ORIGINAL ARTICLE
Facilitating patients with disorders of consciousness to sit without trunk support: a qualitative study Kumiko Miyata, Sadako Yoshimura and Yuko Hayashi
Aims and objectives. This study aimed to clarify why and how clinical nurses facilitate sitting without trunk support among patients with disorders of consciousness. Background. Recent attention has focused on encouraging patients with disorders of consciousness to sit without trunk support, but no reports describe this intervention among patients with poor awareness and physical disuse. Design. Qualitative research design. Methods. We enrolled five clinical nurses with interventional experience in rehabilitating patients with disorders of consciousness to sit without trunk support. Participant observation and semi-structured interviews were used to collect data. The data were analysed by text-mining method. Results. Three reasons for nursing in the sitting position were identified: to raise the patient’s body to assess the recovery of activities of daily living, to adjust their circadian rhythm and encourage the will to sit, and to make it easier to breathe. Five practices were identified: moving the patient to the prone position to sit in safety and comfort, developing postural stability by improving the flexibility of the lower limbs, improving the flexibility of the hip joints, developing trunk balance and encouraging hand use for stability, and ensuring safety by terminating the sitting practice when symptoms of respiratory failure, heart failure, or excessive tiredness developed. Conclusions. The rationale for nursing patients with disorders of consciousness to sit without trunk support was to establish a foundation for independent living. This was achieved by preparing patient’s disused body for activity by improving the flexibility of hip joint in the prone position. This represents a new intervention for patients with disorders of consciousness that could facilitate independent living. Relevance to clinical practice. This study provides empirical and practical evidence from nurses who perform novel clinical interventions that specifically promote independent living. Further accumulation of quantitative clinical results and physiological verification are required.
What does this paper contribute to the wider global clinical community?
• We highlight a nursing standard
•
•
to develop independence among patients with disorders of consciousness. We establish a new nursing skill for patients with disorders of consciousness as practiced by nurses with clinical experience. We provide a physical method for patients with disorders of consciousness to live independently.
Key words: Disorders of consciousness, nursing intervention, rehabilitation, sitting, text-mining approach Accepted for publication: 17 February 2015
Authors: Kumiko Miyata, MSN, RN, Lecturer, Department of Nursing, Hokkaido University of Science, Hokkaido; Sadako Yoshimura, PhD, RN, Professor, Department of Nursing, Faculty of Health Sciences, Hokkaido University, Hokkaido; Yuko Hayashi, PhD, RN, Professor, Department of Nursing, Hokkaido University of Science, Hokkaido, Japan
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Correspondence: Kumiko Miyata, Department of Nursing, Hokkaido University of Science, 7-15-4-1 Maeda, Teine, Sapporo, Hokkaido 006-8585, Japan. Telephone: +81 11 688 7148. E-mail: [email protected]
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504, doi: 10.1111/jocn.12834
Original article
Introduction Progress in medical care has greatly increased the number of people who survive acute brain damage or systemic disease. However, this has also increased the number of patients surviving with prolonged disorders of consciousness (DOC) the incidence of which is reported to be 05–2/ 100,000 population per year (Von Wild et al. 2012). Furthermore, no effective treatment has been established for DOC, and many patients often remain bedridden for prolonged periods (Gosseries et al. 2011). Nursing for patients with DOC typically involves maintaining life, preventing complications, and helping with daily life (Mazaux et al. 2001, Geraghty 2005, Puggina et al. 2012). More recently, clinical nursing has developed methods that promote passive sitting without trunk support among patients with DOC. Okubo (2011) reported that sitting without trunk support activated the electroencephalographs (EEGs) of patients with DOC and raised their consciousness level. However, few reports have described interventions that involve sitting without trunk support, and none have reported dramatic changes in patient statuses. Despite this, nursing patients with DOC, to sit without trunk support, continues to be employed clinically. To develop an evidencebased intervention programme, there is a need to clarify why and how nurses facilitate sitting without trunk support.
