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Consenting on Principles of Rehabilitation Nursing Care

A Delphi Study

Suter-Riederer, Susanne, MScN, RN1,2; Mahrer Imhof, Romy, PhD, RN3; Gabriel, Claudia, RN4; Kesselring, Jürg, MD, FRCP5; Schnepp, Wilfried, PhD, RN2; Imhof, Lorenz, PhD, RN3

doi: 10.1097/rnj.0000000000000111

Purpose Patient-centeredness, evidence-based interventions, and interdisciplinary teamwork have been described as key in neurological rehabilitation nursing. In order to develop future action plans, a group of Swiss rehabilitation nurses sought agreement on concrete principles that led the efforts to develop a common understanding of rehabilitation nursing care in Switzerland.

Design A three-round Delphi study was conducted.

Methods Literature-based statements were formulated and sent out twice to 54 rehabilitation nursing stakeholders. In the third round, the participants ranked the three most important statements out of 13.

Findings Highest priority reached the statements: Rehabilitation nursing care (1) considers the uniqueness of the patients and their family, (2) offers support that promises the greatest potential for patients and their family, and (3) uses evidence-based knowledge.

Conclusion Statements on patient- and family-centeredness were ranked highest. Patients and families’ preferences have to be considered as much as evidence-based knowledge and interventions to support patients and family.

Clinical Relevance The study supported the discussion on action plans and enlivened new services and nursing interventions in a Swiss nursing community.

1 Zurich University of Applied Sciences, Winterthur, Switzerland

2 University of Witten/Herdecke, Witten, Germany

3 Nursing Science & Care GmbH, Winterthur, Switzerland

4 Luzerner Kantonsspital, Lucerne, Switzerland

5 Clinics of Valens, Valens, Switzerland

Correspondence: Susanne Suter-Riederer, MScN, RN, Zurich University of Applied Sciences, Technikumstrasse 81, 8401 Winterthur, Switzerland. E-mail:

The authors declare that there are no conflicts of interest.

Cite this article as: Suter-Riederer, S., Mahrer Imhof, R., Gabriel, C., Kesselring, J., Schnepp, W., & Imhof, L. (2018). Consenting on principles of rehabilitation nursing care: a delphi study. Rehabilitation Nursing, 43(6), E35–E41. doi: 10.1097/rnj.0000000000000111

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The prevalence of neurological disorders is increasing due, in part, to an aging population (Robinson, Callister, Berry, & Dearing, 2008 ; Sharp, McAllister, & Broadbent, 2016). Worldwide, on average 33 individuals out of 100,000 are diagnosed with multiple sclerosis, with the highest prevalence found in Europe (108/100,000) and North America (140/100,000; Browne et al., 2014). The incidence of stroke in Europe is 95/100,000 for women and 141/100,000 for men, whereas in the United States the overall incidence is as high as 269/100,000 in the total population (Mukherjee & Patil, 2011 ; Thrift et al., 2014). The worldwide increase of neurological conditions such as stroke and multiple sclerosis cause disability burden with long-term effects and impose great challenges to patients and families due to impairments in sensory function, orientation, and mobility (Khan, Amatya, Galea, Gonzenbach, & Kesselring, 2017). Despite different underlying causes and individual manifestations, the performance of daily activities is negatively impacted (Turner-Stokes et al., 2007). Healthcare services focus on symptom management and functional recovery, as well as prevention of other acute episodes and subsequent progression of disability. Rehabilitative efforts aim toward the goal that individuals with neurological conditions can live as independently as possible (Kesselring, 2004 ; Khan et al., 2017).

