- Email: [email protected]
Rehabilitative nursing: a core nursing function across all settings
The Canberra Hospital
Rehabilitative nursing: a core nursing ^-^ function across all settings
Nurses are challenged to meet the changing health care needs of the Australian population as they live longer and experience increasing levels of disability. This paper reports on part of the findings of a recent study of rehabilitation nurses and suggests that the findings are relevant to all nurses as they attempt to meet this challenge. Thirty-four registered nurses working in rehabilitation settings in three states of Australia participated in the study. In-depth interviews and focus group discussions were used to collect data and validate interpretations. From the seven domains of practice identified in the findings, this paper discusses only one, the rehabilitative approach. This domain begins to capture the how and why of rehabilitation nursing practice, rather than the what. The rehabilitative approach is about the way the nurses conceptualise and think about their practice and the people they interact with. It is greater than the cliche of holistic care. Given that rehabilitation is a process that the patient undergoes and is not setting specific, the findings of this study offer direction to all nurses in supporting the rehabilitation of their patients. The study, the first of its kind in Australia, provides valuable guidance for the designers of undergraduate and postgraduate nursing programs in Australia. By Julie Pryor • Key words: rehabilitation, nursing approaches, clinical decision making, continuum of care
Introduction
they are the everyday service needs of the population
Nursing is a human science - it is about people's lives:
and as a consequence the responsibility of all nurses.
lives thai are sometimes lived in tired, broken or shat-
Australian nurses are beginning to identily and
tered bodies. Australia's population is not only ageing,
articulate the valuable contribution that a rehabilita-
but t h e p r o p o r t i o n of t h e p o p u l a t i o n living w i t h
tive nursing approach can make to the recipients of
chronic illness and disability is rising (Australian Insti-
nursing care across all health care settings regardless
tute of H e a l t h and Welfare 1998) and as a c o n s e -
of their age or diagnostic category. T h e develop-
quence more Australians are living in tired, broken or
ment of nursing knowledge and skills in rehabilita-
shattered bodies than ever before, Evidence of the real
tion is an imperative given the real health profile of
h e a l t h profile of this c o u n t r y can be found in the
Australia's population, ie increasing disability and
wards of acute hospitals, e m e r g e n c y d e p a r t m e n t s ,
increased life e x p e c t a n c y (Australian Institute of
operating theatres and in the caseload of all human
Health and Welfare 1998). T h e very nature of our
services (Australian Institute of Health and Welfare
n u r s i n g p r a c t i c e n e e d s to he c h a l l e n g e d , not so
1998). Aged care, disability and rehabilitation are not
m u c h with a focus on w h a t w e d o , b u t w i t h an
the exclusive domain of nurses in specialist settings -
examination of how we do it. This paper introduces
Julie Pryor RN CM BA MN MRCNA, Senior Lecturer in Rehabilitation Nursing, School of Nursing, Family and Community Health, University of Western Sydney Email: [email protected] Collegian Vol 9 N n 2 2002
11
[REFEREED ARTICLE]
the notion of a style of nursing recently
providing respiratory and psychosocial
approach,- t h e l e a c h i n g and c o a c h i n g
described as the rehabilitative approach.
care. Dougan (1991) concluded that nurs-
role,- observation, assessment a n d inter-
Drawing on recent research findings, the
es undertake much of the work formerly
pretation,- administering and m o n i t o r i n g
nature ol the rehabilitative approach will
assigned to other members of the team,
t h e r a p e u t i c interventions,- m a n a g e m e n t
be explained and its application across
for example, physical therapy, occupa-
of rapidly changing situations,- manage-
settings discussed.
tional t h e r a p y a n d p s y c h o l o g y . From
ment, advocacy and co-ordination role,
diaries kept by the nurses thai recorded
and monitoring and ensuring the quality
Background to the research
the duration and type of work activities,
of health care practices.
W i t h little r e s e a r c h - b a s e d e v i d e n c e to
Brillhart and Sills (1994) concluded that
inform the development of rehabilitation
the roles and responsibilities of registered
nursing in Australia, an interpretive study
nurses fell into four categories - direct
A total of 34 registered nurses working in
ol the registered nurse working in reha-
patient care, indirect patient care, unit
rehabilitation settings in Australia partici-
bilitation settings was u n d e r t a k e n . T h e
management and unaccounted for time.
pated in the study. Thirteen participated
Method
in one to o n e i n - d e p t h interviews a n d eight of this group participated in a locus
.*H^3ff>i ra;m„ ^H^^osiflty ami reli w i t a ' o o n are kmt th® o^etusive dcMirairt of n urses m ^Ifyeeiofet settiinps - they arcs t lie everyday ^ n m s e m?eds &f the populat m ami as a iso^^eouo^co the r«?r*oot!ii^ibS8i1 an nurses.
group in Sydney (Stage I). A n o t h e r 21 nurses p a r t i c i p a t e d in focus g r o u p s in Adelaide and Melbourne (Stage 2). Lach nurse was individually invited to participate in the study. Selection was informed by identification by the chief investigator of subject matter experts based upon an individual's e x t e n s i v e clinical n u r s i n g
role of t h e nurse in r e h a b i l i t a t i o n has
Waters and Luker (1996) interviewed 56
been debated in the published literature
experience in the field of rehabilitation
staff from various disciplines working in
nursing, enthusiasm for participation and
over many years and rehabilitation nurs-
rehabilitation wards for the elderly.
The
demonstrated commitment to the devel-
ing is p o r t r a y e d at various stages of its
role of t h e nurses was described u n d e r
opment of rehabilitation nursing practice
development around the world.
three categories - general maintenance,
through attendance at conferences, semi-
T h e United States of America has pro-
specialist and carry-on. General mainte-
nars a n d / o r p o s t g r a d u a t e s t u d i e s . T h e
duced a plethora of rehabilitation nursing
n a n c e w o r k i n c l u d e d c o n t i n e n c e , skin
participants are described in Table I.
d o c u m e n t a t i o n . However, while these
care, personal hygiene, dressing and mov-
T h e i n - d e p t h interview s c h e d u l e in
publications exist, they seem to have had
ing. Their specialist role covered the areas
stage 1 consisted of three types of inter-
limited impact elsewhere in the world.
of continence and skin care, while their
views with a m i n i m u m total i n t e r v i e w
Outside the United States, there seems to
carry-on role was in the areas of dressing
time of six hours lor each nurse. T h e first
be a g r e e m e n t that the potential role of
and moving.
t h e nurse in r e h a b i l i t a t i o n is y e t to h e
interview consisted of open-ended ques-
T h i s paper reports on part of the find-
tions asking the nurses about what they
r e a l i s e d . T h i s is e v i d e n c e d in several
ings of a recent research project (Pryor &
did in the rehabilitation setting. At the
reviews of t h e l i t e r a t u r e ( M y c o 1984,
Smith 2000) that identified a rehabilita-
s e c o n d i n t e r v i e w t h e nurses discussed
O'Connor
1997,
tive nursing a p p r o a c h as o n e of seven
noteworthy incidents from their practice.
from
domains in a framework for rehabilitation
At the third interview each nurse was
interested parties (Williams 1984, Waters
nursing practice. It is suggested that this
invited to record aspects of his/her prac-
1986) a n d r e s e a r c h ( H e n d e r s o n el al
approach is not the exclusive domain of
tice that they considered would fit u n d e r
1990, G i b b o n 1 9 9 1 , S h e p p a r d
1994,
rehabilitation nurses a n d that all nurses
a s e r i e s of s e v e n h e a d i n g s . It w a s
W a t e r s 1994, W a t e r s & L u k e r 1 9 9 6 ) .