Background Disorders of consciousness are disorders of arousal and awareness (Posner et al. 2007, Laureys & Tononi 2011) and present with patients ‘breathing spontaneously, but who remain unresponsive and speechless’ (Jennett & Plum 1972). Okubo (2011) reported changes in patients with DOC after sitting without trunk support for 36–65 days, with improvements in eye and finger movement, noises or vocalizations, and alpha and beta wave activation on EEG, as well as reduced drooling. However, several patients with DOC are bedridden with limited ability for spontaneous movement. Long-term bedridden states promote osteoporosis, which can leave patients with DOC at high risk of fracture through relatively minor motion, such as a spasm (Lavrijsen et al. 2007, Oppl et al. 2014). In addition, being bedridden can lead to reduced cardiorespiratory tolerance to movement (Vollman 2010). Thus, prolonged bed rest is not recommended because it is conducive to physical disuse conditions. However, the risks of fractures and hemodynamic changes when moving patients with DOC to the sitting position are unclear. How nurses move patients with DOC into the sitting position, while avoiding these risks, needs further investigation. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Why and how nurses sit patients with DOC
Sitting without trunk support is recommended when providing effective rehabilitation for patients with hemiplegia following cerebrovascular injury, by helping them to regain balance and continue normal activities of daily living in the sitting and standing positions (Shumway-Cook & Woollacott 2006). However, no reports have confirmed the rehabilitative benefit of sitting without trunk support for patients with poor arousal and physical disuse states, and the rationale for this practice may be peculiar to nursing. Therefore, this study aimed to clarify why and how clinical nurses facilitate sitting without trunk support among patients with DOC.
Methods Design Qualitative research design.
Participants Participant nurses were introduced by a researcher familiar with the nursing of patients with DOC. In total, five nurses with clinical experience of nursing patients with DOC in a sitting position without trunk support participated in the study (Table 1). The average age of the nurse participants was 424 years (range, 36–48 years), and they had an average experience of 162 years (range, 8–21 years) as nurses. The clinical domains of the nurses were neurosurgery, internal medicine, surgery, urology and orthopaedics.
Data collection This study was performed in two hospitals in Japan between January and March 2012. The data collection comprised two elements: observations of clinical practice and semi-structured interviews, both of which were conducted with the participating nurses in Japanese by a single researcher. We defined sitting without trunk support as sit-
Table 1 Subjects descriptive characteristics
Nurse
Sex
Age (years)
Years of experience
A B
F F
36 41
8 21
C
F
45
17
D E
F F
48 42
15 20
Experiential domain Neurosurgery, urology Neurosurgery, internal medicine, orthopaedics Internal medicine, urology, surgery Internal medicine Internal medicine, surgery
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K Miyata et al.
ting on the side of a bed, with the feet on the floor, and the back unsupported (Sandin & Smith 1990). Observations were made from the nurse entering to leaving the room, including their performance during the intervention itself. The researcher explained his or her role and the purpose of the study to the participant nurses, the facilities involved, and to the patients and families being nursed; in particular, it was specifically explained that there would be minimal restriction or impact on normal nurse–patient relations. Observation notes of the behaviour of the nurses and the reaction of the patients were recorded in detail. To assess the sitting without trunk support intervention, 10 patients with 4–240 month histories of DOC (Table 2) were enrolled. All patients were nursed at home or in a nursing facility during recuperation, and patients with bone fractures or pneumonia had been admitted to participating hospitals for between one day and 11 years. The range of Glasgow Coma Scale scores at the time of observation was 6–11, and nine patients had contractures. After the observation, semi-structured interviews were conducted in a private room. These interviews were based on the observation notes and a predetermined interview guide comprising two questions. The questions enquired about why the nurse participant made patients with DOC sit without trunk support, and how they achieved it while minimising risk. The interview was performed within 24 hours of the observation. Participants were asked to consent to the research and the use of a digital recorder (an integrated circuit recorder), and the recorded interviews were transcribed verbatim for data analysis. If a question arose during data collection, we re-interviewed the participants. Interviews lasted 47– 62 minutes; two participants were interviewed once, two participants twice, and one participant thrice.
