Author: Heather Block
Block, Heather, 2024 Managing challenging behaviours after traumatic brain injury in the acute hospital setting, Flinders University, College of Nursing and Health Sciences
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Challenging behaviours after traumatic brain injury (TBI) are common, difficult to manage in acute hospital settings, and present many risks of harm to patients, staff and families. People with TBI can experience a range of physical, sensory, communication, cognitive, and behavioural difficulties. Behavioural changes, commonly referred to as challenging behaviours, can include agitation, aggression, disinhibition impulsivity, perseveration, wandering or absconding, and apathy. TBI patients with challenging behaviours experience risks of self-inflicted harm, falls, delayed transitions from acute care to rehabilitation, and adverse functional outcomes. Acute hospital clinicians working with TBI patients with challenging behaviours are frequently exposed to risks of workplace violence. Families of TBI patients with challenging behaviours experience emotional strain, distress and burden during the acute recovery stage. Management of challenging behaviours after TBI in acute settings is variable, with limited evidence for management interventions. Furthermore, clinicians lack the knowledge, skills and confidence to effectively manage challenging behaviours after TBI in the acute setting. The variability in care, lack of knowledge, skills and confidence impedes delivery of quality and consistent care to patients with TBI. This thesis addresses the critical need to understand implementation of evidence-informed TBI behaviour management within the acute hospital setting. TBI behaviour management is complex within the acute hospital context. With incorporation of implementation science frameworks utilised in the research studies, this thesis has demonstrated vital and novel recognition of the contextual factors that can enhance or impede the implementation of evidence-informed TBI behaviour management to patients with TBI in acute hospital settings.
This thesis outlines six research studies that were undertaken to understand the factors relating to the management of challenging behaviours after TBI in the acute hospital setting. A pragmatic multi methods approach underpinned by implementation science was utilised. The original contribution to knowledge from research presented in this thesis includes:
• Feasibility of implementing a consistent approach to the assessment and management of challenging behaviours after TBI in acute hospital settings.
• Identified and evaluated international evidence and clinical practice guidelines for the management of challenging behaviours after TBI in the acute setting, including applicability and implementation into clinical practice.
• There are barriers, but also enablers and contextual factors to the implementation of evidence-informed TBI behaviour management approaches in the acute hospital setting.
• Developed implementation strategies to support future implementation in clinical practice.
Findings from the research studies incorporated in this thesis have addressed a gap in research and clinical practice by identifying the contextual factors that influence the implementation of evidence into practice for TBI behaviour management in the acute hospital setting. Further education and training are required to address barriers to clinician’s knowledge, confidence and skills in adequately managing challenging behaviours after TBI in acute settings. Hospital environments, staffing workforce, and lack of resources were identified barriers. Supportive multi-disciplinary teams, person-centred approaches, with family involvement in care can leverage effective TBI behaviour management in acute hospital settings. Furthermore, there is a need to provide support and information to families of patients with challenging behaviours after TBI in the acute setting. Considerations for further research, implications for policy, and implications for clinical practice are discussed.
This thesis highlights novel and critical implementation factors for evidence-informed management of challenging behaviours after TBI relevant to the acute hospital context. Recommended implementation strategies are outlined for the implementation of improvements into clinical practice. Further research on the effectiveness of both implementation strategies and interventions for the management of challenging behaviours after TBI in the acute hospital setting is warranted.
Keywords: Traumatic Brain Injury, Challenging Behaviour, Acute Hospital, Implementation
Subject: Health Sciences thesis
Thesis type: Doctor of Philosophy
Completed: 2024
School: College of Nursing and Health Sciences
Supervisor: Professor Stacey George