Competing discourses as barriers to change in rehabilitation nursing: a discourse analysis.

Introduction: The power of action research to create change by anchoring research results in practice was challenged in an action research project at a specialized rehabilitation unit for persons with acquired spinal cord injury. Despite the co-researchers' new insights, approaches, and actions supporting patient participation, it was not possible to change the basic conditions for the practicing of nursing. We aimed to raise awareness of the mechanisms that govern barriers by exploring these barriers as experienced by nurses in their effort to change their practice to improve patient participation. Method: We used Fairclough's critical discourse analysis drawing on Foucault's practical systems; ethics (identity, relation to oneself), power (action, relation to others), and knowledge (representation, aspects of the world), which he combines with discourse-analytical concepts. Results: Our discourse analysis of the empirical data at micro-level uncovers the nature of barriers to change in practice. In addition, our analysis at macro-level unveils how these practices are embedded in larger historical, societal, and institutional discourses. This identified two current discourses: a biomedical discourse and a biopsychosocial discourse. In the light of these two discourses, the nurses at micro-level saw themselves as strong agents for the best rehabilitation by acting in accordance with the biopsychosocial discourse. But they were unable to find the time and space to do so due to tasks, structures, and practices specified by an organization dominated by the biomedical discourse.

A meaningful everyday life experienced by adults with acquired neurological impairments: A scoping review.

OBJECTIVE: This scoping review explores the characteristics of a meaningful life appraised by adults living with an acquired neurological impairment. INTRODUCTION: Limitations in function, activity or participation following a neurological injury or disease imposes comprehensive changes on the every-day life of the affected person and close relatives. Including patients' perception of a meaningful life is pivotal to facilitate motivation and individualize rehabilitation efforts to address the patients' wishes, hopes, needs, and preferences. Surprisingly, only little research has been devoted to illuminating what a meaningful life is from the impaired person's perspective. Hence, a scoping review of existing knowledge is needed to facilitate person-centered high-quality rehabilitation and research initiatives. INCLUSION CRITERIA: All studies, published in English or Scandinavian languages describing a meaningful life as experienced by adult persons with neurological impairment were included. No search date range filter was selected. METHODS: This review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews according to a published protocol. A three-step search strategy was conducted in the databases PubMed, Cinahl, PsycINFO and Embase. At least two independent researchers conducted inclusions and exclusions, data extraction, and analyses. Covidence software was used to manage the information. FINDINGS: We identified 307 studies. Of these, 20 were included and quality assessed. Findings are reported in accordance with the PRISMA- SCR checklist and descriptively presented mapped in three main domains and 10 ten sub-domains. CONCLUSION: Current literature conveys no clear definition or perception of what a meaningful life is. However, across the 20 included studies, the following main characteristics were stepped forward as particularly significant for adults living with an acquired neurological impairment in regard to achieving a meaningful life: i) to be part of meaningful relationships and meaningful activities; ii) to become confident with one's perceived identity.

Nursing staff facilitate patient participation by championing the patient's perspective: An action research study in spinal cord injury rehabilitation.

INTRODUCTION: Persons with spinal cord injury have experienced a life-changing event, and they need to engage in the rehabilitation process to adjust to their current situation and future living conditions. Due to the highly contextual and varying psychological and physical ability to participate from patient to patient during rehabilitation, this is difficult for the injured person and for health professionals to support. Therefore, the aim of the study was to develop and facilitate patient participation by engaging nursing staff and from this engagement in the process, disclose methods to support participation. METHODS: The processes conducted were based on an action research approach, from problem identification to the development, test and evaluation of four new nursing initiatives. The initiatives were developed by eight nursing staff members who participated actively as co-researchers in a 2-year study conducted at a Spinal Cord Injury Centre in Denmark from 2016 to 2018. Data evolved from workshops, transcriptions of meetings and written evaluations and was further analysed using Ricoeur's phenomenological-hermeneutic approach. RESULTS: Action research processes facilitated the development of four communicative initiatives and a shift in the nursing staff's support of the patient. In a collaborative process, the nursing staff acted as participants in the patient's rehabilitation. Awareness of the patient's perspective facilitated a caring, attentive and engaged approach from the nursing staff, which promoted rehabilitation tailored to the individual. CONCLUSION: Patient participation was enhanced when nursing staff actively participated in the development of initiatives and a culture supporting a person-to-person approach involving the patient and themselves as equal participants in the collaborative rehabilitation process. PATIENT OR PUBLIC CONTRIBUTION: Eight nursing staff members from the rehabilitation centre participated throughout the study as co-researchers. Patients participated in observations and as informants in interviews during the first phase to identify challenges to patient participation. Patients also participated in testing the nursing initiatives during the action phase (Phase 3). Furthermore, a former patient was a member of the advisory board.

What is a meaningful life for persons with acquired neurological impairments? A scoping review protocol.