Data analysis A text-mining method was used to obtain new knowledge (Feldman & Sanger 2007). This method is compatible with grounded theory and is reportedly less restrictive than other qualitative research methods (Yu et al. 2011). In this research, the sentence periods were set to simple, compound and complex. Paragraphs were set according to changes of subject. Thus, we obtained 759 sentences and 218 paragraphs from interview data in Japanese. Data were analysed using the Japanese text-mining software, KH Coder (Higuchi, 2012). First, a morphological analysis was conducted, and 1611 different words were extracted. Words or phrases with the same meaning were considered synonyms and treated as the same. For example, both ‘I’ and ‘Nurse’ were considered synonyms. A total of 143 synonyms were generated; specifically, more than 90% of words, 924% of sentences, and 989% of paragraphs included synonyms. For the paragraph data, synonyms with the greatest frequency of appearance were as follows: , , , , , , , , , and . Furthermore, the paragraph was considered as a unit of the total, and we searched for synonyms with high similarity and relativity in the emerging pattern by hierarchical cluster analysis (Ward method) and extracted 14 clusters with a 15 degree of dissimilarity. In the cluster analysis, we used the number of times each synonym appeared per paragraph as a reference and excluded the position of the synonym in the sentence and the length of the sentence.
Table 2 Overview of patients’ participating observation History
State at the time of the observation
Nurse
Patient
Sex
Age (years)
Cause of DOC
PIM
Cause of this admission
Length of stay
GCS
Contracture (Yes/No)
A B C
1 1 2 3 4 5 6 7 8 9 10
F F F F F M F F F M M
53 53 84 96 91 82 89 79 94 76 83
HIE HIE Parkinson’s disease CI MID Alzheimer’s disease CI SAH, CI CI, MID SAH, CI CI
8 8 204 120 36 36 132 4 120 240 156
Pneumonia Pneumonia Asthma attack Diarrhoea, fever Pneumonia Pneumonia Bone fracture Pneumonia Bone fracture Pneumonia Pneumonia
3 days 3 days 11 days First day 1 year 3 years 11 years 4 months 1 year 6 years 6 years
9 9 11 11 10 10 9 9 8 6 10
No No Yes Yes Yes Yes Yes Yes Yes Yes Yes
D
E
F, Female; M, Male; PIM, Postinjury month; GCS, Glasgow Coma Scale; HIE, hypoxic ischaemic encephalopathy; CI, cerebral infarction; MID, multi-infarct dementia; SAH, subarachnoid haemorrhage.
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© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Original article
All paragraphs in which synonyms for each cluster appeared totalled 100%. The common meanings of approximately 20% of the paragraph data were extracted with several synonym combinations. The cluster was consistently named in Japanese according to the meaning of the synonym itself. To extract common meanings, data with strong implications for other elements were eliminated. Then, we translated the names of synonyms and clusters to English and back-translated the text to Japanese to confirm its accuracy. In addition, the generation of synonyms, the naming of clusters, the translation process and the back translation were performed with a postdoctoral nursing researcher familiar with qualitative study. The validity of the approach was therefore confirmed.
Ethical considerations This study was approved by the ethics committee of Faculty of Health Sciences, Hokkaido University. We acquired informed, signed consent from the nurses, patient representatives, and research partnership facility managers. We explained (both orally and documented) the purpose of the research, their right to confidentiality, and their right to refuse or decline participation and explained that no disadvantage would result either from participation or from nonparticipation. In addition, if the patient would recover consciousness, get consent by similar procedures. The participant’s names were encrypted and saved. The researchers were nurses with doctoral degrees and were familiar with qualitative and quantitative research.
Results We identified 14 clusters: three clusters related to ‘why’ nurses sat patients with DOC without trunk support and five clusters related to ‘how’ they achieved sitting without trunk support, consistent with the study aims. The contents of each cluster are shown below, according to the following key: italics are used to state the cluster name, and the symbols < and > bound the synonyms.