Comprehensive rehabilitative care services require interprofessional care teams with flexible roles and modes of collaborative practices (Khan, Turner-Stokes, Ng, & Kilpatrick, 2007). In neurorehabilitative settings, nurses have been described as pivotal to provide and ensure a supportive and safe environment 24/7 and to coordinate the services of the interprofessional team (Aadal, Angel, Dreyer, Langhorn, & Pedersen, 2013 ; Karol, 2014). In addition, it has been shown that nurses contribute to functional recovery by improving functionality (Kesselring & Beer, 2005) and enhancing patients’ kinesthetic competence (Fringer, Huth, & Hantikainen, 2014 ; Hatch, Maietta, & Schmidt, 2005) and physical competencies (Imhof, Suter-Riederer, & Kesselring, 2015). Naylor et al. (2013) stated that the nurse–patient–family relationship, a basic tenet of nursing care, is critical to rehabilitation, as it instills a positive force enhancing the quality of patient care. Research has shown that nurses produce an overall sense of safety, support the development of self-care abilities by valuing personal beliefs and meanings (Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002), promote adaptation to changing conditions (Ghafari, Fallahi- Khoshknab, Nourozi, & Mohammadi, 2015), and enhance quality of life (Benito-León, Morales, Rivera-Navarro, & Mitchell, 2003 ; Kwok et al., 2006). In those studies, it became evident that nursing interventions need to embrace caring practices that focus on the patients’ lived experiences in order to be successful (Benner & Wrubel, 1989).

Several international studies described the important role of nurses and their contribution to collaboration within interdisciplinary teams and its effect on care outcomes (Kirkevold, 1997 ; Long, Kneafsey, Ryan, & Berry, 2002 ; O'Connor, 2000 ; Pryor, 2008 ; Royal College of Nursing, 2007 ; Vaughn et al., 2016). Although in these studies underlying principles of rehabilitation nursing have been defined, rehabilitation nursing stakeholders in Switzerland identified a need to discuss and prioritize key attitudes and principles of rehabilitation nursing in Switzerland in order to eventually develop an action plan for practice development and research projects for the next 5 years. They sought a common understanding among practitioners, educators, and nurse managers.

Therefore, a Delphi study was conducted as a first step in a joined consensus process for a 5-year action plan that will include the most potential activities for practice development, revision of existing curricula, and a research agenda for rehabilitation nursing.

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As a first step, a literature search was conducted in the PubMed and CINAHL databases, including gray literature, to synthesize clinical evidence, policies, and research outcomes regarding rehabilitation nursing care (Suter-Riederer, Imhof, Gabriel, & Mahrer-Imhof, 2012). Of 555 documents, 82 articles were included in the analysis. From the 82 articles, 30 pertained to neurological conditions. The analysis revealed four main categories: Rehabilitation nursing has to (1) be patient-centered in as much as patients preferences are key and the patients’ partner must be engaged in the decision-making; (2) be evidence-based, which needs ongoing organizational efforts such as guideline development and evaluating care processes and mentoring of colleagues; (3) broaden its scope to include family in order to react to the changing social realities; and (4) rely on good leadership practices to access resources, build trustful work relationships, and reach shared vision within the interprofessional team (Brady Germain & Cummings, 2010). On the basis of these analyses, 13 statements about rehabilitation nursing were formulated for the Delphi study (see Table 1).

Table 1

Table 1

“Patient-centeredness” was operationalized as nurse-led pathways that include care processes from hospitalization to discharge (Statement 1), flexible temporal and organizational structures (Statement 2) that include patients’ view of illness and health (Statement 4) and leads to patient-specific support (Statements 9 and10).

The category “Evidence-Based Rehabilitation Nursing” contained care plans based on clinical experience and skills (Statement 7), scientific evidence and state of the art interventions (Statement 6), and knowledge development by ongoing nursing research (Statement 8).

The category “Broaden Its Scope to Family” includes family centeredness in all steps of the nursing process (Statements 4 and 5).

Finally, “Good Leadership” was operationalized in four statements that focus on the nurses’ contribution to define and negotiate interprofessional collaboration (Statement 3), to make nurses visible in quality care (Statements 11 and 12), and to monitor changes in organizational structures and processes that influence patient care (Statement 13).

