Effectiveness of a Nurse-Delivered Intervention on Illness Perceptions and Quality of Life in Patients With Injury : Journal of Nursing Research

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Effectiveness of a Nurse-Delivered Intervention on Illness Perceptions and Quality of Life in Patients With Injury

FANN, Wen-Chih1; HUNG, Chang-Chiao2; CHABOYER, Wendy3; LEE, Bih-O4,∗

Author Information
Journal of Nursing Research 29(4):p e163, August 2021. | DOI: 10.1097/JNR.0000000000000439
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Injury is the leading cause of death among people aged 45 years and younger in many countries, including the United States (Centers for Disease Control and Prevention, 2016), the United Kingdom (Kanani & Hartshorn, 2016), and Taiwan (Ministry of Health and Welfare, National Health Insurance Administration, Taiwan, ROC, 2019). Annual medical costs related to mortal injuries total 21.4 billion USD in the United States (Centers for Disease Control and Prevention, 2016). In Taiwan, medical costs associated with injury-related hospitalizations exceed 470 million USD annually (Ministry of Health and Welfare, National Health Insurance Administration, Taiwan, ROC, 2019). Survivors of injury may experience permanent disabilities associated with alarmingly high medication and rehabilitation costs (Kanani & Hartshorn, 2016). Although healthcare professionals have traditionally focused on physical disabilities (Chaboyer et al., 2010), the need to understand and treat cognitive, behavioral, and other disabilities is being increasingly recognized to maximize health outcomes such as quality of life (Baker et al., 2018). Patients with injury may experience short- and longer-term physical and psychological disabilities (Schneiderman et al., 2013). Physical and psychological problems are found in patients with injury and correlate with quality of life (Chaboyer et al., 2010; Schneiderman et al., 2013). For example, a longitudinal study of Swedish patients with trauma found that patients experienced physical functioning declines 3 months after an injury incident (Ringdal et al., 2010). According to Chaboyer et al. (2010), over 50% of patients experienced psychological and functional disabilities 6 months after an injury incident. More recently, some cohort studies have followed patients with injury for up to 1 year. For example, one study performed follow-up assessments of patients at 3 months and 1 year after injury, reporting that patients with visible injuries may have poor psychological health and posttraumatic stress disorder (PTSD) at 12 months after injury (Baecher et al., 2018). Another retrospective study found that the long-term physical functioning and quality of life of patients with severe injury were poorer than those of the general population (Banierink et al., 2019).

The concept of illness perception has been commonly applied in patients with injury as well as in other patient groups. Illness perceptions are the organized, cognitive, and emotional perceptions that individuals experience when facing an illness or health-threatening condition (Leventhal et al., 2016; Willemse et al., 2019). Illness perception was originally modeled to address the five components of consequences, timeline, control, identity, and causes, with each component reflecting different perceptions or internal beliefs toward an illness (Leventhal et al., 2016; Willemse et al., 2019). Moss-Morris et al. (2002) used different patient populations to reconceptualize the components of illness perception, with two components added: illness coherence and emotional representations. Timeline is divided into two subscales, timeline-acute/chronic and timeline cyclical, whereas control is divided into personal control and treatment control (Moss-Morris et al., 2002).

Illness perceptions, related to several health outcomes, have been studied in various patient populations (Sawyer et al., 2019). For example, the relationship between illness perceptions and quality of life has been studied in patients with irritable bowel syndrome (Knowles et al., 2017) and patients with injury (Lee et al., 2008). In previous studies, patients with injury were found to have relatively poor quality of life (Bayo et al., 2019; Van Son et al., 2017) and to have developed negative illness perceptions at 3 months after their injury (Lee et al., 2010). In another study of Taiwanese patients, three components of illness perception, including identity, consequences, and timeline, were identified as significant predictors of the physical quality of life of patients with injury at 3 months after injury (Lee et al., 2008). Moreover, Chaboyer et al. (2010) found that the three components of identity, emotional perceptions, and timeline were found to be predictors of the physical and mental health quality of life of patients with injury at 6 months after injury.