Why and how nurses sit patients with DOC
1 To raise the patient’s body to assess the recovery of activities of daily living. This cluster comprised 12 synonyms. These included the , , , , and . An example with five synonyms is shown below: is leading to life. When we carry out intervention, there is no clear assessment that they do anything. While doing the , I know their possibility by my hands and arms. Maybe it is my . [Nurse C]
2 To adjust circadian rhythm and encourage the will to sit. This cluster comprised 20 synonyms. These included , , , , , , , and . An example with six synonyms is shown below: I have the idea that the of must be improved first. Patients who are bedridden in a have no sense of day and night. We have a of sleeping at night and getting up in the morning to do , but patients do not perform according to any set . Any patient should be encouraged to wake up in the morning and should be dressed to begin . If the patients sit without trunk support on their own, we should assist their back. This informs them that it is the daytime now and creates a . I think that sitting without trunk support is important to induce the to sit. [Nurse A]
3 To make it easier to breathe. This cluster comprised seven synonyms. These included , , and . An example with six synonyms is shown below: I want to the patient’s and contracture better. If I the patient’s rib cage move more, the risk of , , and will be reduced. In other words, I think that good breathing indicates the body that can move. This means that the good body can not only but also the hand becomes free. Moreover, is . As for me, it
Why nurses sat patients with DOC without trunk support Three clusters were generated to explain the reasons for sitting patients with DOC without trunk support as follows: to raise the patient’s body to assess the recovery of activities of daily living, to adjust circadian rhythms and encourage the will to sit, and to make it easier to breathe. These are now expanded with their synonyms in the following three paragraphs: © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
is surely disagreeable to become busy with . Then, I wish to prepare the patient’s body daily. It is a patient’s body. [Nurse D]
How nurses facilitated sitting without trunk support We generated five clusters to describe the practice of sitting without trunk support for patients with DOC. These were as follows: moving the patient to the prone position to sit
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in safety and comfort, developing postural stability by improving the flexibility of the lower limbs, improving the flexibility of the hip joint, developing trunk balance and encouraging hand use for stability, and terminating sitting practice when symptoms of respiratory failure, heart failure, or excessive tiredness developed. These are now expanded with their synonyms in the following five paragraphs:
4 Developing trunk balance and encouraging hand use for stability. This cluster comprised 19 synonyms. These included , , , , , , , , and . An example with seven synonyms is shown below: I think that muscle can also be by sitting without positively. Also, additional stimulation is pro-
1 Moving the patient to the prone position to sit in safety and comfort. This cluster comprised 11 synonyms. These included , , , , and . An example with 11 synonyms is shown below:
duced by independence and through the . To break down their on purpose, I the patient’s body while sitting. This is meant to be a stimulus for them to their bodies on their own, even if there is risk to postural . [Nurse C]
I am careful about and at all times. I also ensure that the blood pressure is maintained above 60–70 (units). If the blood pressure becomes , approximately 60–70, I would never raise the patient’s body suddenly. In that case, I would gradually place the patient in a head-up position to accustom his or her body to the postural change. If the blood pressure is very , I keep the patient supine in bed and come back to them at another time. [Nurse E]
Discussion We identified three reason clusters (i.e., why) and five practice clusters (i.e., how) related to nursing patients with DOC in a sitting posture without trunk support. The reasons were (1) to raise the patient’s body to assess the recovery of activities of daily living, (2) to adjust their circadian rhythm and encourage the will to sit, and (3) to make it easier to breathe. The practice involved (1) moving the patient to the prone position to sit in safety and comfort, (2) developing postural stability by improving the flexibility of the lower limbs, (3) improving the flexibility of the hip joints, (4) developing trunk balance and encouraging hand use for stability and (5) ensuring safety by terminating the sitting practice when symptoms of respiratory failure, heart failure or excessive tiredness developed. In this study, the main reasons for sitting patients were to assess their readiness for independent living and to prepare them by ensuring optimal breathing and a proper circadian rhythm. The sitting position is a fundamental posture for activities of daily living, including eating meals © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Original article
Why and how nurses sit patients with DOC
and defecating. In patients with hemiplegia due to cerebrovascular disease sequelae, it has been reported that the acquisition of sitting balance is correlated with autonomous living (Cabanas-Valdes et al. 2013). This is consistent with our finding that sitting without trunk support was intentionally developed and considered fundamental for independent living. To date, research among patients with DOC has focused on the activation of brain activity, such as the reaction and level of consciousness induced by stimulation, and has focused on sensory stimulation (Oh & Seo 2003) and sitting without trunk support (Okubo 2011). This study adds a novel perspective that sitting without trunk support facilitates the development of independent living among patients with DOC. This study revealed that hip flexibility is specifically encouraged in the prone position as an initial step to improve sitting balance. Research has shown that, after being bedridden for long periods, rehabilitation needs to be modified to account for the physical disuse states that persist after cognitive recovery (Andrews et al. 1996); failure to do so increases the possibility of fracture through even minor movement (Oppl et al.2014). Due to their cardiorespiratory decline, acute shock can also develop after moving patients to the sitting position (Spaak et al. 2005), which has led to a tendency to restrict movement in patients with DOC in an attempt to reduce any risk (Lavrijsen et al. 2007). Consequently, no clear method of rehabilitation has been established for this patient group (Elliott & Walker 2005). This study failed to clarify the beneficial effects of the prone position and of the interventions that improve hip flexibility. Despite this, if correctly performed while carefully observing circulatory dynamics, this research suggests that sitting without trunk support represents a promising intervention. Importantly, this new skill is based on the
fundamental nursing principle of helping patients gain independence as rapidly as possible.