should be prepared to adopt a rehabilita-
explained that the headings were not
Despite this repeated a c k n o w l e d g e m e n t
tive a p p r o a c h w h e n a p p r o p r i a t e . T h e
intended to be mutually exclusive. T h e s e
of nursing's failure to realise its potential,
seven domains are: t h e rehabilitative
h e a d i n g s w e r e t h e n a m e s of B e n n e r ' s
1 9 9 3 , N o l a n et al
Kirkevold 1997), c o m m e n t a r i e s
a clear research based framework for the d e v e l o p m e n t of nursing's rehabilitation
TABLE 1: STUDY PARTICIPANTS Stage 1
Stage 2
Female
11
16
practice in rehabilitation settings is pro-
Male
2
CJI
potential is still missing.
vided by the work of Mayer, Buckley and
Average age
41.5 yrs
37.9 yrs
W h i t e (1990), D o u g a n (1991), Brillhart
Hospital trained
9
19
University or college prepared
4
2
Completed rehabilitation course
6
12
Average t i m e as RN
17 yrs
15.5 yrs
Average experience in rehabilitation
9 yrs
7.2 yrs
Some insight into how nurses actually
a n d Sills (1994) and W a t e r s and Luker (1996). In an observational study of the d i r e c t c a r e p r o v i d e d to r e h a b i l i t a t i o n patients, M a y e r et al (1990) report that registered nurses spent most of their time 12
Collegian Vol 9 N o 2 2002
(1984) domains of nursing practice. Following this, they were invited to code the written transcripts of their own noteworthy incidents using the sub-headings used in the previous exercise. Instructions on h o w to d o this were p r o v i d e d and the i n t e r v i e w e r s t a y e d w i t h e a c h nurse to provide
additional
clarification
if
required. O n c e again, it was explained thai the headings were not mutually exclusive. Twelve ol the thirteen nurses completed the entire interview schedule. T h e m a t i c analysis of the data was conducted. Various existing frameworks were c o n s i d e r e d in light of the p r e l i m i n a r y analysis. Of these Ben tier's d o m a i n s ol nursing practice (1984) appeared to have the most potential and were used as an acceptable beginning framework for the analysis of data. (For further detail of the interview schedule and data analysis see Pryor& Smith 2000.)
performed, adopting a wellness model of
( P r y o r & S m i t h 2000 p20).
care with the specific intent of facilitating
T h e rehabilitative a p p r o a c h is about
Findings
the patient's rehabilitation and discharge
the way the rehabilitation nurses concep-
Seven domains for the specialty practice
from the service. Adopting this approach
tualise and think about their practice and
of rehabilitation nursing as well as the rela-
nurses locus on the person's abilities, to
the people they interact with.
tionship between those domains were
see possibilities rather than focusing on
mindset that informs all other actions. It is
identified (see Table 2). T h e relationship
disabilities. To c o n t r i b u t e effectively to
greater than the cliche of 'holistic' nursing
depicts two domains as c o m p r i s i n g the
the facilitation of a person's rehabilitation,
care a n d more than a c o n s i d e r a t i o n of
what of rehabilitation nursing practice.
nurses must possess a repertoire of inter-
v i e w i n g the person in their c o n t e x t . It
It is a
Interwoven throughout these two domains
p e r s o n a l skills a n d t e c h n i q u e s ,
from
appears to be a factor of an interaction
are the remaining five domains which rep-
which to choose when approaching each
b e t w e e n t h e p e r s o n a l i t y of t h e nurse,
resent the h o w of rehabilitation nursing.
nurse-patient interaction. T h e choice of
their learning experiences, an openness to
T h e domains are not mutually exclusive as
specific skills and t e c h n i q u e s is b a s e d
build a relationship, and an appreciation
a n y t h i n g the nurse d o e s will typically
u p o n an a s s e s s m e n t of t h e p a t i e n t in
of all people as worthy of their attention.
demonstrate features of several domains.
h i s / h e r c o n t e x t at t h a t p o i n t in t i m e ,
T h i s e n a b l e s a special place w h e r e the
Of particular interest is the rehabilita-
being mindful of the patient's long term
nurse and the patient (and significant oth-
tive a p p r o a c h . T h e nurses in this study
and short term goals. It also encompasses
ers) can meet to foster rehabilitation.
adopted the rehabilitative approach in all
particular nursing activities that facilitate
their patient-nurse interactions. This
rehabilitation through the development of
domain is about a style or way of doing
therapeutic relationships with individuals,
R e h a b i l i t a t i o n is t y p i c a l l y e m p h a s i s e d
nursing, rather than the actual activities
and the creation of a rehabilitative milieu.
more as an outcome of health care than a
performed by the nurse. T h e focus is on
Generally, the rehabilitative approach is
feature of the process. It is usually associ-
the way nurses approach their patients.
associated with the nurse's ability to see
ated with the promotion of sell care and
'the big picture', to possess 'a sense of that
independence (sec Pryor 1999b) and this
person' or to possess 'a sense of the whole'
is reflected in t h e various m e a s u r e s of
T h e rehabilitative approach relates to: the manner in which nursing activities are
Discussion
Junction used to determine the effectiveTABLE 2: D O M A I N S OF REHABILITATION NURSING PRACTICE The ' H o w ' of Rehabilitation Nursing D1 The rehabilitative approach
The ' W h a t ' of Rehabilitation Nursing D4
Administering and monitoring therapeutic interventions
D2 The teaching and coaching role D3 Observation, assessment and interpretation D6 Management, advocacy and co-ordination role D7 Monitoring and ensuring the quality of health care practices
ness of rehabilitation services. T h e rehabilitative
approach
clearly
situates
rehabilitation within the process of nursing. It refers to the how and why of nursing, r a t h e r than the w h a t . It d e s c r i b e s h o w nurses c o n t r i b u t e to the rehabilita-
D5
Management of rapidly changing situations
tion of a person and as such has a place across the entire continuum of care. T h e belief t h a t r e h a b i l i t a t i o n is an important philosophy for all health care providers is g r o w i n g in popularity. It is Collegian Vol 9 No 2 2002
13
s u p p o r t e d by b o t h medical (see Smith
facilitate rehabilitation. She n o t e d that
1990) a n d n u r s i n g c o m m e n t a t o r s (see
"those enabling care actions or decisions
fortably with the rehabilitative approach.
W a t e r s 1986, Edwards & tCittier 1 9 9 1 ,
undertaken by the rehabilitation nurse ...
