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Journal of Neuroscience Nursing:
doi: 10.1097/JNN.0b013e318282906e
Article

Effect of an Educational Intervention on Nursing Staff Knowledge, Confidence, and Practice in the Care of Children With Mild Traumatic Brain Injury

Cook, Rebecca S.; Gillespie, Gordon L.; Kronk, Rebecca; Daugherty, Margot C.; Moody, Suzanne M.; Allen, Lesley J.; Shebesta, Kaaren B.; Falcone, Richard A. Jr.

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Author Information

Questions or comments about this article may be directed to Rebecca S. Cook, DNP RN CNP-PC, at becky.cook@cchmc.org. She is a Pediatric Trauma Nurse Practitioner at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Gordon L. Gillespie, PhD RN PHCNS-BC CEN CPEN FAEN, is an Assistant Professor at the College of Nursing, University of Cincinnati, Cincinnati, OH.

Rebecca Kronk, PhD MSN RN CRNP, is an Assistant Professor at the School of Nursing, Duquesne University, Pittsburgh, PA.

Margot C. Daugherty, MSN MEd RN EMT-P, is the Trauma Education Specialist at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Suzanne M. Moody, MPA, is the Clinical Research Coordinator at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Lesley J. Allen, MSN RN CRNP, is a Pediatric Trauma Nurse Practitioner at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Kaaren B. Shebesta, MSN CRNP-AC/PC, is a Pediatric Trauma Nurse Practitioner at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Richard A. Falcone, Jr., MD MPH, is an Associate Professor of Surgery and the Medical Director of Trauma Services at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

This study was fulfilled as a requirement of the Doctor of Nurse Practice Program at Duquesne University School of Nursing.

The authors declare no conflicts of interest.

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Abstract

Background: Nurses are key providers in the care of children with mild traumatic brain injury (mTBI). New treatment recommendations emphasize symptom assessment and brain rest guidelines to optimize recovery. This study compared pediatric trauma core nurses’ knowledge, degree of confidence, and perceived change in practice following mTBI education.

Methods: Twenty-eight trauma core nurses were invited to participate in this voluntary quasiexperimental, one-group pretest–posttest study. Multiple choice questions were developed to assess knowledge, and self-report Likert scale statements were used to evaluate confidence and change in practice. Baseline data of 25 trauma core nurses were assessed and then reassessed 1 month postintervention.

Results: Paired samples analysis showed significant improvement in knowledge (mean pretest: 33.6% vs. mean posttest score: 79.2%; 95% CI [35.6, 55.6]; t = 9.368; p < .001). All but two test questions yielded a significant increase in the number of participants with correct responses. Preintervention confidence was low (0–32% per question) and significantly increased postintervention (26%–84% per question). Despite increased administration of the symptom assessment and identification of interventions for symptom resolution posteducation (χ2 = 6.125, p = .001), these scores remained low.

Conclusion: Findings demonstrate that educational intervention effectively increased trauma core nurses’ knowledge and confidence in applying content into practice. Postintervention scores did not uniformly increase, and not all trauma core nurses consistently transferred content into practice. Further research is recommended to evaluate which teaching method and curriculum content are most effective to educate trauma core nurses and registered nurses caring for patients with mTBI and to identify barriers to incorporating this knowledge in practice.

In the United States, nearly 474,000 children of ages 0–14 years are evaluated in the emergency department (ED) annually for traumatic brain injury (TBI) and 35,136 children require hospitalization (Faul, Xu, Wald, & Coronado, 2010). Mild traumatic brain injury (mTBI) is the most common form of TBI accounting for 70%–90% of all cases (Cassidy et al., 2004). The Centers for Disease Control and Prevention (CDC, 2011) define mTBI as “a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.” Nurses are key providers in the care of children with mTBI and play an integral role in the assessment and education of these patients to promote improved outcomes. Treatment recommendations continue to evolve as new evidence emerges to guide the evaluation and care of the mTBI patient. Materials available to healthcare professionals include the CDC’s (2011)Heads Up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI)” and the American Association of Neuroscience Nurses (AANN) and Association of Rehabilitation Nurses (ARN) practice guideline “Care of the Patient With Mild Traumatic Brain Injury” (AANN & ARN, 2011). Despite these resources, knowledge gaps persist (Chrisman, Schiff, & Rivara, 2011; Watts, Gibbons, & Kurzweil, 2011), leading to inconsistent care practices (Bazarian, McClung, Cheng, Flesher, & Schneider, 2005; Blostein & Jones, 2003). To direct the development of educational interventions and to optimize the care of the child with mTBI, an understanding of nurse knowledge and confidence caring for children with mTBI is needed.