Conclusion This study used a text-mining method to assess why and how nurses rehabilitate patients with DOC in the sitting posture without trunk support. The core reason for this practice was to provide a foundation for those patients to live independently. The practice therefore focused on identifying patients at risk of fracture and cardiorespiratory deterioration due to disuse syndromes and engaging in physical preparation in the prone position to improve the flexibility of the hip joint. This gives us more practical evidence than previous studies that focused on the role of the intervention in improving the level of awareness among patients.
Relevance to clinical practice The primary goals when nursing patients with DOC are maintaining life, preventing complications, and helping with their activities of daily living. This study provides empirical and practical evidence from nurses who perform novel clinical interventions that specifically promote independent living. Verifying the physiological meaning of this intervention would further contribute to its development as a useful nursing skill and, if implemented, should ultimately help to improve the quality of life of patients with DOC.
Contributions Study design: KM, YH; Data analysis: KM, YH and Manuscript Preparation: KM, YH, SY.
References Andrews K, Murphy L, Munday R & Littlewood C (1996) Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. British Medical Journal 313, 13–16. Cabanas-Valdes R, Cuchi GU & Bagur-Calafat C (2013) Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. NeuroRehabilitation 33, 575–592. Elliott L & Walker L (2005) Rehabilitation interventions for vegetative and minimally conscious patients. Neuro-
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psychological Rehabilitation 15, 480– 493. Feldman R & Sanger J (2007) The Text Mining Handbook. Cambridge University Press, New York. Geraghty M (2005) Nursing the unconscious patient. Nursing Standard 20, 54–64. Gosseries O, Vanhaudenhuyse A, Bruno MA, Demertz A, Schnakers C, Boly MM, Maudoux A, Moonen G & Laureys S (2011) Disorders of consciousness: coma, vegetative and minimally conscious states. In States of Con-
sciousness: Experimental Insights into Meditation, Waking, Sleep and Dreams (Cvetkovic D & Cosic I eds). Springer, Heidelberg, pp. 29–56. Jennett B & Plum F (1972) Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1, 734–737. Higuchi K (2012) KH Coder. http:// khc.sourceforge.net/en/. Laureys S & Tononi G (eds) (2011) The Neurology of Consciousness: Cognitive Neuroscience and Neuropathology. Academic Press, London.
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K Miyata et al. Lavrijsen J, van den Bosch H & Vegter J (2007) Bone fractures in the long-term care of a patient in a vegetative state: a risk to conflicts. Brain Injury 21, 993–996. Mazaux JM, De Seze M, Joseph PA & Barat M (2001) Early rehabilitation after severe brain injury: a French perspective. Journal of Rehabilitation Medicine 33, 99–109. Oh H & Seo W (2003) Sensory stimulation programme to improve recovery in comatose patients. Journal of Clinical Nursing 12, 394–404. Okubo N (2011) Sitting without back support position for prolonged consciousness disturbance patients: an intervention program case study. Journal of Neuroscience Nursing 43, E13–E27. Oppl B, Michitsch G, Misof B, Kudlacek S, Donis J, Klaushofer K, Zwerina J
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& Zwettler E (2014) Low bone mineral density and fragility fractures in permanent vegetative state patients. Journal of Bone and Mineral Research 29, 1096–1100. Posner JB, Saper CB, Schiff ND & Plum F (2007) Plum and Posner’s Diagnosis, 4th edn. Oxford University Press, New York. Puggina AC, Paes da Silva MJ, Schnakers C & Laureys S (2012) Nursing care of patients with disorders of consciousness. Journal of Neuroscience Nursing 44, 260–270. Sandin KJ & Smith BS (1990) The measure of balance in sitting in stroke rehabilitation prognosis. Stroke 21, 82–86. Shumway-Cook A & Woollacott MH (2006) Motor Control: Translating Research into Clinical Practice, 3rd edn. Lippincott Williams & Wilkins, Philadelphia, pp.157–298.