OBJECTIVE: This scoping review explores the constitution of a meaningful life as perceived by adults with acquired neurological impairment following an injury or a disease. INTRODUCTION: A neurological injury or disease imposes extensive life changes on the affected person and his or her close relatives. Including the patients' perception of a meaningful life is crucial to facilitate adjustment of any rehabilitation initiatives to the patients' wishes, hopes, needs, and preferences. Even so, the descriptions and common traits of a meaningful life from the impaired person's perspective are scarcely covered in the literature. Hence, a scoping review of existing knowledge is needed to facilitate quality rehabilitation and research initiatives. INCLUSION CRITERIA: All studies, regardless of their design, are included provided they describe a meaningful life as considered or experienced by persons aged 18 years or more with neurological impairment. METHODS: A PICo framework defines the search algorithms used in the databases MEDLINE, Cinahl, PsycINFO and Embase. Using Covidence, the scoping review systematically organizes the identified articles to provide a broad description of the study phenomenon. Furthermore, titles, abstracts, and full-text articles are screened independently by two reviewers to determine if they meet the inclusion criteria. In case of disagreement, a third and fourth reviewer are consulted. The scoping will be reported according to the PRISMA- SCR checklist.

An observational study on body mass index during rehabilitation and follow-up in people with spinal cord injury in Denmark.

STUDY DESIGN: Observational study OBJECTIVE: To describe body mass index (BMI) during rehabilitation in people with a newly sustained spinal cord injury (SCI). SETTING: Inpatient SCI rehabilitation in Denmark. PARTICIPANTS: Inpatients, >18 years, having sustained a SCI within the last 12 months at admission to primary rehabilitation, inclusive of various SCI etiology, neurological level, completeness of the lesion or mobility status. METHODS: Measures of BMI were obtained at admission and discharge as part of standard care. At one SCI center measures of BMI were sampled at follow up 9.5 months after discharge as well. BMI was described by mean and standard deviation (SD). Paired t-test was used to test difference in BMI between admission and discharge. Repeated measures Analysis of Variance (ANOVA) was used for analyzing BMI deriving from three time points. RESULTS: Overall BMI was stable with no change (25.4 kg/m2 at admission and 25.6 kg/m2 at discharge) during rehabilitation at the two national centers. In participants with an American Spinal Injury Association (ASIA) Impairment Scale (AIS) D classification, BMI was higher during rehabilitation compared to the other groups and increased significantly (p = 0.008) from discharge to follow up. CONCLUSIONS: Overall BMI was stable but higher than recommended in people with SCI undergoing rehabilitation at the two national centers in Denmark. Participants with an AIS D SCI were obese according to SCI adjusted BMI and the World Health Organization (WHO) recommendations during rehabilitation and at follow up.

Action research as a catalyst for change: Empowered nurses facilitating patient participation in rehabilitation.

Based on action research as a practitioner-involving approach, this article communicates the findings of a two-year study on implementing patient participation as an empowering learning process for both patients and rehabilitation nurses. At a rehabilitation facility for patients who have sustained spinal cord injuries, eight nurses were engaged throughout the process aiming at improving patient participation. The current practice was explored to understand possibilities and obstacles to patient participation. Observations, interviews and logbooks, creative workshops and reflective meetings led to the development and testing of four new rehabilitation initiatives aimed at enhancing patient participation. This study suggests that skills of critical reflection from action research toolbox shed light on both the notion of patient participation and caring in nursing rehabilitation. By actively involving nurses in research, the knowledge development stems from practice and the solutions therefore became practice-oriented. In addition, the personal and professional development experienced by the involved nurses points to a secondary gain in the form of an analytical and reflective approach to complex issues in relation to patient participation, rehabilitation in general and the individual nurses' sense of professional pride.

SCI-SCREEN: A More Targeted Nutrition Screening Model to Detect Spinal Cord-Injured Patients at Risk of Malnutrition.

PURPOSE: To explore if SCI-SCREEN was applicable as nutritional screening model in a neurorehabilitation unit, able to detect spinal cord injury (SCI) persons at nutritional risk. DESIGN AND METHODS: SCI-SCREEN underwent reliability test by 3 specialist nurses, using 10 consecutive SCI in-patients. Audit of 41 SCI-patients was conducted comparing SCI SCREEN with the Danish-Nutritional-Screening-Model-for-hospitalized-persons (DNSM). FINDINGS: Inter- and intra-tester reliability (Cohen's Kappa: 0.89-0.93) was high. SCI-SCREEN estimated average energy needs 23% lower (mean difference± SD: 2516.2±1349.1kJ) and protein needs 10% lower (9.5±19.7g/day). Risk assessment differed in 61% (CI95: 42.1; 73.7%) of cases and risk-agreement was obtained in 22% (CI95: 10.6; 37.6%). SCI-SCREEN detected 66% (CI95: 44.5; 75.8%) and DNSM 39% at risk of malnutrition. CONCLUSIONS: The SCI-SCREEN model estimates SCI-energy and protein needs more accurately than DNSM by adjusting to SCI-consequences. However, more studies are needed. CLINICAL RELEVANCE: SCI-SCREEN is a reasonable starting-point in the screening procedure and may be a valuable instrument to identify SCI-patients at risk of malnutrition.