Research has shown that nursing interventions can affect illness perceptions and other health outcomes in different patient groups. For example, in one study, an educational intervention was used on patients with pacemaker implantations. Rakhshan et al. (2013) found that all of the components of illness perception, with the exception of treatment control, were positively changed in patients with pacemakers by an intervention. Vranceanu et al. (2015) conducted a study that examined the implementation of a mind–body, skills-based intervention in patients with injury over a period of 1–2 months. The results showed that overall disability and pain were improved, although no change in coping strategies or emotional status was observed. In addition, Zatzick et al. (2013) conducted a study that involved patients who developed severe PTSD after experiencing injuries. Patients in the experimental group were subjected to a stepped intervention that included combined care management, psychopharmacology, and cognitive behavioral psychotherapy. These patients exhibited significantly reduced PTSD symptoms compared with their control group peers. Furthermore, the patients in the intervention group achieved significant improvements in physical function over the 1-year posttest period.

Cognitive behavioral therapy (CBT) has emerged as one of the most effective, evidence-based adjunctive treatments for illnesses (Halford & Brown, 2009). In Siemonsma et al. (2013), a CBT intervention was found to reduce the consequences and to increase personal control in people with chronic low back pain within 4.5 months. In another study using nursing interventions combined with skills learned via CBT, injury-related physical symptoms and perceptions of controllability were found to be positively affected 3 months after injury because of a nursing intervention (Lee et al., 2015). A recent systematic review suggested that the effectiveness of different patterns of intervention on outcomes in patients with injury remains inconclusive (Shepherd-Banigan et al., 2018). Thus, the authors of this research speculated that there may be an opportunity to add new knowledge related to nursing research and nursing practice by conducting a study to examine the effects over 1 year of a nursing intervention on illness perceptions and quality of life in patients with injury.


This study was designed to examine the effect of a nurse-delivered intervention on the illness perceptions and quality of life of patients with injury. The Transparent Reporting of Evaluations with Nonrandomized Designs statement checklist was adopted to enhance reporting quality. The Transparent Reporting of Evaluations with Nonrandomized Designs statement is a 22-item checklist that helps validate the use of nonrandomized and quasi-experimental designs to evaluate interventions (Des Jarlais et al., 2004).


A two-group experimental design was used, and the participants were followed up for 12 months.


Adults aged 20–65 years who had experienced a moderate-to-severe injury were eligible to participate in this study. An Injury Severity Score (ISS) of 9–15 was adopted to indicate moderate injury, and an ISS of 16 or greater was adopted to indicate severe injury (Sluys et al., 2016). To be included in the study, participants were required to have had an ISS ≥ 9, and their injury must have resulted from an accident. Patients with severe head injuries, spinal cord injuries, or burns were excluded. Two participants were matched in terms of ISS scores and gender by artificial selection from the hospital computer by a nurse practitioner (NP) and then randomly assigned to either the experimental or control group. The participants and their carers were blinded to study group assignment. Participants were recruited from one teaching hospital with 2,450 beds. The hospital is one of 14 medical centers in Taiwan that treats more than 2,000 patients with injury each year. Data collection was conducted in five ward units in which patients with injury are treated.

Previous data were used to calculate the correlations between Time 1 and Time 2 and between Time 2 and Time 3 (Lee et al., 2010). The results showed that the correlation coefficients were .45 and .50, respectively. On the basis of the suggestions of Diggle et al. (2013), using a medium effect size of d = 0.5, a power of 0.80, an alpha of .05, a correlation of outcomes between Time 1 and Time 2 of .45, and the number of time intervals set as 4, the required minimum sample size for each group was determined to be 37. Using an anticipated attrition rate of 20%, the target number of participants in each group was set at 45.

The Intervention

CBT is a psychotherapeutic modality, with plentiful evidence of efficacy across multiple morbidities (Dekker et al., 2012). Training nurses in CBT can expand the pool of therapists available to promote patient health outcomes (Halford & Brown, 2009). The intervention NP attended a CBT training program held by the Chinese Association of Group Psychotherapy. The program included basic and advanced courses.

The nurse-delivered CBT intervention was provided to patients in three sessions. The first and second sessions were parts of an in-hospital intervention that was modified from a previous study (Lee et al., 2015) and that was focused on depicting the existing feelings or perceptions regarding the injury based on the dimension of the illness perceptions (Broadbent et al., 2006). The objective of the first session was to establish rapport with the participant, to help the participant understand the meaning of illness perceptions, and to guide the participant in discussing all of the components of injury-related illness perceptions. The second session, held 24 hours after the first session based on the participant's condition and convenience, was designed to clarify and discuss useful information related to injury recovery.