She refers to these functions as 'interpre-
Gibbon & T h o m p s o n 1992, Flannery et al
functions of nursing would overlap c o m -
resulted in clients' adapting to, participat-
tive' a n d ' c o n s o l i n g ' . T h e i n t e r p r e t i v e
1994, H e r m a n n & Bays 1994, H o e m a n
ing in and benefiting from the rehabilita-
function is about more than just leaching,
1996, Pryor 1999a and 1999b) as well as
tion
experiencing
it talks about helping patients and fami-
policy makers (see N S W Health Depart-
congruence with the process" (Thompson
lies understand the ramifications of stroke
ment 1995). Current demographic trends,
1990 p ! 9 8 ) . Similarly, in this study sever-
on their lives. T h e consoling function s h e
technological advances, shortened length
al nurses acknowledged that before any-
notes is closely related to the interpretive
of acute hospitalisation and the commu-
t h i n g else t h e y f r e q u e n t l y n e e d e d to
function, but with an emphasis on "facili-
nity's expectations for a high quality of
explain t h e n a t u r e ol r e h a b i l i t a t i o n t o
tating a normal grieving process, promot-
life situate r e h a b i l i t a t i o n as a valuable
p a t i e n t s a n d t h e i r families. O n e nurse
ing h o p e , a n d p r e v e n t i n g d e p r e s s i o n "
philosophy for all health care services.
told this story:
(Kirkevold 1997 p58).
program,
and
T h e early implementation of the reha-
if is really putting a jigsaw puzzle together for
N u r s e s in t h e p r e s e n t s t u d y s p o k e
bilitation philosophy translates into better
the patient and their relatives. Ij you ask the
about a similar dimension of their relationships with patients. T h e y s p o k e of
patient outcomes. T h e r e is a widespread
father what they want for their son after a
belief within the rehabilitation community
brain injury, they will say 'walk'. But to
preserving personhood, giving hope,
that rehabilitation is optimised when com-
explain for that son to he able to walk it means
instilling optimism, reducing frustration
menced early in the episode of health care
they have to have hip balance and then stand
and reducing fear. O n e nurse explained a
(Boroch 1976, Strykcr 1977, Waters 1986,
balance, and sitting balance and then standing
good relationship as:
H a n l o n & Sharkey 1989, P e n n i n g t o n &
for a short period of time, and then taking a
. . . one based on trust. Then they will have
Burry 1990, G i b b o n & T h o m p s o n 1992,
step. It is explaining the steps to independence
confidence in you and they will believe you
Nolan & Nolan 1998 and 1999). Nonethe-
... We can see what t/je steps are that will come
when you tell them they are making gains. It
less, mainstream nursing literature d o e s
next, but they don't realise what they are.
is not just words - 'aren't you doing well
Like T h o m p s o n ( 1 9 9 0 ) , C a m p b e l l
today' - anyone tan say that, whether you
not portray an awareness of this benefit. T h e notion of a rehabilitative nursing
(1999) reports a role for nurses in facili-
a p p r o a c h as c a p t u r e d in this study is a
tating patients' participation in rehabilita-
new concept in the literature. It describes
tion.
In
her
study
of
nurses
in a
mean it or not h something else. T h e development ol our understanding of the rehabilitative approach is also
an approach that rehabilitation nurses use
rehabilitation setting in Tasmania, C a m p -
supported
as they interact with patients and fami-
bell (1999 p33) notes that nurses encul-
researchers. In particular, Morse's w o r k
lies, which is very person centred. Fur-
turate patients "into the rehab way". T h e
on p a t i e n t s ' e x p e r i e n c e s of ' p r e s e r v i n g
t h e r m o r e , it is s u g g e s t e d t h a t
this
nurses in her ethnographic study support-
self following injury or c h r o n i c illness
approach is central to the effectiveness of
ed the belief that rehabilitation nursing is
(sec Ivlorse & O'Brien 1995, Morse 1997)
rehabilitative nursing practice.
different to acute care nursing, especially
a n d C h a r m a z ' s ( 1 9 8 3 , 1985) w o r k o n
in the way t h e y a p p r o a c h p a t i e n t care
s t r u g g l i n g for self in t h e p r e s e n c e of
and interact with their patients.
chronic illness identify a need for a role
A person-centred approach to rehabilitation nursing is supported by literature spanning 15 years. Waters' (1986) refer-
Patients have also identified that nurs-
ence to rehabilitation as a "whole process
ing is different in rehabilitation settings.
of enabling and facilitating" followed by
In Sheppard's (1994) study, patients in
the c o m m e n t that "the essence of rehabil-
England reported that the nurses in reha-
i t a t i o n s h o u l d p e r m e a t e all n u r s i n g
bilitation weren't like hospital nurses. T h e
actions" is suggestive of a broad approach
understanding and patience of the nurses
to rehabilitation (Waters 1986 p i 7 ) . She
was reported as giving the patients confi-
by
the
work
of
other
for nursing to work in partnership w i t h people through rehabilitation. T h e need for nursing to develop it's psychosocial dimension of practice in rehabilitation is highlighted by Nolan and Nolan (1998) in their review of the literature and nursing curriculum in F.ngland (see also Nolan e t a l 1997).
(Waters 1986 p20) cites Pearson (1985)
dence and h e l p e d restore their sense of
as d e s c r i b i n g " t h e nurse's u n i q u e a n d
sell. T h e p a t i e n t s in Duffy, Payne and
In summary, it is fair to say that while
exclusive role as h e l p i n g the patient to
Boords (1996) Australian study reported
the notion of a rehabilitative approach as
tap the power to heal that lies within him
a generally positive experience of nursing
uncovered in this study is put forward as
a n d to p r o m o t e his c o n t i n u o u s g r o w t h
in a rehabilitation setting. In particular,
a new c o n c e p t in the literature, without
and development". This is similar to the
t h e p a t i e n t s "valued t h e i n t e r p e r s o n a l
doubt there is evidence that others have
nurses' description of their rehabilitative
approach and attitude of the nurses dur-
described some of its c o m p o n e n t parts.
approach. O n e nurse explained "rehabili-
ing interventions and interactions" as well
N o t w i t h s t a n d i n g this, Australian nurses
tation nurses empower the patient to take
as the nurses' vigilance (Duffy et al p29).
r e s p o n s i b i l i t y for their o w n rehabilitation." A n o t h e r s p o k e a b o u t forming "a bond" that "facilitates the process".
Kirkevold's (1997) unique approach to conceptualising the nurse's role in stroke
h a v e c a p t u r e d t h e r i c h n e s s of t h e i r approach through the provision
of
detailed and vivid accounts of their prac-
rehabilitation adds another dimension to
tice that provides a unique window Irom
T h o m p s o n (1990), in her exploration
our understanding of rehabilitation nurs-
w h i c h to u n d e r s t a n d t h e r e h a b i l i t a t i v e
of the culture in rehabilitation settings,
ing. W h i l e she is not explicit that a reha-
approach. Never before has this w i n d o w
adds to our understanding of how nurses
bilitative approach exists, two of her four
been opened so wide.
14
Collegian Vol 9 No2 2000
Implications for nursing
p r i a t e to facilitate o p t i m a l p a t i e n t o u t -
W h i l e t h e i m p l i c a t i o n s of this s t u d y for
c o m e s . T h i s is new t h i n k i n g in nursing
rehabilitation nursing are obvious, it must
and as a profession we are negligent if we
be stressed t h a t there are major implica-
d o not pursue a greater understanding of
tions for all nurses. Nursing as a whole can
the range of nursing styles or approaches
benefit from these findings as we prepare to
and the benefits t h e s e may bring to our
meet the health care needs of an ageing and
patients.
more disabled population. T h e lindings of
approach will be invaluable in the care of
Adopting
a
rehabilitative
this study provide evidence that multiple
Australia's a g e i n g p o p u l a t i o n as n u r s e s
approaches to nursing care exist and can be
strive to support the maintenance of func-
used to improve patient outcomes.
tion and preservation of self.