Spaak J, Montmerle S, Sundblad P & Linnarsson D (2005) Long-term bed rest-induced reductions in stroke volume during rest and exercise: cardiac dysfunction vs. volume depletion. Journal of Applied Physiology 98, 648–654. Vollman KM (2010) Introduction to progressive mobility. Critical Care Nurse 30, 3–5. Von Wild K, Laureys S, Gerstenbrand F, Dolce G & Onose G (2012) The vegetative state – a syndrome in search of a name. Journal of Medicine and Life 5, 3–15. Yu CH, Jannasch-Pennell A & DiGangi S (2011) Compatibility between text mining and qualitative research in the perspectives of grounded theory, content analysis, and reliability. The Qualitative Report 16, 730–744.
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Facilitating patients with disorders of consciousness to sit without trunk support: a qualitative study Kumiko Miyata, Sadako Yoshimura and Yuko Hayashi
Aims and objectives. This study aimed to clarify why and how clinical nurses facilitate sitting without trunk support among patients with disorders of consciousness. Background. Recent attention has focused on encouraging patients with disorders of consciousness to sit without trunk support, but no reports describe this intervention among patients with poor awareness and physical disuse. Design. Qualitative research design. Methods. We enrolled five clinical nurses with interventional experience in rehabilitating patients with disorders of consciousness to sit without trunk support. Participant observation and semi-structured interviews were used to collect data. The data were analysed by text-mining method. Results. Three reasons for nursing in the sitting position were identified: to raise the patient’s body to assess the recovery of activities of daily living, to adjust their circadian rhythm and encourage the will to sit, and to make it easier to breathe. Five practices were identified: moving the patient to the prone position to sit in safety and comfort, developing postural stability by improving the flexibility of the lower limbs, improving the flexibility of the hip joints, developing trunk balance and encouraging hand use for stability, and ensuring safety by terminating the sitting practice when symptoms of respiratory failure, heart failure, or excessive tiredness developed. Conclusions. The rationale for nursing patients with disorders of consciousness to sit without trunk support was to establish a foundation for independent living. This was achieved by preparing patient’s disused body for activity by improving the flexibility of hip joint in the prone position. This represents a new intervention for patients with disorders of consciousness that could facilitate independent living. Relevance to clinical practice. This study provides empirical and practical evidence from nurses who perform novel clinical interventions that specifically promote independent living. Further accumulation of quantitative clinical results and physiological verification are required.
What does this paper contribute to the wider global clinical community?
• We highlight a nursing standard
•
•
to develop independence among patients with disorders of consciousness. We establish a new nursing skill for patients with disorders of consciousness as practiced by nurses with clinical experience. We provide a physical method for patients with disorders of consciousness to live independently.