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Background and Significance

mTBI or concussion is frequently referred to as the silent epidemic because of its subtle or imperceptible symptoms. The incidence is believed to be much higher than reported as the patient/family may fail to report the injury, and injuries may not be recognized or diagnosed by the healthcare professional (Mateo, 2003). Emphasis in care tends to focus on the identification of more severe TBI or documentation of readily apparent symptoms such as headache and vomiting. However, the negative sequelae of mTBI, referred to as “post-concussion symptoms,” encompasses somatic, cognitive, emotional, and sleep-related domains that are of variable degree and duration (Gioia, Isquith, Schneider, & Vaughan, 2009). Postconcussion symptoms may be overt or not readily recognized by the patient, caregiver, teachers, coaches, or nurses (Stevens, Penprase, Kepros, & Dunneback, 2010). As many as 35% of children with mTBI develop postconcussive syndrome defined as ongoing symptoms beyond 3 months (Yeates et al., 1999), but symptoms may persist up to 1 year (Barlow et al., 2010).

Postconcussion symptoms negatively affect quality of life and ability to participate in routine activities including school (Barlow et al., 2010; Blinman, Houseknecht, Snyder, Wiebe, & Nance, 2009; Carroll, Cassidy, Holm, Kraus, & Coronado, 2004). Thomas et al. (2011) report that the mean time for children treated and released from the ED to return to normal activities following mTBI was 13.5 days. The most common postconcussion symptoms for children during acute inpatient hospitalization were headache and fatigue (Blinman et al., 2009). In contrast, 2–3 weeks following mTBI, excess sleep was the most common symptom, and trouble in falling asleep and nervousness were rated as the most severe. Postconcussion symptoms may also adversely impact academic performance necessitating further evaluation and modification in school work (Hooper et al., 2004; Kirkwood, Yeates, & Wilson, 2006; Sesma, Slomine, Ding, & McCarthy, 2008). Informed nurses can use this knowledge to provide anticipatory guidance to the patient/family.

Nurses are key providers in facilitating symptom assessment in the ED and during acute hospitalization. Standardized assessment of postconcussion symptoms using symptom checklists is an important component of care that provides objective data to support care interventions, discharge instructions, activity restrictions following mTBI, and referral for follow-up (Blinman et al., 2009; Gioia et al., 2009; Powell, Ferraro, Dikmen, Temkin, & Bell, 2008). Self- or parent-reported symptom checklists such as the Postconcussion Scale (Lovell, Collins, Iverson, Johnston, & Bradley, 2004), the Rivermead Postconcussion Symptoms Questionnaire (King, Crawford, Wenden, Moss, & Wade, 1995), or the Acute Concussion Evaluation (CDC, 2011) used during hospitalization and at designated intervals postdischarge, document severity, and the progression or resolution of symptoms (Gioia et al., 2009; Grubenhoff, Kirkwood, Gao, Deakyne, & Wathen, 2010). For example, Nance, Polk-Williams, Collins, and Wiebe (2009) implemented the Postconcussion Scale and reported that 83.4% of children exhibited an abnormal symptom score during acute hospitalization and 38.1% at the 2- to 3-week follow-up. Blinman et al. (2009) reported similar findings with 83.6% of children demonstrating abnormal symptom scores during hospitalization and 49% at the 2- to 3-week follow-up.