T h e d e v e l o p m e n t of
rehabilitative
Mayer G, Buckley R, White T 1990 Direct nursing care given to patients in a subacute rehabilitation centre. Rehabilitation Nursing l5(2):86-88 Morse J M, O'Brien B 1995 Preserving self from victim, to patient, to disabled person. Journal oj Advanced Nursing 2 1:886-896 Morse J M 1997 Responding to threats to integrity. Advances in Nursing Science I9(4):2 I -36 Myco I' 1984 Stroke and its rehabilitation: the perceived role of the nurse in medical and nursing literature. Journal of Advanced Nursing 9:429439 New South Wales Health Department 1995 A policy framework for medical rehabilitation in NSW. New South Wales Health Department, North Sydney Nolan M, Nolan J, Booth A 1997 Preparation for mulii professional/agency health care practice. The nursing contribution to rehabilitation within the mullidisciplinary team: literature review and curriculum analysis. University of Sheffield, Sheffield Nolan M, Nolan J 1998 Rehabilitation: realizing the potential nursing contribution. British Journal of Therapy and Rehabilitation 5(3): 120-1 24 Nolan M, Nolan J 1999 Rehabilitation, chronic illness and disability: the missing elements in nurse e d u c a t i o n . Journal oj Advanced Nursing 29(4):958-966
skills in all nurses is essential in light of
References
the shrinking health dollar and the short-
Australian Institute of Health and Welfare 1998 Australia's health I99H. Australian Institute of I Icalth and Welfare, Canberra Bcnncr I1 1984 From novice to expert, excellence and power in clinical nursing practice. Addison-Wesley, Menlo Park CA Boroch R M 1976 Hemeiits of rehabilitation in iiiirsmij.an introduction. C V Mosby, St Louis Brillhan B, Sills l: 1994 Analysis of the roles and responsibilities of rehabilitation nursing staff. Rehabilitation Nursing 19(3): 145-1 50 Campbell M 1999 Time and motion. How nurses workO ' C o n n o r S E 1993 Nursing and rehabilitation: ing within a rehabilitation ward view their practice; an the interventions of nurses in stroke patient ethnographic study. U n p u b l i s h e d Bachelor uf care. Journal of Clinical Nursing 2:29-34 Nursing thesis, University of Tasmania Penington C R, Bttrry H C 1990 Introduction to medCharmaz K. 1983 Loss of self: a fundamental form ical rehabilitation: an Australian perspective. Melof suffering in the chronically il! Sociology oj bourne University Press, Melbourne Health and illness 5:168-195 Pryor J 1999a How prepared are nurses for practice in a Charmaz K 1985 Struggling for a self: identity rehabilitation setting? M o n o g r a p h Series N o 1. levels of the chronically ill. Research Sociology oj Rehabilitation Nursing Research and DevelopHeaithCare 6:283-321 ment Unit, Royal Rehabilitation Centre SydD o u g a n D 1991 An analysis of rehabilitation ney nurses' time allocation. Rehabilitation Nursing Pryor J 1999b N u r s i n g and rehabilitation, hi: 16(0:37-39 Pryor J (ed) Rehabilitation - a vital nursing function. Duffy L, Payne M, Boord N 1996 Patients' experiences of nursing care during rehabilitation a phenomena- Royal College of Nursing, Australia, Canberra logical study. Royal C o l l e g e of N u r s i n g , A C T 1-13 Australia, Canberra Pryor J, Smith G 2000 A framework for the specialty Edwards P L, Kittlcr A W 1991 Integrating rehaPractice oj rehabilitation nursing. Monograph Series bilitation content into nursing curricula. RehaN o 4. Rehabilitation Nursing Research and bilitation Nursing !6(2):33-45 Development Unit, Royal Rehabilitation CenFlannery J, Korchek S, Behm L 1994 A national tre Sydney survey of neuroscience and rehabilitation curSheppard B 1994 Patients' views of rehabilitation. ricula in NLN-approved programs: a need for Nursing Standard 91 \{))27-30 change? Journal of Nursing Education 33(3): I 34Smith D 1990 Foreword. In: P e n i n g t o n G R, 136 Burry H C (eds) Introduction to rehabilitation: an Gibbon B 1991 A reassessment of nurses' attitudes Australian perspective. M e l b o u r n e U n i v e r s i t y t o w a r d s stroke p a t i e n t s in general medical Press, Carlton:v-vi wards. Journal oj Advanced Nursing 16:1 336-1 342 Stryker R I 977 Rehabilitative aspects oj acute and Gibbon B, Thompson A 1992 T h e role of nurses chronic nursing care. W B Sanders, Philadelphia in rehabilitation. Nursing Standard 6(36):32-35 I hompson I L C 1990 A qualitative investigation of Hanlon D, Sharkey F L 1989 Professional practice rehabilitation nursing care in an inpatient rehabilitation of rehabilitation nursing. In Dittmar S S (ed), unit using Leininger's theory LInpublished PhD theRehabilitation nursing- process and application. sis, Wayne State LIniversity, Detroit, Michigan Mosby, St Louis Waters K R 1986 T h e role of nursing in rehabiliHenderson E J, Morrison J A, Young E A, Penttation. CARE_Science and Practice 5{i): 17-2 t land B 1990 T h e nurse in rehabilitation after Waters K R 1994 G e l l i n g dressed in the early severe brain injury. Clinical Rehabilitation 4:167morning: styles of staff/patient interaction on 172 rehabilitation hospital wards for elderly people. Hermann C P, Bays C L 1994 Professional rehaJournal of Advanced Nursing 19:239-248 bilitation nursing: an elective course for nursing Waters K R, Luker K A 1996 Staff perceptions on students. Rehabilitation Nursing 19(3): 160-168 the role of the nurse in rehabilitation wards for H o e m a n S 1996 Rehabilitation nursing: process and elderly people. Journal of Clinical Nursing 5:105application 2nd ed. Mosby, St Louis 1 14 Kirkcvold M 1997 T h e role of nursing in the Williams S L 1984 Role of t h e rehabilitation rehabilitation of acute stroke patients: towards nurse. The New Zealand Nursing Journal Decema unified theoretical perspective. Advances in ber^. Nursing Science 19(4):55-64
e n e d l e n g t h of i n p a t i e n t stay. For m a n y nurses rehabilitation is an integral aspect of t h e i r p r a c t i c e , e v e n w h e n t h e y h a v e had no formal exposure to rehabilitation education or the literature. This, however, is far Irom the norm. T h e lime has c o m e to situate rehabilitation in all undergraduate and postgraduate nursing programs as we seek to prepare nurses to provide nursing care to an Australian population that is ageing and includes an increasing numb e r of p e o p l e w i t h c h r o n i c illness a n d functional limitations.
Limitations of the study Like all research this study has limitations. T h e first limitation relates to the number of research participants. W h i l e this numb e r (n = 34) is c o n s i d e r e d r e a s o n a b l e for the qualitative design of this study, further data is n e e d e d to s t r e n g t h e n these findings. S u b s e q u e n t studies should seek to include nurses involved in n o n - i n p a t i e n t rehabilitation as their views were not considered in this study. In addition, the data collected in this study pertains only to the nurses' reports of their own practice. It has not sought to validate t h e nurses' r e p o r t with observat i o n of t h e i r a c t u a l p r a c t i c e .
Further
research to validate the nurses' reports with o b s e r v a t i o n of practice will enrich our u n d e r s t a n d i n g of rehabilitation nursing practice. This may also uncover addit i o n a l a s p e c t s of r e h a b i l i t a t i o n
nursing
practice that have not been reported here.