Key words: Disorders of consciousness, nursing intervention, rehabilitation, sitting, text-mining approach Accepted for publication: 17 February 2015
Authors: Kumiko Miyata, MSN, RN, Lecturer, Department of Nursing, Hokkaido University of Science, Hokkaido; Sadako Yoshimura, PhD, RN, Professor, Department of Nursing, Faculty of Health Sciences, Hokkaido University, Hokkaido; Yuko Hayashi, PhD, RN, Professor, Department of Nursing, Hokkaido University of Science, Hokkaido, Japan
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Correspondence: Kumiko Miyata, Department of Nursing, Hokkaido University of Science, 7-15-4-1 Maeda, Teine, Sapporo, Hokkaido 006-8585, Japan. Telephone: +81 11 688 7148. E-mail: [email protected]
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504, doi: 10.1111/jocn.12834
Original article
Introduction Progress in medical care has greatly increased the number of people who survive acute brain damage or systemic disease. However, this has also increased the number of patients surviving with prolonged disorders of consciousness (DOC) the incidence of which is reported to be 05–2/ 100,000 population per year (Von Wild et al. 2012). Furthermore, no effective treatment has been established for DOC, and many patients often remain bedridden for prolonged periods (Gosseries et al. 2011). Nursing for patients with DOC typically involves maintaining life, preventing complications, and helping with daily life (Mazaux et al. 2001, Geraghty 2005, Puggina et al. 2012). More recently, clinical nursing has developed methods that promote passive sitting without trunk support among patients with DOC. Okubo (2011) reported that sitting without trunk support activated the electroencephalographs (EEGs) of patients with DOC and raised their consciousness level. However, few reports have described interventions that involve sitting without trunk support, and none have reported dramatic changes in patient statuses. Despite this, nursing patients with DOC, to sit without trunk support, continues to be employed clinically. To develop an evidencebased intervention programme, there is a need to clarify why and how nurses facilitate sitting without trunk support.
Background Disorders of consciousness are disorders of arousal and awareness (Posner et al. 2007, Laureys & Tononi 2011) and present with patients ‘breathing spontaneously, but who remain unresponsive and speechless’ (Jennett & Plum 1972). Okubo (2011) reported changes in patients with DOC after sitting without trunk support for 36–65 days, with improvements in eye and finger movement, noises or vocalizations, and alpha and beta wave activation on EEG, as well as reduced drooling. However, several patients with DOC are bedridden with limited ability for spontaneous movement. Long-term bedridden states promote osteoporosis, which can leave patients with DOC at high risk of fracture through relatively minor motion, such as a spasm (Lavrijsen et al. 2007, Oppl et al. 2014). In addition, being bedridden can lead to reduced cardiorespiratory tolerance to movement (Vollman 2010). Thus, prolonged bed rest is not recommended because it is conducive to physical disuse conditions. However, the risks of fractures and hemodynamic changes when moving patients with DOC to the sitting position are unclear. How nurses move patients with DOC into the sitting position, while avoiding these risks, needs further investigation. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Why and how nurses sit patients with DOC
Sitting without trunk support is recommended when providing effective rehabilitation for patients with hemiplegia following cerebrovascular injury, by helping them to regain balance and continue normal activities of daily living in the sitting and standing positions (Shumway-Cook & Woollacott 2006). However, no reports have confirmed the rehabilitative benefit of sitting without trunk support for patients with poor arousal and physical disuse states, and the rationale for this practice may be peculiar to nursing. Therefore, this study aimed to clarify why and how clinical nurses facilitate sitting without trunk support among patients with DOC.
Methods Design Qualitative research design.
Participants Participant nurses were introduced by a researcher familiar with the nursing of patients with DOC. In total, five nurses with clinical experience of nursing patients with DOC in a sitting position without trunk support participated in the study (Table 1). The average age of the nurse participants was 424 years (range, 36–48 years), and they had an average experience of 162 years (range, 8–21 years) as nurses. The clinical domains of the nurses were neurosurgery, internal medicine, surgery, urology and orthopaedics.
Data collection This study was performed in two hospitals in Japan between January and March 2012. The data collection comprised two elements: observations of clinical practice and semi-structured interviews, both of which were conducted with the participating nurses in Japanese by a single researcher. We defined sitting without trunk support as sit-
Table 1 Subjects descriptive characteristics
Nurse
Sex
Age (years)
Years of experience
A B
F F
36 41
8 21
C
F
45
17
D E
F F
48 42
15 20
Experiential domain Neurosurgery, urology Neurosurgery, internal medicine, orthopaedics Internal medicine, urology, surgery Internal medicine Internal medicine, surgery
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K Miyata et al.