Parents are particularly concerned with what to expect after their child sustains mTBI and seek information from their healthcare providers (Gagnon, Swaine, Champagne, & Lefebvre, 2008). Ideally, nurses are in the position to provide this education and therefore must be knowledgeable of current research on which to base their practice (Pieper & Bear, 2011). This includes knowledge of mTBI, postconcussion symptoms, symptom assessment, and treatment recommendations to provide appropriate discharge instruction and anticipatory guidance to the patient/family (AANN & ARN, 2011). Application of evidence-based practice guidelines is imperative as educational interventions and patient reassurance significantly reduce symptom report and behavioral changes following mTBI (Mittenberg, Canyock, Condit, & Patton, 2001; Ponsford, 2005; Ponsford et al., 2001). Yet studies demonstrate clinicians do not routinely provide mTBI education, and a significant number of patients do not receive specific follow-up instructions or recommendations for return to exertional activities including school and sports (Bazarian, Veenema, Brayer, & Lee, 2001; Nance et al., 2009). This places the patient at risk for unrecognized postconcussion symptoms and negative outcomes (Powell et al., 2008).

mTBI in the military (Helmick, Parkinson, Chandler, & Warden, 2007; Schwab et al., 2007) and sports (McCrory et al., 2009) has been highly publicized in recent years leading to new treatment recommendations for physical and cognitive rest. This includes adequate rest, limited exertion, and graded return to activity or play once symptoms have resolved (CDC, 2011; McCrory et al., 2009). These recommendations are sometimes referred to as brain rest guidelines. Brain rest is necessary to prevent patients from returning to activities or sports prior to resolution of postconcussion symptoms, which could delay recovery, exacerbate brain injury, or increase risk of mortality because of second impact syndrome (CDC, 2011). Second impact syndrome occurs when an individual with residual postconcussion symptoms sustain a second or repetitive head injury that results in acute cerebral edema and herniation (Fisher & Vaca, 2004). Any individual with mTBI is at risk for second impact syndrome and should be educated as to safe return to recreational and sports activities. However, adolescent athletes with a history of prior mTBI participating in contact sports such as football, hockey, or boxing are most vulnerable (Webbe & Barth, 2003). The CDC (2011) states “any presentation of lingering and/or persistent symptoms associated with mTBI indicates incomplete recovery and prudent management is indicated, especially pertaining to activities such as work, school, and sports” (p. 7). To achieve optimal patient outcomes, it is essential to ascertain an accurate diagnosis, appropriate referrals, and provide patient/family education (CDC, 2011).

Despite significant gains in understanding the consequences of mTBI and the availability of guidelines to facilitate management (McCrory et al., 2009), this knowledge has not been effectively applied to clinical practice (Gioia, Collins, & Isquith, 2008; Sharpe, Kool, Shepherd, Dalziel, & Ameratunga, 2012). Nurses are not familiar with resources such as the Acute Concussion Evaluation and lack guidelines for mTBI discharge instructions (Bay & Strong, 2011). Nurses also self-report knowledge deficits and lack of confidence in the identification of mTBI, treatment, and prognosis (Watts et al., 2011). Similar findings were found by Chrisman et al. (2011), who evaluated physician knowledge and confidence using the CDC’s Heads Up Toolkit. These authors emphasize the need for effective modalities to educate healthcare professionals as to clinical features of mTBI and current recommendations for mTBI assessment, symptom management, and safe return to activity. More concerning is the lack of literature to support effective educational interventions on this topic.

The purpose of this study was to determine the effect of an educational intervention on the pediatric trauma nurses’ knowledge and perceived value of brain rest guidelines for the care of children following mTBI. The specific aims of the study were to (a) compare changes in knowledge for symptom assessment and brain rest, (b) evaluate degree of confidence interpreting the symptom assessment score and providing discharge instructions to patients/families, and (c) analyze the self-reported change in the nurse’s practice.