Conclusion T h e explicit description of a rehabilitative a p p r o a c h to nursing c o n t a i n e d in t h e s e findings should not be seen as the exclusive property of rehabilitation nurses. T h e rehabilitative a p p r o a c h belongs in every nurses' toolkit, to draw upon w h e n a p p r o -
Collegian Vol 9 N o 2 2002
15
Rehabilitative nursing: a core nursing ^-^ function across all settings
Nurses are challenged to meet the changing health care needs of the Australian population as they live longer and experience increasing levels of disability. This paper reports on part of the findings of a recent study of rehabilitation nurses and suggests that the findings are relevant to all nurses as they attempt to meet this challenge. Thirty-four registered nurses working in rehabilitation settings in three states of Australia participated in the study. In-depth interviews and focus group discussions were used to collect data and validate interpretations. From the seven domains of practice identified in the findings, this paper discusses only one, the rehabilitative approach. This domain begins to capture the how and why of rehabilitation nursing practice, rather than the what. The rehabilitative approach is about the way the nurses conceptualise and think about their practice and the people they interact with. It is greater than the cliche of holistic care. Given that rehabilitation is a process that the patient undergoes and is not setting specific, the findings of this study offer direction to all nurses in supporting the rehabilitation of their patients. The study, the first of its kind in Australia, provides valuable guidance for the designers of undergraduate and postgraduate nursing programs in Australia. By Julie Pryor • Key words: rehabilitation, nursing approaches, clinical decision making, continuum of care
Introduction
they are the everyday service needs of the population
Nursing is a human science - it is about people's lives:
and as a consequence the responsibility of all nurses.
lives thai are sometimes lived in tired, broken or shat-
Australian nurses are beginning to identily and
tered bodies. Australia's population is not only ageing,
articulate the valuable contribution that a rehabilita-
but t h e p r o p o r t i o n of t h e p o p u l a t i o n living w i t h
tive nursing approach can make to the recipients of
chronic illness and disability is rising (Australian Insti-
nursing care across all health care settings regardless
tute of H e a l t h and Welfare 1998) and as a c o n s e -
of their age or diagnostic category. T h e develop-
quence more Australians are living in tired, broken or
ment of nursing knowledge and skills in rehabilita-
shattered bodies than ever before, Evidence of the real
tion is an imperative given the real health profile of
h e a l t h profile of this c o u n t r y can be found in the
Australia's population, ie increasing disability and
wards of acute hospitals, e m e r g e n c y d e p a r t m e n t s ,
increased life e x p e c t a n c y (Australian Institute of
operating theatres and in the caseload of all human
Health and Welfare 1998). T h e very nature of our
services (Australian Institute of Health and Welfare
n u r s i n g p r a c t i c e n e e d s to he c h a l l e n g e d , not so
1998). Aged care, disability and rehabilitation are not
m u c h with a focus on w h a t w e d o , b u t w i t h an
the exclusive domain of nurses in specialist settings -
examination of how we do it. This paper introduces
Julie Pryor RN CM BA MN MRCNA, Senior Lecturer in Rehabilitation Nursing, School of Nursing, Family and Community Health, University of Western Sydney Email: [email protected] Collegian Vol 9 N n 2 2002
11
[REFEREED ARTICLE]
the notion of a style of nursing recently
providing respiratory and psychosocial
approach,- t h e l e a c h i n g and c o a c h i n g
described as the rehabilitative approach.
care. Dougan (1991) concluded that nurs-
role,- observation, assessment a n d inter-
Drawing on recent research findings, the
es undertake much of the work formerly
pretation,- administering and m o n i t o r i n g
nature ol the rehabilitative approach will
assigned to other members of the team,
t h e r a p e u t i c interventions,- m a n a g e m e n t
be explained and its application across
for example, physical therapy, occupa-
of rapidly changing situations,- manage-
settings discussed.
tional t h e r a p y a n d p s y c h o l o g y . From
ment, advocacy and co-ordination role,
diaries kept by the nurses thai recorded
and monitoring and ensuring the quality
Background to the research
the duration and type of work activities,
of health care practices.
W i t h little r e s e a r c h - b a s e d e v i d e n c e to
Brillhart and Sills (1994) concluded that
inform the development of rehabilitation
the roles and responsibilities of registered
nursing in Australia, an interpretive study
nurses fell into four categories - direct
A total of 34 registered nurses working in
ol the registered nurse working in reha-
patient care, indirect patient care, unit
rehabilitation settings in Australia partici-
bilitation settings was u n d e r t a k e n . T h e
management and unaccounted for time.
pated in the study. Thirteen participated
Method
in one to o n e i n - d e p t h interviews a n d eight of this group participated in a locus
.*H^3ff>i ra;m„ ^H^^osiflty ami reli w i t a ' o o n are kmt th® o^etusive dcMirairt of n urses m ^Ifyeeiofet settiinps - they arcs t lie everyday ^ n m s e m?eds &f the populat m ami as a iso^^eouo^co the r«?r*oot!ii^ibS8i1 an nurses.
group in Sydney (Stage I). A n o t h e r 21 nurses p a r t i c i p a t e d in focus g r o u p s in Adelaide and Melbourne (Stage 2). Lach nurse was individually invited to participate in the study. Selection was informed by identification by the chief investigator of subject matter experts based upon an individual's e x t e n s i v e clinical n u r s i n g
role of t h e nurse in r e h a b i l i t a t i o n has
Waters and Luker (1996) interviewed 56
been debated in the published literature
experience in the field of rehabilitation
staff from various disciplines working in
nursing, enthusiasm for participation and
over many years and rehabilitation nurs-
rehabilitation wards for the elderly.
The
demonstrated commitment to the devel-
ing is p o r t r a y e d at various stages of its
role of t h e nurses was described u n d e r
opment of rehabilitation nursing practice
development around the world.
three categories - general maintenance,
through attendance at conferences, semi-
T h e United States of America has pro-
specialist and carry-on. General mainte-
nars a n d / o r p o s t g r a d u a t e s t u d i e s . T h e
duced a plethora of rehabilitation nursing
n a n c e w o r k i n c l u d e d c o n t i n e n c e , skin
participants are described in Table I.
d o c u m e n t a t i o n . However, while these
care, personal hygiene, dressing and mov-
T h e i n - d e p t h interview s c h e d u l e in
publications exist, they seem to have had
ing. Their specialist role covered the areas
stage 1 consisted of three types of inter-
limited impact elsewhere in the world.
of continence and skin care, while their
views with a m i n i m u m total i n t e r v i e w
Outside the United States, there seems to
carry-on role was in the areas of dressing
time of six hours lor each nurse. T h e first
be a g r e e m e n t that the potential role of
and moving.
t h e nurse in r e h a b i l i t a t i o n is y e t to h e
interview consisted of open-ended ques-
T h i s paper reports on part of the find-
tions asking the nurses about what they
r e a l i s e d . T h i s is e v i d e n c e d in several
ings of a recent research project (Pryor &
did in the rehabilitation setting. At the
reviews of t h e l i t e r a t u r e ( M y c o 1984,
Smith 2000) that identified a rehabilita-
s e c o n d i n t e r v i e w t h e nurses discussed
O'Connor
1997,
tive nursing a p p r o a c h as o n e of seven
noteworthy incidents from their practice.
from
domains in a framework for rehabilitation
At the third interview each nurse was
interested parties (Williams 1984, Waters
nursing practice. It is suggested that this
invited to record aspects of his/her prac-
1986) a n d r e s e a r c h ( H e n d e r s o n el al
approach is not the exclusive domain of
tice that they considered would fit u n d e r
1990, G i b b o n 1 9 9 1 , S h e p p a r d
1994,
rehabilitation nurses a n d that all nurses
a s e r i e s of s e v e n h e a d i n g s . It w a s
W a t e r s 1994, W a t e r s & L u k e r 1 9 9 6 ) .