The third session extended the in-hospital intervention using a method described by Lee et al. (2015) and subsequently tailored for this study. This third session includes a follow-up telephone interview early after hospital discharge and focuses on helping patients adapt to the postinjury transitional period. The extension strategies added to the intervention in this study made this intervention somewhat different from that in Lee et al. (2015). These included a follow-up telephone call made at 10–14 days after hospital discharge and the use of a common-thinking-errors sheet and an evidence-for-and-against useful thoughts sheet based on CBT (Cohen & Mannarino, 2008).

An NP who was not involved in recruitment or data collection delivered the intervention. The intervention NP had been working with patients with injury for more than 15 years, was trained in CBT techniques by a practicing psychologist for 16 hours, and was CBT certified.

Data Collection

A senior NP who held national NP certification was in charge of collecting preintervention data, following up with the participants, and assessing the outcomes. This NP was blinded to the study group assignment. Demographic and clinical data and the Brief Illness Perception Questionnaire (the Brief IPQ) were collected before hospital discharge. Follow-up data on the two groups were collected at 3, 6, and 12 months after hospital discharge using the Brief IPQ and the World Health Organization Quality of Life Questionnaire (the WHOQOL-BREF). The recruiting NP and the researchers were blinded to group allocation. The allocation concealment ended when a given pair of two patients was discharged from the hospital. Data were collected from January 2013 to December 2015.


The Brief IPQ is a nine-item scale that provides a rapid assessment of an individual's perceptions of illness (Broadbent et al., 2006; Woodhouse et al., 2018). Each item in this scale is designed to assess one dimension of illness perception. The ninth item, that is, the item addressing the cause of injury, was excluded because the indicated reasons for injury did not apply to the patients in this study (Chaboyer et al., 2010). Thus, the eight items used in the Brief IPQ addressed the following dimensions: consequences, timeline, personal control, treatment control, identity, illness concern, coherence, and emotional representation. Three items, namely, personal control, treatment control, and coherence, are scored from 1 (worst) to 10 (best), whereas the remaining five items are scored from 1 (best) to 10 (worst). The overall score ranges from a best possible score of 1 to a worst possible score of 10. The Chinese version of the Brief IPQ was translated by Lin and Xue (The Illness Perception Questionnaire, 2020). The coefficients of test–retest reliability for the Brief IPQ ranged from .69 to .73, and the Cronbach's α of the subscales ranged from .70 to .84.

The WHOQOL-BREF is a 28-item scale used to measure four domains, including physical, psychological, social relationship, and environment. This scale has been tested transculturally in clinical settings (Yao, 2000). Scores range from 1 to 5, with higher scores indicating better quality of life (Yao, 2000). The reliability and validity of the Chinese WHOQOL-BREF have been tested in several clinical settings, including on caregivers of patients with injury (Wu et al., 2014). In this study, the Cronbach's α of the subscales for the WHOQOL-BREF ranged from .86 to .89, and the overall Cronbach's α of the scale was .90.

Ethical Considerations

Institutional review board approval (IRB No. 10202-013) was received from the board of the study hospital. The purposes of the study were explained to the participants. The participants received both written and oral information about the study before they provided informed consent.

Statistical Analyses

Descriptive statistics were used to summarize the sample and the scores on the Brief IPQ and the WHOQOL-BREF. Group differences in sample characteristics were assessed using independent-sample t tests for continuous variables and Fisher's exact tests for categorical variables. Generalized estimating equation (GEE) analysis was used to evaluate the intervention effects on the Brief IPQ and the WHOQOL-BREF across the follow-ups. Each GEE model included the main effects of time (baseline as the reference category) and intervention effect (control group as the reference category), the two-way interaction effects of Time × Intervention, and the main effects of control variables (patient characteristics). The differences between the two groups in terms of the change from baseline to the later follow-ups were warranted when the interaction effects were significant, suggesting the intervention effect was supported. Patient characteristics (Table 1) were treated as the control variables in the GEE model. Robust standard errors were selected to calculate significance of parameter estimates, and the exchangeable working correlation matrix was used to adjust for the time effect (Liang & Zeger, 1986). All of the analyses were performed using SPSS Version 22 (IBM, Inc., Armonk, NY, USA).