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Methods

Design

A quasiexperimental, one-group pretest–posttest design was used to evaluate change in nurse knowledge, perceived value of symptom assessment and brain rest guidelines, confidence in applying these interventions in practice, and perceived self-reported change in practice. This study was approved by the institutional review boards at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, and Duquesne University, Pittsburgh, Pennsylvania.

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Sample

Pediatric trauma core nurses from an urban 450-bed pediatric level 1 trauma center were invited to participate in this study. The trauma core nurses were experienced registered nurses (RNs) who have shown competence in providing expert trauma care to pediatric patients. All 28 trauma core nurses are certified in Pediatric Advanced Life Support and Trauma Nurse Core Curriculum, and audit Advanced Trauma Life Support and participate in quarterly human patient simulation sessions with the multidisciplinary trauma team and complete annual competencies. There were 13 trauma core nurses based in the ED and 15 specialty resource unit (SRU) trauma core nurses who float between nursing units caring for patients in the ED and throughout acute inpatient units. The ED trauma core nurses do not utilize a formal symptom assessment tool. The SRU trauma core nurses assist with the administration of the symptom assessment on the inpatient unit but have not received formal training. Twenty-five trauma core nurses attended the educational session of which all consented and completed both the pretest and 1 month posttest. This included 11 ED trauma core nurses and 14 SRU trauma core nurses. Demographic information is summarized in Table 1.

Table 1
Table 1
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Instruments

A review of the literature failed to identify instruments to measure knowledge of current mTBI assessment and care recommendations. A pretest–posttest was developed and composed of questions to assess knowledge, degree of confidence interpreting content, and self-reported application of content into current practice. Ten multiple choice questions were designed based on two case studies to evaluate knowledge of postconcussion symptoms, symptom assessment, and brain rest guidelines. Multiple choice questions were scored as correct or incorrect to yield a pretest and posttest score ranging from 0% to 100%. Two Likert scale items evaluated confidence in interpreting symptom assessment score and using the score to apply brain rest guidelines when providing discharge instructions. Three Likert scale items evaluated application of content in their current practice. The posttest measure included three additional items to assess the value of the educational session and transferability to clinical practice. All Likert scale items were ranked from 1 (strongly disagree) to 5 (strongly agree).

Instruments were reviewed for content and face validity, clarity of questions, effectiveness of instructions, and the time required for completion via peer review with healthcare providers from Trauma Service including two advanced practice nurses, a trauma education specialist, an outpatient nurse, and a research coordinator, as well as two physicians from Pediatric Rehabilitation and Sports Medicine. The pretest and posttest were then pilot-tested by five Neuroscience RNs who did not participate in the study; minimal revisions were made.

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Intervention

A 90-minute educational session on mTBI was developed with content experts from Trauma, Pediatric Rehabilitation, and Sports Medicine and presented by the masters-prepared trauma education specialist. Defined objectives addressed mTBI in children, postconcussion symptoms, symptom assessment, and brain rest guidelines. The content of the session was based on the CDC’s (2011) guidelines as discussed in the “Heads Up Toolkit.” Discussion emphasized pediatric, anatomic, and physiologic considerations, mechanisms of injury, common symptoms, role of diagnostic imaging, evidence to support symptom assessment, and treatment recommendations for safe return to activities. Case scenarios were utilized to facilitate discussion and application of brain rest guidelines for discharge instructions.

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Procedures

Participants were notified via e-mail 1 week prior to their mandatory bimonthly staff meeting of the opportunity to participate in the research component of the educational session. Training was part of their ongoing continuing education; however, their participation in the study was voluntary. Immediately prior to the educational session, informed consent was obtained, and the pretest was administered. The posttest was administered 30 days following the educational session and accessed via hyperlink to an online test. This was done to allow an opportunity for the trauma core nurse to apply content within their practice and determine retention of program content. Reminder e-mails to complete the posttest were sent 1 week later to all participants to optimize participation. To minimize coercion and bias, the trauma nurse education specialist obtained consent and conducted the educational session. To protect confidentiality of study participants and to match the pretest–posttest data, a unique identification number was provided by the participant at the time of consent.

