Reflecting on a Self-Care Process in the Home Setting for Traumatic Brain Injury Survivors

Mary K. Coyle, MS APRN BC; Elisabeth Moy Martin, MA RNC

Disclosures

J Neurosci Nurs. 2007;39(5):274-277. 

In This Article

The Home Setting for TBI Survivors

The home rehabilitation program was one component of a randomized controlled trial in the Defense and Veterans Head Injury Program. Its purpose was to compare home versus in-patient cognitive rehabilitation of military patients with moderate to severe head injury. Inclusion criteria consisted of one or more of the following: participants having a moderate to severe TBI as evidenced by a loss of consciousness with posttraumatic amnesia lasting 24 hours or more or positive findings on magnetic resonance imaging (MRI) or computed tomography (CT) scan. Participants had to be able to give informed consent, be within 90 days of their injury, and could not have had a prior severe TBI. All participants received a multidisciplinary evaluation which included psychiatric, neurological (including laboratory review), and neuropsychological testing and psychosocial, speech, and occupational therapy evaluations (Salazar et al., 2000; Warden et al., 2000). Participants were randomly assigned to either an intensive, standardized 8-week in- hospital cognitive rehabilitation program (n = 67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n = 53). Results of this trial showed that at 1-year follow-up there were no significant differences between the two groups in return to employment or fitness for duty (Salazar et al.). Fitness for duty was defined as physical and emotional competence to perform military duties. A subgroup analysis of participants (n = 75) who were unconscious 1 hour or more after TBI demonstrated a higher fitness-for-duty rate in the in-hospital program compared with the home program (p < .05; Salazar et al.). This study supports the view that participants who have loss of consciousness less than 1 hour from TBI may do well with home interventions; however, further research is needed (Warden et al.). The home program set expectations of positive adjustments during recovery from TBI using weekly telephonic monitoring by nurses.

Prior to beginning the home program, a nurse met with each participant to discuss his or her treatment and participation in the home program. Once expectations were established with an emphasis placed on return to duty, the participants' home situations were considered; times were also agreed upon for weekly telephone calls. Participants were expected to engage in activities they found meaningful in their lives. Throughout the 8-week home program, participants received guidance on home activities, as well as weekly telephone calls from the nurse. These calls addressed participants' needs to perform daily interventions of 30-minute cognitive and physical exercises. Moreover, during the calls, nurses monitored patient safety, assessed unhealthy behaviors, and intervened when necessary.

During the telephone calls, some participants reported postconcussive symptoms of headaches, fatigue, depression, irritability, and memory difficulties. Nurses assessed the degree to which these symptoms (along with anxiety, dysphoria, irritability, and angry outbursts) affected daily functioning and interactions with others. Support was provided with problem solving for those symptoms affecting daily living. Figure 1 describes nursing actions used during telephone calls.

Nursing Activities

Over time, participants increasingly self-monitored their behaviors and some participants were able to discuss consequences of behaviors with thoughts and feelings. Addressing family burdens and coping behaviors remains an important area for further assessment and research in the rehabilitation process.

During the telephone calls, nurses asked participants about their daily activities, whether they had self-administered prescribed medications, and what type of socialization occurred during the time since the last telephone call. The majority of participants reported following the prescribed 30 minutes of daily cognitive (e.g., reading) and physical exercise. Some also participated in community activities (e.g., volunteering as a firefighter). Furthermore, a wide variety of vocational skills was evident, along with engagement in an extensive range of home interests. Specifically, these interests included: home repair, personal fitness, assisting with child rearing, and grocery shopping. Reported activities included auto repair, farm work, home construction, carpentry, electrical work, plumbing, machinery repair, socializing with peers at the fire station, fishing, playing musical instruments, and camping (Warden et al., 2000). Some participants needed encouragement to perform unfamiliar activities, such as cooking or washing dishes, and some young males were not used to shopping, so they were encouraged to try and succeed at a new task (Martin, Coyle, Warden, & Salazar, 2003).

Participants gradually assumed responsibility of themselves and their self-care behaviors. For instance, families often assisted initially with financial record keeping, with the participant gradually resuming his or her responsibilities independently (Warden et al., 2000). Resumption of responsibilities could be viewed as a fundamental practice to deal with symptoms and illnesses (Dunnell & Cartwright, 1972).

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