Table 1. - Demographic and Clinical Data for the Experimental and Control Groups
Variable Experimental Group (n = 47) Control Group (n = 47) p
n % n %
Gender 1.000
 Male 31 66.0 31 66.0
 Female 16 34.0 16 34.0
Age (years; M and SD) 32.4 10.3 32.6 10.2 .904
Marital status .249
 Single 37 78.7 31 66.0
 With spouse 10 21.3 16 34.0
Education (years) .435
 < 12 2 4.3 5 10.6
 ≥ 12 45 95.7 42 89.4
Employment .386
 Yes 38 80.9 42 89.4
 No 9 19.1 5 10.6
Injury mechanism 1.000
 Vehicle accident 37 78.7 38 80.9
 Fall or other 10 21.3 9 19.1
Injury severity score (M and SD) 11.6 4.7 11.3 3.5 .711
Injury severity 1.000
 9–15 39 83.0 40 85.1
 16–25 8 17.0 7 14.9
Length of hospital stay (days; M and SD) 10.4 5.3 9.4 5.9 .392
Note. Data are expressed as mean (standard deviation) for continuous variables and frequency (percentage) for categorical variables.


Ninety-four patients with injury were recruited and randomized into the experimental and control groups. The participants in both groups had an average age in the early 30s. A substantial majority in both groups were employed before injury, injured in vehicular accidents, and classified as having a moderate injury (ISS = 9–15). A minority in both groups were classified as having a severe injury (ISS > 16). The mean lengths of hospital stay in the experimental and control groups were 10.4 (SD = 5.3) and 9.4 (SD = 5.9) days, respectively (Table 1). No significant differences in gender, age, marital status, educational level, employment status, injury mechanism, ISS, injury severity, or length of hospital stay were found between the two groups (Table 1).

The descriptive statistics of the Brief IPQ across the follow-ups in both groups are shown in Table 2, and the summary statistics of the GEE models for each domain and the overall score of the Brief IPQ are shown in Table 3. The results show that the interaction effect of the intervention over time was significant at 3 months in the personal control domain (B = 1.26, p < .05) and the treatment control domain (B = 1.50, p < .01), indicating that improvement from baseline to 3 months was greater in the experimental group than in the control group. The interaction effect of the intervention over time was significant at 6 months in the emotional representation domain (B = −2.59, p < .001), indicating the positive effect of the intervention at 6 months. Noticeably, the intervention effect on the Brief IPQ overall score was supported at 3 months (B = −0.60, p < .05) and 6 months (B = −0.82, p < .001). However, no evidence for an intervention effect was found for any domains of the Brief IPQ at 12 months (see Figure 1).