Data were entered into an Excel database and independently checked for data entry reliability. The pretest and posttest data were matched using the participant’s unique identifier. Descriptive statistics were used to analyze demographic data. The paired samples t test was used to analyze the pretest-to-posttest scores. A McNemar chi-square test was used to determine the change in value of educational content within practice and intent to apply symptom assessment and provision of brain rest guidelines in discharge instructions from pretest to posttest. Alpha was set at .05 for statistical significance. All analyses were conducted using the Statistical Package for Social Sciences (SPSS) Version 18.0 (Armonk, NY).

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Results

Nurse Knowledge

Paired samples analysis showed that the educational session resulted in significant improvement in trauma core nurses’ knowledge of symptom assessment and brain rest guidelines (mean pretest: 33.6% vs. mean posttest score: 79.2%; 95% CI [35.6, 55.6]; t = 9.368; p < .001). Independent samples t test showed no statistically significant difference between test scores for ED and SRU trauma core nurses (pretest mean: 30% vs. 36.4%, t = 0.900, p = .379; posttest mean 77.3% vs. 80.7%, t = 0.573, p = .572). The ED trauma core nurses’ scores improved the most from baseline; however, their increase in knowledge acquisition was not found to be significantly higher than that of the SRU trauma core nurses (t = 0.299, p = .768). Pearson’s product–moment showed no statistically significant correlation (p > .05) between pretest–posttest scores and years of RN experience (r = −.297, p = .149) and years of trauma core nurse experience (r = −.349, p = .087).

All pretest scores were low and varied as they related to interpretation and use of symptom assessment score to identify interventions for symptom management and application of brain rest guidelines for return to activity (refer to Table 2). On the posttest, all but two test questions yielded a significant increase in the number of participants with a correct response. The first question addressed the need to return to the prior asymptomatic level in the presence of worsening symptoms following graded return to activity. Further analysis of this question showed that the SRU trauma core nurses increased their percentage of correct answers more than the ED trauma core nurses (paired difference: 28.6% vs. 18.1%). The second question required the RN to identify the correct range of the symptom assessment score.

Table 2
Table 2
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Prior to the education session, the questions with the lowest proportion of trauma core nurses selecting a correct answer included the role of concussion grading scales (n = 3, 12%), time frame for recovery from mTBI in children and adolescents (n = 4, 16%), and severity of symptoms at initial presentation and 7–10 days following mTBI (n = 0, 0%). Alternatively, these were the same questions that the trauma core nurses showed considerable improvement on the posttest. In spite of this, concussion grading scales and recovery in children continued to yield low scores following the education.

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Perceived Confidence and Change in Practice

Self-report statements were dichotomized and analyzed as the percentage of trauma core nurses who (a) strongly agreed and agreed and (b) were neutral, disagreed, and strongly disagreed. Preintervention confidence was low (0–32% per question) and increased significantly in four of five of the questions with the postintervention confidence ranging from 36% to 84% per question (see Table 3 for χ2 and p values). Although the trauma core nurses reported a significant increase in the identification of interventions to promote symptom resolution following the educational session (χ2 = 6.125, p = .001), in general, the scores remained low. Between-group analyses determined that SRU trauma core nurses increased their use of the symptom assessment (50%–86%) and utilized this information to identify interventions to address postconcussion symptoms (7.1%–57.1%). Trauma core nurses’ perceived accuracy providing discharge instructions using brain rest guidelines was also significant (χ2 = 14.063, p < .001).