should be prepared to adopt a rehabilita-
explained that the headings were not
Despite this repeated a c k n o w l e d g e m e n t
tive a p p r o a c h w h e n a p p r o p r i a t e . T h e
intended to be mutually exclusive. T h e s e
of nursing's failure to realise its potential,
seven domains are: t h e rehabilitative
h e a d i n g s w e r e t h e n a m e s of B e n n e r ' s
1 9 9 3 , N o l a n et al
Kirkevold 1997), c o m m e n t a r i e s
a clear research based framework for the d e v e l o p m e n t of nursing's rehabilitation
TABLE 1: STUDY PARTICIPANTS Stage 1
Stage 2
Female
11
16
practice in rehabilitation settings is pro-
Male
2
CJI
potential is still missing.
vided by the work of Mayer, Buckley and
Average age
41.5 yrs
37.9 yrs
W h i t e (1990), D o u g a n (1991), Brillhart
Hospital trained
9
19
University or college prepared
4
2
Completed rehabilitation course
6
12
Average t i m e as RN
17 yrs
15.5 yrs
Average experience in rehabilitation
9 yrs
7.2 yrs
Some insight into how nurses actually
a n d Sills (1994) and W a t e r s and Luker (1996). In an observational study of the d i r e c t c a r e p r o v i d e d to r e h a b i l i t a t i o n patients, M a y e r et al (1990) report that registered nurses spent most of their time 12
Collegian Vol 9 N o 2 2002
(1984) domains of nursing practice. Following this, they were invited to code the written transcripts of their own noteworthy incidents using the sub-headings used in the previous exercise. Instructions on h o w to d o this were p r o v i d e d and the i n t e r v i e w e r s t a y e d w i t h e a c h nurse to provide
additional
clarification
if
required. O n c e again, it was explained thai the headings were not mutually exclusive. Twelve ol the thirteen nurses completed the entire interview schedule. T h e m a t i c analysis of the data was conducted. Various existing frameworks were c o n s i d e r e d in light of the p r e l i m i n a r y analysis. Of these Ben tier's d o m a i n s ol nursing practice (1984) appeared to have the most potential and were used as an acceptable beginning framework for the analysis of data. (For further detail of the interview schedule and data analysis see Pryor& Smith 2000.)
performed, adopting a wellness model of
( P r y o r & S m i t h 2000 p20).
care with the specific intent of facilitating
T h e rehabilitative a p p r o a c h is about
Findings
the patient's rehabilitation and discharge
the way the rehabilitation nurses concep-
Seven domains for the specialty practice
from the service. Adopting this approach
tualise and think about their practice and
of rehabilitation nursing as well as the rela-
nurses locus on the person's abilities, to
the people they interact with.
tionship between those domains were
see possibilities rather than focusing on
mindset that informs all other actions. It is
identified (see Table 2). T h e relationship
disabilities. To c o n t r i b u t e effectively to
greater than the cliche of 'holistic' nursing
depicts two domains as c o m p r i s i n g the
the facilitation of a person's rehabilitation,
care a n d more than a c o n s i d e r a t i o n of
what of rehabilitation nursing practice.
nurses must possess a repertoire of inter-
v i e w i n g the person in their c o n t e x t . It
It is a
Interwoven throughout these two domains
p e r s o n a l skills a n d t e c h n i q u e s ,
from
appears to be a factor of an interaction
are the remaining five domains which rep-
which to choose when approaching each
b e t w e e n t h e p e r s o n a l i t y of t h e nurse,
resent the h o w of rehabilitation nursing.
nurse-patient interaction. T h e choice of
their learning experiences, an openness to
T h e domains are not mutually exclusive as
specific skills and t e c h n i q u e s is b a s e d
build a relationship, and an appreciation
a n y t h i n g the nurse d o e s will typically
u p o n an a s s e s s m e n t of t h e p a t i e n t in
of all people as worthy of their attention.
demonstrate features of several domains.
h i s / h e r c o n t e x t at t h a t p o i n t in t i m e ,
T h i s e n a b l e s a special place w h e r e the
Of particular interest is the rehabilita-
being mindful of the patient's long term
nurse and the patient (and significant oth-
tive a p p r o a c h . T h e nurses in this study
and short term goals. It also encompasses
ers) can meet to foster rehabilitation.
adopted the rehabilitative approach in all
particular nursing activities that facilitate
their patient-nurse interactions. This
rehabilitation through the development of
domain is about a style or way of doing
therapeutic relationships with individuals,
R e h a b i l i t a t i o n is t y p i c a l l y e m p h a s i s e d
nursing, rather than the actual activities
and the creation of a rehabilitative milieu.
more as an outcome of health care than a
performed by the nurse. T h e focus is on
Generally, the rehabilitative approach is
feature of the process. It is usually associ-
the way nurses approach their patients.
associated with the nurse's ability to see
ated with the promotion of sell care and
'the big picture', to possess 'a sense of that
independence (sec Pryor 1999b) and this
person' or to possess 'a sense of the whole'
is reflected in t h e various m e a s u r e s of
T h e rehabilitative approach relates to: the manner in which nursing activities are
Discussion
Junction used to determine the effectiveTABLE 2: D O M A I N S OF REHABILITATION NURSING PRACTICE The ' H o w ' of Rehabilitation Nursing D1 The rehabilitative approach
The ' W h a t ' of Rehabilitation Nursing D4
Administering and monitoring therapeutic interventions
D2 The teaching and coaching role D3 Observation, assessment and interpretation D6 Management, advocacy and co-ordination role D7 Monitoring and ensuring the quality of health care practices
ness of rehabilitation services. T h e rehabilitative
approach
clearly
situates
rehabilitation within the process of nursing. It refers to the how and why of nursing, r a t h e r than the w h a t . It d e s c r i b e s h o w nurses c o n t r i b u t e to the rehabilita-
D5
Management of rapidly changing situations
tion of a person and as such has a place across the entire continuum of care. T h e belief t h a t r e h a b i l i t a t i o n is an important philosophy for all health care providers is g r o w i n g in popularity. It is Collegian Vol 9 No 2 2002
13
s u p p o r t e d by b o t h medical (see Smith
facilitate rehabilitation. She n o t e d that
1990) a n d n u r s i n g c o m m e n t a t o r s (see
"those enabling care actions or decisions
fortably with the rehabilitative approach.
W a t e r s 1986, Edwards & tCittier 1 9 9 1 ,
undertaken by the rehabilitation nurse ...