In the second step, the Delphi methodology was used to garner repeated feedback from expert rehabilitation nurses from multiple rounds (Hasson, Keeney, & McKenna, 2000 ; Keeney, Hasson, & McKenna, 2001).

In the first round, the 13 statements were sent out to a group of stakeholders and expert rehabilitation nurses (N = 54) with a request to rate the statements on a 10-point Likert scale and to provide comments on each statement if necessary (Table 1). Agreement was defined as a rating of 6 points or higher. Consensus on a statement was considered achieved when more than 80% of the participants agreed with a statement. The provided comments were analyzed, and statements were reformulated by the researchers in agreement with the feedback comments.

For the second round, the adapted list of statements was sent out together with a log of researchers’ comments to the feedback and rationale for changes made to the statements. As in the first round, participants were asked to rate the statements and provide feedback again.

In the third round, participants were asked to rank the statements and to highlight their first three priorities by assigning 1–3 points (3 points = first priority, 2 points = second priority, 1 point = third priority). The advice was to rank the statements in order to focus on the three most important statements in the further discussion for advancing Swiss rehabilitation nursing.

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The Swiss Interest Group of Rehabilitation Care (IGRP) called upon members to participate. Eventually, 54 experts from the German-speaking part of Switzerland participated in the study. They were on average 43-year-old women (M = 43.1, SD = ±8.2) who had 19 years of professional rehabilitation nursing experience. Twenty-seven percent were practicing in a variety of rehabilitation settings as nurses, 37% were nursing managers, and 31% were clinically experienced nurse educators. Forty-one percent worked in a neurorehabilitation setting at the time of the Delphi study.

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First Round

In the first round, the response rate was high (98.1%, n = 53). All 13 statements rated higher than 80% on the agreement scale and remained on the list (Table 1). A total of 102 comments were sent back to the research team. Many comments referred to Statement 1 (n = 21), highlighting the need for discussion on nurse-led pathways and its implications. Further comments were related to include family networks into the statements (Statements 2, 4, and 9) and highlighted the importance of scientific evidence and clinical experience (Statements 6, 7, and 10) of the continuum from hands-on to hands-off care or vice versa (Statement 9) and of an active participation of the patients (Statements 5 and 10). Some commented on the lack of a political statement. These comments demonstrated that advocating for a good healthcare system was pivotal for rehabilitation nurses. Eventually, seven statements retained their original wording (Statements 1, 3, 6, 8, 11, 12, and 13), six were modified (Statements 2, 4, 5, 7, 9, and 10), and one new statement (Statement 14) was added (old and new texts are shown in Table 1).

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Second Round

In the second round, the response rate was 88.9% (n = 48). For 13 of the 14 statements, consensus (more than 80% agreement) was achieved. Statement 1 “manage nurse-led pathways” garnered only an acceptance rate of 69% and was eventually excluded from further consideration. In addition, participants added 50 comments, mainly to Statements 7 and 9 as well as to the new Statement 14 on politics.

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Third Round

In the third round, the response rate was 79.6% (n = 43). In this round, all 13 statements received priority points from the participants (Table 2). Statement 4 “rehabilitation nursing considers the uniqueness of the patients and their family networks in all steps of the nursing process” was given first priority (33 points). Second priority (30 points) was given to Statement 10 “rehabilitation nursing offers support that promises greatest potential for patients and their family networks to deal with changing situations.” The third statement to receive the most priority points was Statement 6 (28 points) “rehabilitation nursing uses evidence-based knowledge.”