Table 2. - Descriptive Statistics of Brief IPQ and WHOQOL-BREF Across the Follow-Ups in the Experimental and Control Groups
Scale/Domain Experimental Group Control Group
Baseline (n = 47) 3 Month (n = 37) 6 Month (n = 34) 12 Month (n = 32) Baseline (n = 47) 3 Month (n = 40) 6 Month (n = 39) 12 Month (n = 32)
B p B p B p B p B p B p B p B p
Brief IPQ
 Personal control a 6.5 1.6 7.9 1.9 7.4 1.9 7.4 1.6 6.2 1.8 6.3 1.6 7.1 1.8 6.8 2.2
 Treatment control a 7.7 1.7 8.3 1.7 7.7 1.7 7.5 2.1 7.7 1.7 6.7 1.9 7.5 2.1 7.5 2.0
 Consequences b 7.8 2.0 5.8 1.9 4.6 2.0 4.4 2.6 8.1 2.1 6.7 2.0 5.8 2.3 5.2 2.5
 Timeline b 5.4 2.0 4.8 1.7 4.8 2.0 4.8 1.8 5.7 1.8 5.5 2.0 5.6 2.6 5.6 2.4
 Identity b 5.8 2.6 4.0 1.6 4.4 1.8 4.4 1.9 6.1 2.1 5.5 1.7 5.1 2.2 4.8 2.0
 Illness concern b 8.7 1.7 9.0 1.5 7.2 1.6 7.8 2.2 9.3 1.3 9.0 2.0 8.5 2.0 8.0 2.1
 Coherence a 7.8 1.9 8.4 1.5 8.6 1.7 8.1 1.9 8.0 1.9 8.1 1.7 7.9 1.8 8.4 1.8
 Emotional representation b 5.1 2.9 6.0 2.5 3.9 2.3 5.0 2.5 4.9 2.9 6.4 2.2 6.3 2.1 5.0 2.7
 Overall score b 5.1 0.9 4.4 0.7 3.9 1.0 4.2 1.0 5.3 1.0 5.2 1.2 4.8 1.3 4.5 1.2
 Physical health 14.6 3.2 13.6 1.9 13.9 1.9 14.7 2.4 15.6 2.8 13.1 2.7 14.0 3.1 14.3 2.8
 Psychological health 14.8 2.0 14.4 2.4 14.6 2.5 15.3 2.2 14.5 2.2 14.2 2.4 14.5 2.6 13.8 2.7
 Social relationships 14.8 1.8 14.6 2.5 15.3 2.6 15.0 2.7 15.3 2.4 14.3 2.5 14.4 2.4 14.5 2.5
 Environment 14.9 2.1 15.1 2.3 15.7 2.0 15.9 1.9 14.8 2.4 14.0 2.0 15.0 2.5 14.8 2.6
Note. IPQ = Illness Perception Questionnaire; WHOQOL-BREF = World Health Organization Quality of Life Questionnaire.
a 1 = worst to 10 = best. b 1 = best to 10 = worst.

Table 3. - GEE Analysis of Intervention Effect on Brief IPQ
Variable Consequences Timeline Personal Control Treatment Control
Intercept 7.76*** < .001 4.53*** < .001 4.47*** < .001 8.14*** < .001 5.97*** < .001 9.73*** < .001 8.79*** < .001 4.03** .005 5.03*** < .001
 Experimental vs. control −0.35 .400 −0.40 .308 0.21 .545 −0.07 .841 −0.45 .345 −0.48 .134 −0.15 .691 0.17 .764 −0.19 .344
 3 months vs. baseline −1.41*** < .001 −0.31 .408 0.08 .838 −0.95** .008 −0.57 .143 −0.26 .414 0.23 .479 1.37* .012 −0.07 .672
 6 months vs. baseline −2.26*** < .001 −0.19 .697 0.79* .028 −0.17 .585 −0.94* .011 −0.77** .009 −0.02 .953 1.42** .005 −0.42* .016
 12 months vs. baseline −2.91*** < .001 −0.29 .524 0.59 .195 −0.13 .780 −1.45*** <.001 −1.25*** <.001 0.50 .176 0.05 .930 −0.88*** <.001
Interaction term
 3 months vs. baseline −0.49 .326 −0.25 .636 1.26* .021 1.50** .002 −1.10 .059 0.50 .254 0.32 .454 −0.55 .467 −0.60* .011
 6 months vs. baseline −0.95 .081 −0.54 .393 0.09 .861 0.23 .613 −0.59 .308 −0.73 .111 0.82 .096 −2.59*** < .001 −0.82*** .001
 12 months vs. baseline −0.62 .306 −0.21 .726 0.35 .535 −0.02 .968 0.10 .866 0.40 .462 −0.15 .763 −0.15 .842 −0.05 .846
Note. GEE = generalized estimating equation; IPQ = Illness Perception Questionnaire.
*p < .05. **p < .01. ***p < .001.

Figure 1.:
Observed Mean Values of (A) Personal Control, (B) Treatment Control, (C) Emotional Representation, and (D) Total Score of the IPQ in the Experimental and Control Groups Across Follow-Ups

The descriptive statistics of the WHOQOL-BREF across follow-ups in both groups are presented in Table 2, and the summary statistics of the GEE models for each WHOQOL domain are presented in Table 4. The results of the GEE indicate that the interaction effects of the intervention at 6 months (B = 1.38, p < .01) and 12 months (B = 1.06, p < .05) were significant in the social relationships domain, revealing that the improvements from baseline to 6 months and to 12 months were greater in the experimental group than in the control group. However, no evidence for an intervention effect was found at 3 months or at all for the other domains of the WHOQOL-BREF. The changes in the “social relationships domain” across the follow-ups in each group are presented in Figure 2.