She refers to these functions as 'interpre-
Gibbon & T h o m p s o n 1992, Flannery et al
functions of nursing would overlap c o m -
resulted in clients' adapting to, participat-
tive' a n d ' c o n s o l i n g ' . T h e i n t e r p r e t i v e
1994, H e r m a n n & Bays 1994, H o e m a n
ing in and benefiting from the rehabilita-
function is about more than just leaching,
1996, Pryor 1999a and 1999b) as well as
tion
experiencing
it talks about helping patients and fami-
policy makers (see N S W Health Depart-
congruence with the process" (Thompson
lies understand the ramifications of stroke
ment 1995). Current demographic trends,
1990 p ! 9 8 ) . Similarly, in this study sever-
on their lives. T h e consoling function s h e
technological advances, shortened length
al nurses acknowledged that before any-
notes is closely related to the interpretive
of acute hospitalisation and the commu-
t h i n g else t h e y f r e q u e n t l y n e e d e d to
function, but with an emphasis on "facili-
nity's expectations for a high quality of
explain t h e n a t u r e ol r e h a b i l i t a t i o n t o
tating a normal grieving process, promot-
life situate r e h a b i l i t a t i o n as a valuable
p a t i e n t s a n d t h e i r families. O n e nurse
ing h o p e , a n d p r e v e n t i n g d e p r e s s i o n "
philosophy for all health care services.
told this story:
(Kirkevold 1997 p58).
program,
and
T h e early implementation of the reha-
if is really putting a jigsaw puzzle together for
N u r s e s in t h e p r e s e n t s t u d y s p o k e
bilitation philosophy translates into better
the patient and their relatives. Ij you ask the
about a similar dimension of their relationships with patients. T h e y s p o k e of
patient outcomes. T h e r e is a widespread
father what they want for their son after a
belief within the rehabilitation community
brain injury, they will say 'walk'. But to
preserving personhood, giving hope,
that rehabilitation is optimised when com-
explain for that son to he able to walk it means
instilling optimism, reducing frustration
menced early in the episode of health care
they have to have hip balance and then stand
and reducing fear. O n e nurse explained a
(Boroch 1976, Strykcr 1977, Waters 1986,
balance, and sitting balance and then standing
good relationship as:
H a n l o n & Sharkey 1989, P e n n i n g t o n &
for a short period of time, and then taking a
. . . one based on trust. Then they will have
Burry 1990, G i b b o n & T h o m p s o n 1992,
step. It is explaining the steps to independence
confidence in you and they will believe you
Nolan & Nolan 1998 and 1999). Nonethe-
... We can see what t/je steps are that will come
when you tell them they are making gains. It
less, mainstream nursing literature d o e s
next, but they don't realise what they are.
is not just words - 'aren't you doing well
Like T h o m p s o n ( 1 9 9 0 ) , C a m p b e l l
today' - anyone tan say that, whether you
not portray an awareness of this benefit. T h e notion of a rehabilitative nursing
(1999) reports a role for nurses in facili-
a p p r o a c h as c a p t u r e d in this study is a
tating patients' participation in rehabilita-
new concept in the literature. It describes
tion.
In
her
study
of
nurses
in a
mean it or not h something else. T h e development ol our understanding of the rehabilitative approach is also
an approach that rehabilitation nurses use
rehabilitation setting in Tasmania, C a m p -
supported
as they interact with patients and fami-
bell (1999 p33) notes that nurses encul-
researchers. In particular, Morse's w o r k
lies, which is very person centred. Fur-
turate patients "into the rehab way". T h e
on p a t i e n t s ' e x p e r i e n c e s of ' p r e s e r v i n g
t h e r m o r e , it is s u g g e s t e d t h a t
this
nurses in her ethnographic study support-
self following injury or c h r o n i c illness
approach is central to the effectiveness of
ed the belief that rehabilitation nursing is
(sec Ivlorse & O'Brien 1995, Morse 1997)
rehabilitative nursing practice.
different to acute care nursing, especially
a n d C h a r m a z ' s ( 1 9 8 3 , 1985) w o r k o n
in the way t h e y a p p r o a c h p a t i e n t care
s t r u g g l i n g for self in t h e p r e s e n c e of
and interact with their patients.
chronic illness identify a need for a role
A person-centred approach to rehabilitation nursing is supported by literature spanning 15 years. Waters' (1986) refer-
Patients have also identified that nurs-
ence to rehabilitation as a "whole process
ing is different in rehabilitation settings.
of enabling and facilitating" followed by
In Sheppard's (1994) study, patients in
the c o m m e n t that "the essence of rehabil-
England reported that the nurses in reha-
i t a t i o n s h o u l d p e r m e a t e all n u r s i n g
bilitation weren't like hospital nurses. T h e
actions" is suggestive of a broad approach
understanding and patience of the nurses
to rehabilitation (Waters 1986 p i 7 ) . She
was reported as giving the patients confi-
by
the
work
of
other
for nursing to work in partnership w i t h people through rehabilitation. T h e need for nursing to develop it's psychosocial dimension of practice in rehabilitation is highlighted by Nolan and Nolan (1998) in their review of the literature and nursing curriculum in F.ngland (see also Nolan e t a l 1997).
(Waters 1986 p20) cites Pearson (1985)
dence and h e l p e d restore their sense of
as d e s c r i b i n g " t h e nurse's u n i q u e a n d
sell. T h e p a t i e n t s in Duffy, Payne and
In summary, it is fair to say that while
exclusive role as h e l p i n g the patient to
Boords (1996) Australian study reported
the notion of a rehabilitative approach as
tap the power to heal that lies within him
a generally positive experience of nursing
uncovered in this study is put forward as
a n d to p r o m o t e his c o n t i n u o u s g r o w t h
in a rehabilitation setting. In particular,
a new c o n c e p t in the literature, without
and development". This is similar to the
t h e p a t i e n t s "valued t h e i n t e r p e r s o n a l
doubt there is evidence that others have
nurses' description of their rehabilitative
approach and attitude of the nurses dur-
described some of its c o m p o n e n t parts.
approach. O n e nurse explained "rehabili-
ing interventions and interactions" as well
N o t w i t h s t a n d i n g this, Australian nurses
tation nurses empower the patient to take
as the nurses' vigilance (Duffy et al p29).
r e s p o n s i b i l i t y for their o w n rehabilitation." A n o t h e r s p o k e a b o u t forming "a bond" that "facilitates the process".
Kirkevold's (1997) unique approach to conceptualising the nurse's role in stroke
h a v e c a p t u r e d t h e r i c h n e s s of t h e i r approach through the provision
of
detailed and vivid accounts of their prac-
rehabilitation adds another dimension to
tice that provides a unique window Irom
T h o m p s o n (1990), in her exploration
our understanding of rehabilitation nurs-
w h i c h to u n d e r s t a n d t h e r e h a b i l i t a t i v e
of the culture in rehabilitation settings,
ing. W h i l e she is not explicit that a reha-
approach. Never before has this w i n d o w
adds to our understanding of how nurses
bilitative approach exists, two of her four
been opened so wide.
14
Collegian Vol 9 No2 2000
Implications for nursing
p r i a t e to facilitate o p t i m a l p a t i e n t o u t -
W h i l e t h e i m p l i c a t i o n s of this s t u d y for
c o m e s . T h i s is new t h i n k i n g in nursing
rehabilitation nursing are obvious, it must
and as a profession we are negligent if we
be stressed t h a t there are major implica-
d o not pursue a greater understanding of
tions for all nurses. Nursing as a whole can
the range of nursing styles or approaches
benefit from these findings as we prepare to
and the benefits t h e s e may bring to our
meet the health care needs of an ageing and
patients.
more disabled population. T h e lindings of
approach will be invaluable in the care of
Adopting
a
rehabilitative
this study provide evidence that multiple
Australia's a g e i n g p o p u l a t i o n as n u r s e s
approaches to nursing care exist and can be
strive to support the maintenance of func-
used to improve patient outcomes.
tion and preservation of self.