Table 2

Table 2

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In agreement with other studies, this Delphi study revealed that rehabilitation expert nurses highlighted the patient- and family-centeredness as most important in rehabilitation nursing (Portillo, Corchón, López-Dicastillo, & Cowley, 2009). The uniqueness of the patients and their families (Statement 4) requires that in rehabilitation settings nursing interventions have to address patients’ needs and be negotiated with patients and their family. Furthermore, the consensus of these nurses on Statement 2 (advocates for patient and family in the interdisciplinary team) shows that nurses have an obligation to advocate for patients and families within the interprofessional team and the setting they work (Royal College of Nursing, 2007 ; Vaughn et al., 2016).

Patients and family members themselves wish interaction and attention to their needs (Gill, Dunning, McKinnon, Cook, & Bourke, 2014). Statement 10 “rehabilitation nursing offers support that promises greatest potential for patients and their family networks to deal with changing situations” ranked second and includes the expectation that patients and family members partner with rehabilitation nurses in decision-making. Priority 3 implies that evidence-based interventions are used. In order to develop the knowledge of rehabilitation nursing further, nursing intervention studies are necessary.

These three priorities point out that patient’s preferences and their lifeworlds have to be included in the daily work of rehabilitation nurses and tailored interventions are obviously at the center of their work. The feedback comments showed that nurses think that knowing the patients is necessary and is as important as scientific evidence (Benner & Wrubel, 1989 ; Robinson et al., 2008 ; Suter-Riederer et al., 2012). However, they were also aware that they may not possess sufficient knowledge to understand the patients’ situation entirely (James, Andershed, Gustavsson, & Ternestedt, 2010).

In order to adapt interventions to the patients’ preferences and goals, nurses think that patients should be encouraged to state how they would like to live with their disabilities and what they want to achieve. It can be assumed that nurses tailor their interventions toward the patients’ needs to enhance functionality and their lifeworld preferences at the same time. This could explain the many comments to Statement 9 (rehabilitation nursing is on a continuum between hands-on and hands-off care). Nurses see themselves translating achievements of therapeutic sessions into everyday life situations according to the patients’ preferences.

The experts rated theoretical and practical knowledge in Statements 6, 7, and 8 as very important. They confirm that supporting patients in rehabilitation, especially patients with neurological diseases, requires specialized knowledge and skills. Hence, the experts acknowledged that rehabilitation nurses contribute to patients’ functional improvement and enhance self-management skills through activating resources and focusing on living with a chronic illness in patients and families (Schulman-Green et al., 2012). The elements, therefore, suggest that clinical expertise is not limited to assessing and meeting the needs of patients but also include the creation of a safe and trustworthy environment (Nieminen, Mannevaara, & Fagerström, 2011).

Recent literature shows that to recognize patient suffering, facilitate compassion, know the patients’ individuality, and focus on solutions rather than problems are key principles (Sharp et al., 2016). Therefore, nurse sensitive outcomes have to include measures that recognize patients’ needs and attend to lifeworld experiences of patients and families in the evaluation process. The statement rated fifth “rehabilitation nursing defines outcome measures” recognizes insufficient progress in this field. Although the body of knowledge regarding nurse-sensitive outcomes has increased in the last decade, measuring the nurses’ impact is an on-going challenge (Beck et al., 2013). Most outcome measures in rehabilitation settings are functional and neglect to focus on patient experiences with specific interventions or on the long-term outcomes beyond physical functionality, such as self-confidence, self-awareness, or quality of life. In the future, new measures are required that are sensitive to and representative of the true contributions that nurses make in the interdisciplinary care process.

The comments in the Delphi study showed that nurses were not always adequately recognized for their contribution within the therapeutic team. The nurses highlighted the specific contribution to a tailored rehabilitation process. The experts and the literature confirm that measuring the effect of nursing interventions recognizes these influencing factors and its direct correlation with patients’ outcomes and well-being. Therefore, in Statement 3 they voted for interprofessional collaboration as central to patients’ outcomes. They recognized that collaboration needs mutual collaborative practices, permanent support from a strong leadership, and rules on how to deal with conflicts and divergent interests. Especially in research projects, nursing interventions have to be included in experimental studies and tested with specific nurse-sensitive outcome measures.

