe way. CONCLUSIONS: Gender stereotypes affected the daily working lives of male nurses in inpatient rehabilitation. To counter the risk of misinterpretation male nurses used a range of strategies to address the barriers encountered daily in their working lives. However, male nurse efforts were often influenced by conditions outside of their control. In inpatient rehabilitation, male nurses practised cautiously to keep themselves safe in order to practise nursing.

The usual bowel care regimes of people living in the community with spinal cord injury and factors important for integrating bowel care into everyday life.

PURPOSE: To describe the usual bowel care regimes of people living in the community with spinal cord injury and factors important for integrating bowel care into everyday life. METHODS AND MATERIALS: Descriptive and interpretive thematic analysis of transcribed semi-structured interviews with 11 men living with spinal cord injury, aged 23-77 years, 8-45 years post injury. RESULTS: Participants had different levels and types of injuries. While there were common aspects of the bowel care routines of study participants, none was exactly the same as any other. Each had developed a routine in accordance with the needs of their own body, preferences, and convenience in relation to availability of carers and work commitments. Personal factors in the person with SCI were important for successful integration of bowel care into their everyday life. CONCLUSION: An appropriate and consistent bowel care routine was found to be significant in enabling people with spinal cord injury to experience wellness and quality in their everyday lives. Characteristics and actions of the person with SCI enabled the person to actively drive the process of integrating bowel care into their everyday life. How best to foster the development of these personal factors warrant further investigation.IMPLICATIONS FOR REHABILITATIONSupport for the ongoing development of self-management of bowel dysfunction expertise by people living with spinal cord injury needs to continue after discharge from hospital.Characteristics of the person with spinal cord injury, such as a state of mind indicating acceptance of their situation, motivation to avoid bowel accidents and constipation, and willingness to take responsibility, are important factors influencing the integration of bowel care into everyday life.Actions undertaken by the person with spinal cord injury, such as discipline to establish, refine and maintain a bowel care regime, and proactive self-management are important factors influencing the integration of bowel care into everyday life.This small study suggests the role of personal factors in the development of self-management expertise, for example the development of a self-management mindset and the acquisition of skills to drive that process, should be considered during rehabilitation.

"Spirituality is everybody's business": an exploration of the impact of spiritual care training upon the perceptions and practice of rehabilitation professionals.

PURPOSE: This study explored the impact of a brief spiritual care training program upon the perceptions and self-reported practice of rehabilitation professionals working in traumatic injury. METHODOLOGY AND METHODS: A qualitative study. Semi-structured interviews were held with staff from a rehabilitation hospital in Sydney, Australia, between six and eight weeks after participation in spiritual care training. A thematic analysis was conducted. RESULTS: Of the 41 rehabilitation professionals who attended the training (1 h online, 1.5 h face to face), 16 agreed to be interviewed. The majority worked in spinal cord injury and were female. Half reported holding a Christian affiliation. One overarching theme and six sub-themes were identified from the qualitative data. The overarching theme was "spirituality is everybody's business". The six sub-themes were: (i) increased awareness of the nature of spirituality, (ii) realisation of the importance of spirituality to clients, (iii) a desire to keep spirituality on the radar, (iv) identifying barriers to providing spiritual care (v) incorporating spirituality into practice, and, (vi) recognising spirituality as personally meaningful. CONCLUSIONS: A brief spiritual care training program can impact positively upon perceptions and practice of rehabilitation professionals. Ongoing training is needed to ensure that staff retain what was learnt.IMPLICATIONS FOR REHABILITATIONBrief spiritual care training can impact positively upon rehabilitation professionals' perceptions of spirituality and lead to practice change in the delivery of spiritual care across many clinical disciplines.The stories of patients and family members are powerful staff education tools in spiritual care training.Client spirituality is an under recognised resource that staff can draw upon in supporting and enhancing the rehabilitation process.

Dietary management of neurogenic bowel in adults with spinal cord injury: an integrative review of literature.

OBJECTIVE: To examine the literature for current evidence on the dietary management of neurogenic bowel in adults with spinal cord injuries (SCIs). BACKGROUND: Neurogenic bowel dysfunction presenting as faecal incontinence or constipation is a common occurrence in individuals with SCI. It poses numerous challenges for the management of bowel function and has a significant impact on quality of life following SCI. Dietary management is a common, early treatment strategy as a conservative approach for neurogenic bowel; however, current recommendations rely on expert opinion only. METHODS: An integrative review of the literature using a systematic search was conducted using Medline, Embase, CINAHL, Proquest, and Google Scholar. The selected articles were critically appraised using Critical Appraisal Skills Programme checklists by two independent reviewers. The risk of bias of studies and the quality of evidence for outcomes were assessed using the risk of bias tool and the grading of recommendations, assessment, development, and evaluation system in the Cochrane handbook for systematic review of interventions. RESULTS: Thirteen studies that met the inclusion criteria were identified exploring a variety of diet-related factors: foods, dietary behaviours, and multiple interventions including a diet plan. However, the dietary management strategies used varied significantly between studies, posing challenges to ascertain its efficacy. CONCLUSION: Given the low level of evidence and paucity of data on dietary management of neurogenic bowel, the efficacy of dietary strategies (alone or in combination with others) in managing neurogenic bowel cannot be substantiated from the studies identified. Therefore, more robust studies are warranted to bridge this gap.IMPLICATIONS FOR REHABILITATIONConsumption of ∼15 g dietary fibre is shown to be beneficial in managing neurogenic bowel in SCI.Further research is required to strengthen evidence for fibre recommendations and investigating the potential benefits of traditional and non-traditional dietary approaches.