T h e d e v e l o p m e n t of
rehabilitative
Mayer G, Buckley R, White T 1990 Direct nursing care given to patients in a subacute rehabilitation centre. Rehabilitation Nursing l5(2):86-88 Morse J M, O'Brien B 1995 Preserving self from victim, to patient, to disabled person. Journal oj Advanced Nursing 2 1:886-896 Morse J M 1997 Responding to threats to integrity. Advances in Nursing Science I9(4):2 I -36 Myco I' 1984 Stroke and its rehabilitation: the perceived role of the nurse in medical and nursing literature. Journal of Advanced Nursing 9:429439 New South Wales Health Department 1995 A policy framework for medical rehabilitation in NSW. New South Wales Health Department, North Sydney Nolan M, Nolan J, Booth A 1997 Preparation for mulii professional/agency health care practice. The nursing contribution to rehabilitation within the mullidisciplinary team: literature review and curriculum analysis. University of Sheffield, Sheffield Nolan M, Nolan J 1998 Rehabilitation: realizing the potential nursing contribution. British Journal of Therapy and Rehabilitation 5(3): 120-1 24 Nolan M, Nolan J 1999 Rehabilitation, chronic illness and disability: the missing elements in nurse e d u c a t i o n . Journal oj Advanced Nursing 29(4):958-966
skills in all nurses is essential in light of
References
the shrinking health dollar and the short-
Australian Institute of Health and Welfare 1998 Australia's health I99H. Australian Institute of I Icalth and Welfare, Canberra Bcnncr I1 1984 From novice to expert, excellence and power in clinical nursing practice. Addison-Wesley, Menlo Park CA Boroch R M 1976 Hemeiits of rehabilitation in iiiirsmij.an introduction. C V Mosby, St Louis Brillhan B, Sills l: 1994 Analysis of the roles and responsibilities of rehabilitation nursing staff. Rehabilitation Nursing 19(3): 145-1 50 Campbell M 1999 Time and motion. How nurses workO ' C o n n o r S E 1993 Nursing and rehabilitation: ing within a rehabilitation ward view their practice; an the interventions of nurses in stroke patient ethnographic study. U n p u b l i s h e d Bachelor uf care. Journal of Clinical Nursing 2:29-34 Nursing thesis, University of Tasmania Penington C R, Bttrry H C 1990 Introduction to medCharmaz K. 1983 Loss of self: a fundamental form ical rehabilitation: an Australian perspective. Melof suffering in the chronically il! Sociology oj bourne University Press, Melbourne Health and illness 5:168-195 Pryor J 1999a How prepared are nurses for practice in a Charmaz K 1985 Struggling for a self: identity rehabilitation setting? M o n o g r a p h Series N o 1. levels of the chronically ill. Research Sociology oj Rehabilitation Nursing Research and DevelopHeaithCare 6:283-321 ment Unit, Royal Rehabilitation Centre SydD o u g a n D 1991 An analysis of rehabilitation ney nurses' time allocation. Rehabilitation Nursing Pryor J 1999b N u r s i n g and rehabilitation, hi: 16(0:37-39 Pryor J (ed) Rehabilitation - a vital nursing function. Duffy L, Payne M, Boord N 1996 Patients' experiences of nursing care during rehabilitation a phenomena- Royal College of Nursing, Australia, Canberra logical study. Royal C o l l e g e of N u r s i n g , A C T 1-13 Australia, Canberra Pryor J, Smith G 2000 A framework for the specialty Edwards P L, Kittlcr A W 1991 Integrating rehaPractice oj rehabilitation nursing. Monograph Series bilitation content into nursing curricula. RehaN o 4. Rehabilitation Nursing Research and bilitation Nursing !6(2):33-45 Development Unit, Royal Rehabilitation CenFlannery J, Korchek S, Behm L 1994 A national tre Sydney survey of neuroscience and rehabilitation curSheppard B 1994 Patients' views of rehabilitation. ricula in NLN-approved programs: a need for Nursing Standard 91 \{))27-30 change? Journal of Nursing Education 33(3): I 34Smith D 1990 Foreword. In: P e n i n g t o n G R, 136 Burry H C (eds) Introduction to rehabilitation: an Gibbon B 1991 A reassessment of nurses' attitudes Australian perspective. M e l b o u r n e U n i v e r s i t y t o w a r d s stroke p a t i e n t s in general medical Press, Carlton:v-vi wards. Journal oj Advanced Nursing 16:1 336-1 342 Stryker R I 977 Rehabilitative aspects oj acute and Gibbon B, Thompson A 1992 T h e role of nurses chronic nursing care. W B Sanders, Philadelphia in rehabilitation. Nursing Standard 6(36):32-35 I hompson I L C 1990 A qualitative investigation of Hanlon D, Sharkey F L 1989 Professional practice rehabilitation nursing care in an inpatient rehabilitation of rehabilitation nursing. In Dittmar S S (ed), unit using Leininger's theory LInpublished PhD theRehabilitation nursing- process and application. sis, Wayne State LIniversity, Detroit, Michigan Mosby, St Louis Waters K R 1986 T h e role of nursing in rehabiliHenderson E J, Morrison J A, Young E A, Penttation. CARE_Science and Practice 5{i): 17-2 t land B 1990 T h e nurse in rehabilitation after Waters K R 1994 G e l l i n g dressed in the early severe brain injury. Clinical Rehabilitation 4:167morning: styles of staff/patient interaction on 172 rehabilitation hospital wards for elderly people. Hermann C P, Bays C L 1994 Professional rehaJournal of Advanced Nursing 19:239-248 bilitation nursing: an elective course for nursing Waters K R, Luker K A 1996 Staff perceptions on students. Rehabilitation Nursing 19(3): 160-168 the role of the nurse in rehabilitation wards for H o e m a n S 1996 Rehabilitation nursing: process and elderly people. Journal of Clinical Nursing 5:105application 2nd ed. Mosby, St Louis 1 14 Kirkcvold M 1997 T h e role of nursing in the Williams S L 1984 Role of t h e rehabilitation rehabilitation of acute stroke patients: towards nurse. The New Zealand Nursing Journal Decema unified theoretical perspective. Advances in ber^. Nursing Science 19(4):55-64
e n e d l e n g t h of i n p a t i e n t stay. For m a n y nurses rehabilitation is an integral aspect of t h e i r p r a c t i c e , e v e n w h e n t h e y h a v e had no formal exposure to rehabilitation education or the literature. This, however, is far Irom the norm. T h e lime has c o m e to situate rehabilitation in all undergraduate and postgraduate nursing programs as we seek to prepare nurses to provide nursing care to an Australian population that is ageing and includes an increasing numb e r of p e o p l e w i t h c h r o n i c illness a n d functional limitations.
Limitations of the study Like all research this study has limitations. T h e first limitation relates to the number of research participants. W h i l e this numb e r (n = 34) is c o n s i d e r e d r e a s o n a b l e for the qualitative design of this study, further data is n e e d e d to s t r e n g t h e n these findings. S u b s e q u e n t studies should seek to include nurses involved in n o n - i n p a t i e n t rehabilitation as their views were not considered in this study. In addition, the data collected in this study pertains only to the nurses' reports of their own practice. It has not sought to validate t h e nurses' r e p o r t with observat i o n of t h e i r a c t u a l p r a c t i c e .
Further
research to validate the nurses' reports with o b s e r v a t i o n of practice will enrich our u n d e r s t a n d i n g of rehabilitation nursing practice. This may also uncover addit i o n a l a s p e c t s of r e h a b i l i t a t i o n
nursing
practice that have not been reported here.
Conclusion T h e explicit description of a rehabilitative a p p r o a c h to nursing c o n t a i n e d in t h e s e findings should not be seen as the exclusive property of rehabilitation nurses. T h e rehabilitative a p p r o a c h belongs in every nurses' toolkit, to draw upon w h e n a p p r o -
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