Table 3
Table 3
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Perceived Value

At 1 month posttest, perceived value of the educational session was also evaluated on a 5-point Likert scale (strongly disagree to strongly agree). Trauma core nurses overwhelmingly agreed/strongly agreed that the educational session promoted understanding of symptom assessment and brain rest guidelines (96%) was a valuable learning experience (100%) and that this knowledge could be transferred to clinical practice (100%). A Spearman’s rho analysis showed a positive correlation between valuable learning experience and translation to practice (ρ = .901, p < .001). Values of the learning experience and transferability to practice were found to significantly correlate with the use of the symptom assessment score to identify interventions to promote symptom resolution (ρ = .410, p = .021; ρ = .424, p = .017) and provision of accurate discharge instructions using brain rest guidelines (ρ = .641, p < .001; ρ = .652, p < .001). No significant correlation was found with routine administration of symptom assessment in current practice (ρ = .235, p = .130).

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Discussion

This study explored the effect of an educational session on increasing pediatric trauma core nurses’ knowledge and confidence caring for children with mTBI. Active participation was enhanced by the use of case-based learning scenarios and reflection to encourage trauma core nurses to ask questions and engage in dialogue. This approach was important, because case-based learning enhances critical thinking and takes into consideration prior experiences as well as preexisting knowledge (Kaddoura, 2011).

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Nurse Knowledge

Overall, this learning program resulted in trauma core nurses achieving positive learning outcomes. The ED trauma core nurses’ pretest–posttest scores showed a trend for improving more than the SRU trauma core nurses, but this was not statistically significant. This was not unexpected given that the ED trauma core nurses do not currently utilize a formal symptom assessment tool, whereas the SRU trauma core nurses have familiarity from administering this tool on inpatient units. The SRU trauma core nurses also attend inpatient trauma rounds and collaborate with the trauma advanced practice nurses where they have been exposed to the symptom assessment and brain rest guidelines.

Although posttest scores were significantly better than the pretest scores, in general, posttest scores remained unacceptably low, indicating that the trauma core nurses did not gain sufficient knowledge from the educational session. This reveals that the material covered needs to be enhanced to improve learning outcomes. This directs development of future educational offerings that targets these key concepts to ensure that the educational content and format is appropriate to meet the needs of the learners. Redesign of the current program to emphasize key learning points and/or consideration of different active learning strategies is recommended.

Graded return to activity is a crucial concept of concussion management. It did not appear that the education adequately prepared the trauma core nurses to correctly instruct the patient/family about what the child should do in the event that their symptoms worsened following an increase in activity level. This is an important learning opportunity and should be further emphasized in redesigning the program. Additional case studies applying this concept could be added to the session to facilitate improved understanding.

Two questions in particular continued to challenge the trauma core nurses following the educational session. The SRU trauma core nurses responded that the role of concussion grading scales should be used in conjunction with the physical exam. In actuality, concussion grading scales are no longer recommended to guide return to play (McCrory et al., 2009), but ongoing evaluation is imperative. Second, the trauma core nurses realized recovery may take longer in adolescents, but not in children. This implies that the trauma core nurses may not appreciate that children of all ages are at risk for postconcussion symptoms, and therefore, symptom assessment is essential to children of all ages and not just adolescents. In addition, most children with mTBI are released from the ED and postconcussion symptoms may not be readily apparent. As discussed previously, as many as 38.1%–49% of children (Blinman et al., 2009; Nance et al., 2009) are symptomatic 2–3 weeks following injury and again emphasizes the need for ongoing symptom assessment and an individualized approach to return to activity and play. A significant amount of material was presented during the educational session, and these aspects may need to be further emphasized or additional education provided to reinforce learning. Time to contemplate newly acquired knowledge and opportunity to act on the information within clinical practice may also need to be considered to make this more meaningful (Daley, 2001). One month may not have been sufficient time to process the information and apply to practice.

The SRU trauma core nurses significantly improved their scores applying brain rest guidelines at discharge (p = .013). Again, this group of nurses is exposed to this information in the inpatient setting and may have had more opportunity to apply this knowledge given that they care for patients in both the ED and inpatient units. This suggests that prior knowledge is valuable to the learning experience.