Table 4. - GEE Analysis of Intervention Effect on WHOQOL-BREF
Variable Physical Health Psychological Health Social Relationships Environment
B p B p B p B p
Intercept 14.35*** < .001 14.22*** < .001 15.32*** < .001 14.51*** < .001
Treatment −0.96 .123 0.29 .502 −0.45 .298 0.06 .902
 Experimental vs. control
 3 months vs. baseline −2.34*** < .001 −0.27 .497 −0.96* .015 −0.73 .051
 6 months vs. baseline −1.61** .002 −0.08 .839 −0.80* .025 0.18 .638
 12 months vs. baseline −1.05* .047 −0.67 .137 −0.97* .012 0.02 .962
Interaction term
 3 months vs. baseline 1.37 .074 −0.08 .887 0.87 .098 0.86 .087
 6 months vs. baseline 1.02 .213 −0.08 .891 1.38** .008 0.56 .277
 12 months vs. baseline 1.09 .170 1.04 .071 1.06* .044 0.87 .121
Note. GEE = generalized estimating equation; WHOQOL-BREF = World Health Organization Quality of Life Questionnaire.
*p < .05. **p < .01. ***p < .001.

Figure 2.:
Observed Mean Values of the Social Relationships Domain of the World Health Organization Quality of Life Questionnaire in the Experimental and Control Groups Across Follow-Ups


The effects of a nurse-delivered intervention over a 12-month follow-up period were examined in this study. The outcomes showed that the intervention had positive effects on the cognitive illness perceptions, emotional perceptions, and quality of life of the participants in the experimental group at 3, 6, and 12 months after hospital discharge.

Moreover, these participants registered significant improvements in personal control and treatment control at 3 months after injury, suggesting that the intervention helped promote confidence in recovery and greater adherence to postinjury treatment. These findings are consistent with those in the study by Lee et al. (2015), which showed that in-hospital interventions help patients improve their perceptions and increase their confidence in their ability to control their postinjury conditions at 3 months after injury.

These findings do make sense for patients with injury because the time around 3 months after an injury is typically a transitional period for patients from the subacute stage to the rehabilitation stage. However, different from Lee et al.'s (2015) study, this study did not detect significant decreases in injury-related physical symptoms. This may be attributable to the average age of the patients in this study being lower than the average ages of the patients in Lee et al. (2015) and Chaboyer et al. (2010), which may have led to the participants in this study to self-perceive a relatively fast physical recovery and a lower intervention effect on this dimension.

Although previous studies have reported many physical symptoms in patients with injury at 3 months after injury (Chaboyer et al., 2010; Lee et al., 2008), no intervention effect on physical outcomes at 3 months after injury was found in this study. Importantly, positive changes in 3-month overall illness perceptions in the experimental group were found in this study. General illness perceptions include the physical symptoms domain. These findings may not contradict with previous findings, as positive perceptions may fluctuate in patients with injury who experience physical or psychological disabilities.

The intervention changed the emotional perceptions of participants at 6 months after injury. As standardized care for patients with injury is not provided across hospitals in Taiwan, the participants in this study appeared to have emotional problems that require greater focus in terms of treatment. This result is quite important because previous studies found that patients with injury experience emotional problems at 6 months after hospital discharge (Chaboyer et al., 2010; Schneiderman et al., 2013). This new evidence indicates that it is crucial for clinicians to provide mental support during the first 6 months after injury.

Findings from this study indicate that the overall score for illness perceptions was positively changed by the intervention at 3 and 6 months after injury. These results are similar to Rakhshan et al. (2013), although the intervention effects in this study persisted significantly longer. These results may be attributable to the combined effect of the nursing intervention and CBT skills helping patients change their perceptions.

No evidence of intervention effects on illness perceptions was found at 12 months after hospital discharge. Therefore, the intervention may not provide an effect that extends beyond 6 months after injury. This may be because the patients have almost completely recovered from their injury or have already acclimated to their postinjury status. Although research has shown that up to 40% of patients with severe injury experience psychological problems at 12 months after injury (Vles et al., 2005), this study did not indicate that the intervention had any effect on 12-month health outcomes. We speculate that over 80% of the participants in this study had moderate rather than major injuries. Thus, the extent of long-term disability may be significantly less in this study than in Vles et al. (2005).