Monitoring changes in the healthcare system and subsequent changes within the management of organizations was considered pivotal elements of rehabilitation nursing (Flodgren, Rojas-Reyes, Cole, & Foxcroft, 2012). Because the first set of statements lacked a statement on involvement in politics, the first round produced feedback that rehabilitation nursing needs to be engaged in politics, whether to improve financial resource allocation for patients and families or to improve working conditions for the nurses. Although it ranked 12th of 13 statements, more than 80% of the participants agreed that political engagement for rehabilitation nursing is important.

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Implications for Practice

The Delphi process and the subsequent discussion of the statements within the Academic Association of Rehabilitation Nurses influenced the development of new services for patients in the rehabilitation setting. For example, the idea of patient- and family-centered care has been used to develop an Advanced Practice Nurse program specific for patients with Parkinson’s disease and stroke and their families (Gabriel, 2015 ; Hamric, Hanson, Tracy, & O'Grady, 2014).

The consensus and ranking of the approaches and principles in this study also influenced several nursing studies in Switzerland. For example, a nursing study evaluating a new intervention to enhance the mobility of patients tailored the intervention to the patients’ capabilities and preferences (Imhof et al., 2015). The intervention was based on kinesthetic principles (Hatch et al., 2005), and the nurses were trained to comply with statements on practical necessary knowledge and skills. The nurses provided nurse-specific inputs into other research projects and advocated for patients and families in the study within the interprofessional team. The ongoing discussion during the whole research process was supported by all involved nurses and physicians, acknowledging the unique contribution that nurses could provide in patients’ rehabilitation.

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Strength and Limitations

A combination of literature review and Delphi study was used to explore knowledge and clinical expertise in the field of rehabilitation nursing and to reach consensus on main approaches and principles of rehabilitation nursing. The Delphi study initiated a discussion that contributed to advancing rehabilitation nursing in Switzerland. The results are specific to the situation in Switzerland. Furthermore, the participants were experts and stakeholders in rehabilitation nursing, which might lower the general acceptance by all nurses in rehabilitation settings because they were not included in the study. Therefore, the statements have to be discussed with many more nurses and other healthcare professionals from other disciplines.

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The Delphi methodology was useful to reach agreement within the stakeholders of rehabilitation nurse experts. Key elements were identified to develop rehabilitation nursing care in Switzerland. In addition, the discussion led to advancement of a mutual understanding because everyone’s perspective during the process were openly explained and distributed. The resulting statements were helpful in developing new nursing interventions in rehabilitation and even in determining the principles for outcome measures in nursing research. Effective principles of nursing interventions in rehabilitation care include focusing on lived experiences, person-centered care, and the transformation of therapeutic outcomes into daily life. The integration of lived experiences may shift the more commonly held focus on physical functioning to a broader view of the patients’ needs and quality of life. In accordance with the notion that interdisciplinary teams are needed to produce effective clinical interventions in neurorehabilitation settings, further research is needed to explore the true contribution of nursing interventions within rehabilitation settings. High-quality, nurse-sensitive outcome measures must be developed based on the principles of effective nursing interventions.

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Key Practice Points

  • The article presents the results from a Delphi study, which has been pursued to reach a consensus on the underlying principles of rehabilitation nursing in Switzerland.
  • It gives insight in a Delphi process that contained three rounds.
  • The findings show that patient- and family-centeredness is considered a key principle of rehabilitation nursing.
  • The principles influenced the development of new services and intervention studies within the rehabilitation nursing community and enlivened the discussion about an action plan for practice development.
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The authors would like to thank the IGRP that funded the Delphi study, the experts who participated in the development of the theses, the Swiss Multiple Sclerosis Society, and The Nursing Science Foundation Switzerland for funding junior scientists.

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Delphi technique; neurological rehabilitation; nurses’ role

© 2018 Association of Rehabilitation Nurses.