What is the concept of caring for patients with brain injury?

What is the concept of caring for patients with brain injury?


prepared by: Hatem Alsrour


Review of Literature
Traumatic Brain Injury
Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object that penetrates brain tissue, such as a bullet or shattered piece of skull, also can cause traumatic brain injury.

The defining of traumatic brain injury (TBI) is fundamental for reporting, comparison, and interpretation of studies on TBI. Changing epidemiologic patterns, an increasing recognition of significance of mild TBI, and a better understanding of the subtler neurocognitive neuro affective deficits that may result from these injuries make this need even more critical (David K. et, al, 2010).

Each year, over 2.5 million people in the United States sustain a TBI (Centers for Disease Control and Prevention, 2014), including more than 511, 257 adolescents aged 0 to 14 years (Faul, Xu, Wald, & Coronado, 2010). More than 35,136 adolescents have injuries that are moderate to severe TBIs and require hospitalizations (Faul et al., 2010). Adolescents [and older adults age 75 years or older] are most likely to sustain a TBI (Centers for Disease Control and Prevention, 2014). The severity levels of TBI are characterized as mild, moderate, and severe (Rao et al., 2010). TBI causes significant impairments in psychomotor, verbal, and cognitive functioning (Green et al., 2006), with moderate to severe TBI causing chronic impairments that survivors of TBI will live with over their lifetime (Himanen et al., 2006).

Trauma patients are common cases for emergency technicians. Trauma is a common medical emergency with the highest number of calls to EMS (Khoshknab, et, al. 2012, P 20). In Iran, trauma is the second most common cause of mortality in all age groups after cardiovascular diseases (Beuran M, et, al, 2011, P 574).

Each year an estimated 69 million individuals will suffer a TBI, the vast majority of which will be mild (81%) and moderate (11%) in severity. Per capita, the highest annual incidence of all cause TBI is observed in the AMR – US / Can and EUR (1299 and 1012 cases per 100,000 people, respectively). Taking into account regional populations, however, the greatest burden of His is in the SEAR (18.3 million) and WPR (17.3 million). The health care systems in LMICs encounter nearly 3 times as many total TBIs than those in HICs. These estimates are limited by relatively low quality data from LMICs and suggest the need for more robust and accurate injury reporting. The global disparity in health care between regions with fewer resources and a high disease burden and those with greater assets and a lower burden deserves attention and action. Michael C. Dewan, et, al. April 2019, P 1039 – 1408).

Retrospective review Of consecutive case registered in major trauma center database, Riyadh, from 2001 to 2009, out of 3796 patients identified, 1219 patients (32.1%) suffered head injury (mean age 8.6 years; males 78.4%). Children under 12 years comprised 66.3%. Motor vehicle crash (MVC) was the commonest cause (34.2%), followed by pedestrian injury (30.3%) and falls (28.4%). When stratified by age, falls (45.6%) were the most common etiology under 6 years while MVC was the leading cause in high school students (74.4%). The latter group had the lowest mean (SD) Glascow coma scale scores ( 8.58 [4.7]), highest mean injury severity scale scores (23.4 [21]), highest rate of craniotomy (7%) and highest mortality (20%). Overall, motor vehicle crash (MVC) was the leading cause of head injury (34.2%), followed by pedestrian injuries (30.3%), falls (28.4%), motorcycle crash (2.3%), violence (1.4%), and others (3.4%). The mechanism of injury was different according to the age group. While falls was the leading cause of head injury in patients less than 6 years (45.9%), pedestrian-related injuries were the most common (45.9%) between 6 to 12 years, and MVC was the leading mechanism of head injuries in the age groups of 12 – 16 and 16 – 18 (47.2% and 74.4% respectively) (Sultan Alhabdan, et, al.7 feb 2013, P 20).

A search of news reports about deadly traffic accidents in the KSA finds literally hundreds of news stories in newspapers and news sites such as Al Eqtisadiah, Al Madina, Al Riyadh , Al-Yaum, Arab News and one of the most widely circulated newspapers published in the KSA called Okaz. Headlines such as “1 Dead and 4 In Critical Condition After Fatal Saudi 4 Arabia Road Accident (Kwentong, 2016)”, “Saudi road crash kills 15, including six children (Toumi, 2016),” and “Nine killed in road accident near Hail (Rasooldeen, 2016),” are common news stories in the KSA. Moreover, numerous reports and studies beginning over twenty years ago have recognized this problem and been warning the government to adopt measures to address the crisis (Ansari, Akhdar, Mandoorah, & Moutaery, 2000).

Nurses have an important and large role in care of patients with moderate -to- severe TBI during acute and non-acute care. As an essential member of the interdisciplinary teams, nurses hold numerous roles and responsibilities to assist with the patient’s treatment and recovery, including:

1. Assessing the patient;

2. Coordinating and communicating care;

3. Conducting technical and physical care;

4. Integrating prescribed therapies;

5. Providing emotional support to the patient and their family;

6. Advocating for the patient;

7. Involving the patient and family in care; and

8. Educating the patient and family (Long, Kneafsey, Ryan, & Berry, 2002b; Ryan, 2009).

These roles and responsibilities depend on the severity of the patient’s injuries and their time since injury; as the patient’s condition changes, nurses modify their plan of care. These modifications will likely occur more when caring for patients with acute, new- onset moderate -to- severe TBI compared to patients in the chronic stage.