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Change in Perceived Confidence and Practice

The trauma core nurses gained considerable confidence interpreting the symptom assessment score and providing discharge instruction to the patient/family. This is important because Watts et al. (2011) found that civilian and military nurses were least comfortable with the assessment and treatment of the mTBI patient. Chrisman et al. (2011) reported similar findings with physicians who were provided with the CDC’s (2011)Heads Up Toolkit.” This toolkit was mailed to a random group of physicians but was not associated with a statistically significant increase in the level of confidence to manage concussion or the use of standardized symptom assessment. The didactic presentation of information in this study may attribute for this improved perception of confidence. Regardless, educational efforts need to consider the complexity of mTBI and that guidelines for management may be confusing and difficult to apply in practice. It was interesting that the SRU trauma core nurses applied brain rest guidelines so well after the training. Again, this may be related to their exposure to this material in the inpatient setting as discussed previously.

Despite knowledge of the benefit of the symptom assessment and confidence to administer it, only 52% of the trauma core nurses reported administering the symptom assessment in their practice postintervention. This variable was self-reported and not verified in the medical record; however, it is hypothesized that factors contributing to this issue may include the apparent absence or failure to recognize acute postconcussion symptoms and the lack of a formal system to document findings (Bay, 2011). Nurses may document overt symptoms such as headache or vomiting but typically do not assess for sleep, cognitive, or affective complaints. If formal tools are not readily available to provide a thorough and more complete assessment, symptoms may not be recognized. The patient may resume activities that increase the risk of negative outcomes (Ponsford et al., 2001). This may be further explained by the fact that, in the ED, trauma core nurses primarily care for patients in the trauma bay where rapid screening for life-threatening injuries is the focus and not full symptom assessment. Over 50% of all trauma core nurses reported minimal exposure to caring for the mTBI patient postintervention. This may have limited the opportunity to apply this knowledge in practice. If other RNs also care for the mTBI patient, it may be necessary to implement a systems change that would educate all nurses about mTBI or require the trauma core nurse to discharge all trauma patients to improve care and documentation.

Lastly, only a portion of the trauma core nurses reported they applied the mTBI education within their practice to direct care interventions (36%) to facilitate symptom resolution. This implies that the trauma core nurses need additional clarification as to specific interventions that can be provided and that greater emphasis should be placed on this content at future educational sessions. This supports Melnyk’s (2002) notion that knowledge in and of itself does not necessarily equate to a behavior change.

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Value

The trauma core nurses reported the knowledge gained in the educational program was valuable and applicable to their practice, but this did not correlate with administration of the symptom assessment in their current practice. One explanation in the ED is that there is no guideline in place for completion of the symptom assessment. On the inpatient units, there is no process in place to remind the SRU trauma core nurse to complete the symptom assessment. Although most documentation is completed in the electronic medical record, the symptom assessment is documented on paper. A hard copy form must be located, thus increasing the likelihood for failure to complete the symptom assessment. Another factor is that the patient/family often will defer the assessment until a later time because the patient is unavailable, asleep, or irritable. The length of stay for a patient requiring hospitalization following mTBI tends to be short, and this increases the risk of not completing symptom assessment prior to discharge. One consideration is to incorporate the symptom assessment into the electronic medical record with an order set and electronic medical record best practice prompts to cue the nurse to administer the symptom assessment when opening the patient’s electronic medical record. Utilizing technologies such as electronic order sets and computerized documentation can facilitate care delivery and provider compliance that may ultimately lead to improved patient care (Rager-Zuzelo, Gettis, Whitekettle-Hansell, & Thomas, 2008; Rosenal et al., 2009).

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Implications for Nursing Practice

This study brings to light important considerations for nursing practice. Knowledge gaps continue to exist in the care of children with mTBI, necessitating the need for the development of effective methods to educate staff about current treatment recommendations. The study also discusses potential barriers that may impede the ability of the nurse to provide evidence-based care and reinforces the need for the implementation of formal systems to support care. Lastly, this study suggests that acquiring knowledge and confidence may not be sufficient to transform practice.