The intervention resulted in better “social relationships” in terms of quality of life at 6 and 12 months after injury. These participants had better social relationships with others, indicating that the intervention improved connections with their social networks. We speculate that the patients were influenced in terms of their cognitive perceptions at 3 months and emotional perceptions at 6 months after injury and thus may have had better social skills at 6–12 months after injury. No prior research evidence is available to compare with these results. To retest the intervention effects, future research may adopt the intervention protocol and follow-up time points used in this study to investigate patients with major injuries or specific types of injuries (e.g., injuries to extremities).

In summary, this study aimed to explore whether the developed nurse-driven intervention has short- and long-term impacts on outcomes in patients with injury, including illness perceptions and quality of life. The nurse intervention was found to partially improve patients' short- and long-term outcomes. Most importantly, this study provides a new and unique finding that the investigated nurse intervention may affect 1-year outcomes in patients with injury. The study results are of significant value for patients, clinicians, and the government. With regard to patients, their postinjury expectations should be regularly assessed to identify the critical barriers to recovery. Meanwhile, clinicians, including nurses, physicians, rehabilitation therapists, and social workers, should be made better aware of patient outcomes after injury. By receiving treatment consisting of interdisciplinary interventions, patients may obtain better quality-of-life-related health outcomes, which may ultimately reduce national medical costs.

Relevance to Clinical Practice

The findings of this study suggest that case management may be necessary to improve outcomes in patients with injury and that the core concept of case management should include injury-related interventions, even when a hospital does not have a standard care management protocol for these patients. Under a care management model, nurses and other clinicians such as physicians, rehabilitation therapists, and social workers may be made better aware of the illness perceptions and care needs of patients by visiting these patients on a daily basis to review progress, ensure optimal care is given, and schedule regular postdischarge follow-up visits.

Hospitals may incorporate illness perceptions as a foundation for assessment. It is important to implement early identification of expectations to highlight the needs of patients with injury and to assist them to reshape their illness perceptions. For example, the Brief IPQ (Broadbent et al., 2006) may be used to quickly assess patient expectations regarding an injury at hospital discharge and at 3 and 6 months after discharge. After these assessments, multidisciplinary professional services may be deployed to help patients reduce inconsistencies between these expectations and reality.

With regard to rehabilitation efforts, providing comprehensive care to patients with injury to help them adapt to postinjury recovery rather than providing acute care, nurses and clinicians may combine rehabilitation practice and test the effects on the illness perceptions of these patients. In rehabilitation units or during outpatient department visits, regular assessments of each patient's expectations and barriers to recover may be necessary to improve the quality of life of patients with injury.


The data were collected in only one hospital, which may limit the external validity of this study. Another limitation was the complicated nature of injury mechanisms, which may limit the applicability of findings to patients in other injury categories. Finally, only a minority of the patients included in the study were classified with a severe injury. This may be attributable to the exclusion of patients with severe head, spinal cord, or burn injuries.


The findings showed that the nurse-delivered CBT intervention had long-term effects and positively changed patients' illness perceptions and quality of life. This study adds some new evidence that may facilitate the recovery of patients with injury, especially in the 6- to 12-month postinjury period. Moreover, the findings of this study suggest that nurses and other clinicians should be involved in the intervention to provide interprofessional care at different periods for patients. In addition, regular assessment of the illness perceptions and self-care abilities of patients with injury may be helpful to their successful recovery and rehabilitation. Although some components of illness perceptions and quality of life were not changed by the intervention, further research may be used to test the applicability of the intervention.


The authors would like to thank National Science Council (grant number: NSC 101-2314-B-255-005-MY3) and Kaohsiung Medical University Neuroscience (grant number: KMU-TC109B03) for providing the research grants for this study.

Authors Contributions

Study conception and design: BOL

Data collection: BOL

Data analysis and interpretation: BOL, CCH

Drafting of the article: WCF, BOL

Critical revision of the article: BOL, WCF, WC


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illness perceptions; nurse-delivered intervention; patients with injury; quality of life

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