Research on Nurse’s Attitudes about TBI

Nurse’s attitudes about patients with moderate – to- severe TBI are important as it is likely that all nurses will provide care to these patients with these injuries at some point in their practice. This is because patients with acute or chronic moderate –to –severe TBI can be found on any hospital unit, depending on severity of injury, time since injury, and comorbidities (Mc Quillan & Mitchell, 2002).

However, much of the research on nurses’ beliefs has focused on beliefs about patients with mild TBI, which limits application to nursing care of patients with moderate -to- severe TBI in the United States and globally. So, the existing research has shown that nurses and nursing students have several inaccurate beliefs about recovery after mild TBI (Ernst et al., 2009).

Items in the Ernst (2009) study focused on misconceptions about use of seatbelts, unconsciousness, impairments caused by TBI, and recovery after TBI, but did not focus on specific nursing care responsibilities or learning preferences. In other studies, both nursing students and nurses have also been shown to have negative attitudes towards patients with TBI, including use of visibility of injury as an indicator of how much care a patient should receive (Linden & McClure, 2012; Linden & Redpath, 2011).

Although nursing beliefs were assessed in these studies, specific beliefs about the nursing role to care for patients with moderate-to-severe TBI were not included. Overall, these findings are concerning because provider perceptions can influence behavior in practice (Ernst et al., 2009; Grol, 1997). Furthermore, nurses with misconceptions about TBI may share inaccurate information with patients and families (Ernst, 2009), which has major implications for patient and family education.

Research has also shown that nurses report feeling ill-prepared to care for patients with various types of brain injuries (Long, Kneafsey, Ryan, & Berry, 2002a; Pryor & Smith, 2002), For instance, in a survey of 137 nurses conducted by Long et al (2002), two-thirds of nurses felt their prior training and education had not adequately prepared them with knowledge and skills necessary to care for patients undergoing rehabilitation after a stroke (Long et al., 2002a). Nurses have also reported the belief that specialized education and training is needed to care for patients with neurological conditions (Baker, 2012). According to Baker (2012), in a study of nurses’ perceptions of educational requirements to care for patients with neurological conditions, 91% of registered nurses reported that nurses should be required to have access to specialist education and training when caring for patients with neurological conditions.

Nurses also reported wanting more education in multiple areas, including management of patients’ behaviors and families’ concerns (Baker, 2012). Studies on this topic recommended additional educational and training interventions for nurses (Baker, 2012; Edwards, 2006; Pryor & Smith, 2002). Examples of educational and training interventions could include continuing education meetings and workshops (Forsetlund et al., 2009), coursework (Keane, 1991), and online training (Ruiz, Mintzer, & Leipzig, 2006). However, research in this area has broadly focused on brain injury, without specifically measuring nurses’ beliefs about caring for patients with moderate-to-severe TBI.

Impairments Caused by TBI
Characteristics of patients with TBI vary as a function of injury severity (Rao et al., 2010). The consequences of mild TBI typically include physical and mental fatigue, emotional distress, impairments in attention and concentration, and somatic symptoms such as headaches and sensitivity to light and sound, all of which typically resolve within a few weeks (Brain Injury Association of America, 2015b). In comparison, moderate-to-severe TBI is associated with significant impairments in sensorimotor, cognitive, and psychosocial functioning. Cognitive impairments include problems with executive functioning, memory, and attention (Dikmen, Machamer, Winn, & Temkin, 1995), which reduce capacity for new learning and decrease speed of information processing (Millis et al., 2001). While deficits typically improve spontaneously in the early months after injury, most patients with moderate-to-severe injury have lifelong challenges that have a tremendous impact on everyday independence, work, and social life (Faul et al., 2010).

Related studies

Damkliang, et, al, study (2013) Titled “Thai emergency nurses’ management of patients with severe traumatic brain injury: comparison of knowledge and clinical management with best available evidence”. The aim of this study was to explore Thai emergency nurses’ management of patients with severe TBI. An exploratory descriptive mixed method design was used to conduct this two stage study: survey methods were used to examine emergency nurses’ knowledge regarding management of patients with severe TBI (Stage 1) and observational methods were used to examine emergency nurses’ clinical management of patients with severe TBI (Stage 2). The study setting was the emergency department (ED) at a regional hospital in Southern Thailand. The results of this study showed that 34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were observed in 20 patients with severe TBI over 40 h. In this study there were five major areas identified for the improvement of care of patients with severe TBI:

1. End-tidal carbon dioxide (ETCO2) monitoring and targets;

2. Use of analgesia and sedation;

3. Patient positioning;

4. Frequency of nursing assessment;

5. Dose of Mannitol diuretic.

There is variation in Thai nurses’ knowledge and care practices for patients with severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge translation intervention that is ecologically valid, appropriate to the Thai healthcare context and acceptable to the multidisciplinary care team is needed.