Enhancing inpatient rehabilitation through the engagement of patients and nurses.

AIM: This paper is a report of a study conducted to describe nurses' knowledge, experiences and perceptions of a rehabilitation nursing practice development project conducted in their workplace. BACKGROUND: Several studies over the past two decades have led to increasing clarity about the nursing role in rehabilitation. Practice development is a useful vehicle for using the findings of such studies to enhance person-centred practice in rehabilitation settings. METHOD: This qualitative study, in which grounded theory informed data collection and analysis, involved interviews with 21 nurses working in an inpatient rehabilitation unit in Australia about their knowledge, experiences and perceptions of a rehabilitation nursing practice development project conducted in their workplace. The three rounds of interviews were conducted as follows: 1) December 2005-January 2006; 2) June-July 2006; and 3) October 2006. FINDINGS: Practice development was an effective vehicle for developing rehabilitation nursing practice. While collaboration and leadership were critical to the effectiveness of the project, the use of a clinically credible practice development facilitator and a focus on the development of collective nursing practice also seem to have been important. Through the introduction of new activities, both patient and nurse engagement in rehabilitation was enhanced and, as a consequence, the nurses developed a deeper appreciation of their role in rehabilitation. CONCLUSION: Carefully and collaboratively designed and sensitively implemented work-based practice development initiatives can change the context and culture of inpatient care. The use of a facilitator with relevant clinical nursing expertise to engage staff individually and collectively with research findings and to reflect on their practice and skill development is worth exploring in similar initiatives.

Factors contributing to nurse job satisfaction in the acute hospital setting: a review of recent literature.

AIM: To explore and discuss from recent literature the common factors contributing to nurse job satisfaction in the acute hospital setting. BACKGROUND: Nursing dissatisfaction is linked to high rates of nurses leaving the profession, poor morale, poor patient outcomes and increased financial expenditure. Understanding factors that contribute to job satisfaction could increase nurse retention. EVALUATION: A literature search from January 2004 to March 2009 was conducted using the keywords nursing, (dis)satisfaction, job (dis)satisfaction to identify factors contributing to satisfaction for nurses working in acute hospital settings. KEY ISSUES: This review identified 44 factors in three clusters (intra-, inter- and extra-personal). Job satisfaction for nurses in acute hospitals can be influenced by a combination of any or all of these factors. Important factors included coping strategies, autonomy, co-worker interaction, direct patient care, organizational policies, resource adequacy and educational opportunities. CONCLUSIONS: Research suggests that job satisfaction is a complex and multifactorial phenomenon. Collaboration between individual nurses, their managers and others is crucial to increase nursing satisfaction with their job. IMPLICATIONS FOR NURSING MANAGEMENT: Recognition and regular reviewing by nurse managers of factors that contribute to job satisfaction for nurses working in acute care areas is pivotal to the retention of valued staff.

Nurses create a rehabilitative milieu.

Despite the recognition of milieu therapy as a nursing intervention, nursing's contribution to the creation of inpatient environments that facilitate patient rehabilitation has been underresearched. A large study conducted in five inpatient rehabilitation units in Australia that sought to develop a grounded theory of nursing's contribution to inpatient rehabilitation has begun to address this gap in the literature. Analysis of data collected from 53 nurses during interviews and observations of their everyday practice revealed that nurses act purposefully to create a milieu conducive to rehabilitation. In doing so, they target all patients using a range of strategies that include allowing time, keeping patients'spirits up, protecting patients from embarrassment, and making hospitals more homelike than is typically experienced in acute-care environments. As a consequence, rehabilitative milieu therapy is proposed as a subset of milieu therapy.

A snapshot of rehabilitation referrals in rural New South Wales.

The aim of this paper is to describe patterns of referral to inpatient rehabilitation in rural NSW. Archival records of referrals to one rural speciality medical rehabilitation service during 2004 and 2005 were analysed using descriptive statistics displayed using tables and graphs. Seventy-six referrers referred 922 patients for inpatient rehabilitation. Almost two-thirds (63.6%) came from the local acute hospital. Most referrals (80.4%) were considered appropriate for inpatient rehabilitation. Almost three-quarters (72.5%) of the patients referred were admitted.