Research supports that key aspects of mTBI educational efforts address the trajectory of postconcussion symptoms in children, time frame for recovery, defunct role of concussion grading scales, and need for an individualized approach to care to facilitate full recovery (Chrisman et al., 2011; Watts et al., 2011). One aspect to consider in providing staff education is the preferred learning methods of staff nurses. Watts et al. (2011) identified that nurses prefer to learn by shadowing another provider or reading articles or textbooks, but they seek knowledge most frequently through internet searches. Development of mTBI competency that is completed annually or the addition of one-on-one mentoring by the nurse educator to reinforce knowledge and to assess for barriers to practice should be considered. Following formal training, these methods can be utilized for ongoing reinforcement and updates of current treatment recommendations.

Addressing system barriers is also imperative to promote evidence-based practice. This study did not evaluate barriers to practice; however, systematic processes must be in place in the ED and inpatient setting to enhance mTBI assessment and discharge education (Bay & Strong, 2011). This includes tools such as electronic documentation for the mTBI symptom assessment, formalized discharge instructions to optimize completeness and consistency, and electronic medical record best practice prompts to assure these processes occur prior to the patient’s discharge. Use of these standardized processes can also improve the quality of documentation and impact outcomes (Ragoo & McNaughton, 2005). Further research is needed to identify how to overcome these barriers.

Nurses must not only be knowledgeable of current guidelines such as “Care of the Patient With Mild Traumatic Brain Injury” (AANN & ARN, 2011) but take an active part in the change process to incorporate them into their practice. This includes participation in the evidence-based process to become familiar with current literature, take an active role in guideline development, and apply and evaluate the effectiveness of these guidelines to ultimately yield positive outcomes and practices that are realistic and valued.

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Limitations

There are several limitations of this study. Although the response rate was high, this study was limited by the small sample size and the single group pretest–posttest design. Because of the small sample size, demographic variables such as RN age in years and number of patients with mTBI cared for in the last five shifts were categorized limiting analysis and interpretation of the sample. Second, this study was performed at one clinical site inclusive of a select group of nurses. Subsequently, the findings may not be representative of all RNs who provide care to patients with mTBI or practice in different settings. It may also have been beneficial to evaluate if the trauma core nurses had prior education on symptom assessment/brain rest guidelines and if they were knowledgeable of such resources as the AAAN and ARN (2011) practice guideline: “Care of the Patient With Mild Traumatic Brain Injury.” Determining barriers to their ability to apply these guidelines in daily practice would have been beneficial. This information would help to direct educational efforts and promote system changes to overcome obstacles. Lastly, administration of the symptom assessment in current practice and the accuracy of discharge instruction were self-reported. Validation of the self-report data in the electronic medical record would verify the precision of this information.

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Conclusion

Nurse knowledge and confidence caring for children with mTBI is lacking. Given the high incidence and clinical significance of mTBI, nurses must be knowledgeable of symptoms and current treatment recommendations, as well as confident in providing education to patients/families. Effective training programs are imperative to convey this information and promote implementation in daily practice. Overall, this educational program achieved its primary purpose of increasing nurse knowledge of mTBI and confidence with care. However, posttest scores did not achieve 100% uniformity, and not all trauma core nurses are consistently transferring this knowledge into their nursing practice. On the basis of these study results, future programs should incorporate a hands-on or more in-depth problem-based learning approach to allow the opportunity for nurses to integrate content into practice. In addition, further research is recommended to evaluate teaching methods and curriculum content that are most effective to educate trauma core nurses and RNs that care for patients with mTBI and to identify barriers to incorporating this knowledge in practice.

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Acknowledgments

Special thanks to the Trauma Core Nurses at Cincinnati Children’s Hospital Medical Center for their support with this project.

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References

American Association of Neuroscience Nurses & Association of Rehabilitation Nurses. (2011). Care of the patient with mild traumatic brain injury. AANN and ARN clinical practice guideline series. Retrieved from http://www.rehabnurse.org/uploads/files/cpgmtbi.pdf

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Keywords:: knowledge; mild traumatic brain injury; nurse

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