Conceptual / Theoretical Framework: Research Proposal
This study was guided by rigorous conceptual and theoretical frameworks, namely, Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths ” 2002 – 2006 ” (Faul M, Xu L, Wald M, & Coronado V. : 2010).

The importance of the study

The importance of current research is illustrated by the following points:

1. Theoretical importance: The theoretical importance of the current research is as follows:

a. This study shows the importance of nurses’ attitude regarding care of patient with Traumatic brain injury in emergency department Hail.

b. This study coincides with the new vision of Saudi Arabia (2030) to raise the level of health services in different regions of Saudi Arabia and improve the performance of the nurses in emergency department in KSA hospitals.

c. Gap of Knowledge: to the best of the researcher’s knowledge, this is the 1st study in SA to investigate the nurses’ attitudes regarding care of patient with Traumatic brain injury in emergency department Hail.

2. Practical importance: The practical importance of the current research is as follows:

a) It contributes to helping the Saudi Ministry of Health to keep abreast of scientific and technical developments in improving the mechanism of caring with TBI patients.

b) It helps to clarify the obstacles that faced by the nurses in emergency department.

c) Interested researchers may benefit from the study, its findings and recommendations.


Problem of the research

The main objective of this study is to identify the nurses’ attitude towards caring for patients with traumatic brain injuries in hail hospitals – emergency department.

Aim and objectives

The aim of this study was to highlight encounters between injured patients and nurses in the trauma team and to explore whether the theory of caring and uncaring encounters in nursing and health care is applicable in emergency care.

The research questions

Following is the research question for the study:

1. What is the concept of caring for patients with brain injury?

2. What are the challenges faced by the nurses?

3. What is the position of emergency nursing?

4. How does the nursing team care for a critical patient such as a traumatic brain injury (TBI)?

5. What are the nursing capabilities to provide patient care?

6. What is the nurses’ attitude towards caring for patients with brain injuries in emergency department?

7. What are the obstacles that nurses face while working in the emergency department?

Philosophical Stance

Traumatic brain injury (TBI), also known as concussion or closed head injury, is a significant public health problem with clinical relevance for nurses who have professional responsibilities within civilian and military communities.

Research design:

The study will use a descriptive analysis of data collection using a web based survey


The researcher will use valid questionnaire tool to investigate the opinions of the nurses who work in emergency department ” at the time of the study in hail hospital to achieve the objectives of the study. The questionnaire will be constructed in order to answer the study questions. The questionnaire consists of two main parts:

1. Part 1: The personal data of the study sample

2. Part 2: It consists of the fields of study, where each field consists of a certain number of questions which aim at achieving the objectives of the study.

Sampling technology

The sample will be chosen randomly

Sample Size

The total size of the study population is (150) nurses who work in Hail Hospitals in general, and the size of the study sample is (60) nurses, who are nurses who work in the emergency departments in the hospital at the time of this study.

Ethical issues:

Approval to conduct this study will be obtained from the Ministry of Health. Participants who will take part in this research will be given consent forms that they must read and sign before participating in the survey. Participating in this study will be voluntary and participants will not be caused harm. Also, the anonymity, respect, and dignity of the participants will be maintained. The data that will be collected using the survey will be kept confidential. The identity of the participants that will take part in this study will remain confidential.


The data points that were collected include demographic variables describing the survey respondent, their workplace, the types of patients they saw, and their educational level. The next section asked them to rank preferred learning methods and then mark all learning methods they used in their practice.

Data analysis

Data were analyzed in SPSS / 20 (IBM Corp., Armonk, NY, USA) using descriptive and inferential statistics. To compare the level of knowledge, attitude, clinical skills on the one hand and demographic variables on the other hand, independent samples t-test and one-way ANOVA were utilized. Then, compare mean scores on different levels of the variables in questionnaires. Mean scores of knowledge, attitude, and performance were compared using Pearson’s correlation coefficient, and means on more than two groups (e.g., mean knowledge per levels of education) were compared using one-way ANOVA. Furthermore, two groups were compared using independent samples t-test.

Terminology of the study:


Trauma brain injury:

Traumatic brain injury (TBI) is a no degenerative, no congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.


An attitude refers to a set of emotions, beliefs, and behaviors toward a particular object, person, thing, or event. Attitudes are often the result of experience or upbringing, and they can have a powerful influence over.

The research setting

The setting of the research is all nurses who work in emergency department ” at the time of the study.

Work Plan

Table (1)

The expected timetable to achieve the goals of the project in 6 months

Work to be Achieved

Duration in month

Assigned person







Literature review

Student under supervision of supervisor

Design of the data collection sheet

Getting the approvals to conduct the research in the study hospitals

Pilot study to test availability of all independent variables. Then, editing the questionnaire if required.

Data collection

Data entry

Statistical analysis

Display and Interpretation of the results

Extensive literature reviews to write up the discussion. Then, writing up the final report and preparing for the publication.

General perception of the study chapters

Chapter 1: General Research Framework (Study Problem)

Chapter 2. literature review

Chapter3. Methodology of the study.

Chapter 4. Discussion and results.

Chapter 5. Conclusion



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