ting on the side of a bed, with the feet on the floor, and the back unsupported (Sandin & Smith 1990). Observations were made from the nurse entering to leaving the room, including their performance during the intervention itself. The researcher explained his or her role and the purpose of the study to the participant nurses, the facilities involved, and to the patients and families being nursed; in particular, it was specifically explained that there would be minimal restriction or impact on normal nurse–patient relations. Observation notes of the behaviour of the nurses and the reaction of the patients were recorded in detail. To assess the sitting without trunk support intervention, 10 patients with 4–240 month histories of DOC (Table 2) were enrolled. All patients were nursed at home or in a nursing facility during recuperation, and patients with bone fractures or pneumonia had been admitted to participating hospitals for between one day and 11 years. The range of Glasgow Coma Scale scores at the time of observation was 6–11, and nine patients had contractures. After the observation, semi-structured interviews were conducted in a private room. These interviews were based on the observation notes and a predetermined interview guide comprising two questions. The questions enquired about why the nurse participant made patients with DOC sit without trunk support, and how they achieved it while minimising risk. The interview was performed within 24 hours of the observation. Participants were asked to consent to the research and the use of a digital recorder (an integrated circuit recorder), and the recorded interviews were transcribed verbatim for data analysis. If a question arose during data collection, we re-interviewed the participants. Interviews lasted 47– 62 minutes; two participants were interviewed once, two participants twice, and one participant thrice.
Data analysis A text-mining method was used to obtain new knowledge (Feldman & Sanger 2007). This method is compatible with grounded theory and is reportedly less restrictive than other qualitative research methods (Yu et al. 2011). In this research, the sentence periods were set to simple, compound and complex. Paragraphs were set according to changes of subject. Thus, we obtained 759 sentences and 218 paragraphs from interview data in Japanese. Data were analysed using the Japanese text-mining software, KH Coder (Higuchi, 2012). First, a morphological analysis was conducted, and 1611 different words were extracted. Words or phrases with the same meaning were considered synonyms and treated as the same. For example, both ‘I’ and ‘Nurse’ were considered synonyms. A total of 143 synonyms were generated; specifically, more than 90% of words, 924% of sentences, and 989% of paragraphs included synonyms. For the paragraph data, synonyms with the greatest frequency of appearance were as follows: , , , , , , , , , and . Furthermore, the paragraph was considered as a unit of the total, and we searched for synonyms with high similarity and relativity in the emerging pattern by hierarchical cluster analysis (Ward method) and extracted 14 clusters with a 15 degree of dissimilarity. In the cluster analysis, we used the number of times each synonym appeared per paragraph as a reference and excluded the position of the synonym in the sentence and the length of the sentence.
Table 2 Overview of patients’ participating observation History
State at the time of the observation
Nurse
Patient
Sex
Age (years)
Cause of DOC
PIM
Cause of this admission
Length of stay
GCS
Contracture (Yes/No)
A B C
1 1 2 3 4 5 6 7 8 9 10
F F F F F M F F F M M
53 53 84 96 91 82 89 79 94 76 83
HIE HIE Parkinson’s disease CI MID Alzheimer’s disease CI SAH, CI CI, MID SAH, CI CI
8 8 204 120 36 36 132 4 120 240 156
Pneumonia Pneumonia Asthma attack Diarrhoea, fever Pneumonia Pneumonia Bone fracture Pneumonia Bone fracture Pneumonia Pneumonia
3 days 3 days 11 days First day 1 year 3 years 11 years 4 months 1 year 6 years 6 years
9 9 11 11 10 10 9 9 8 6 10
No No Yes Yes Yes Yes Yes Yes Yes Yes Yes
D
E
F, Female; M, Male; PIM, Postinjury month; GCS, Glasgow Coma Scale; HIE, hypoxic ischaemic encephalopathy; CI, cerebral infarction; MID, multi-infarct dementia; SAH, subarachnoid haemorrhage.
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© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Original article
All paragraphs in which synonyms for each cluster appeared totalled 100%. The common meanings of approximately 20% of the paragraph data were extracted with several synonym combinations. The cluster was consistently named in Japanese according to the meaning of the synonym itself. To extract common meanings, data with strong implications for other elements were eliminated. Then, we translated the names of synonyms and clusters to English and back-translated the text to Japanese to confirm its accuracy. In addition, the generation of synonyms, the naming of clusters, the translation process and the back translation were performed with a postdoctoral nursing researcher familiar with qualitative study. The validity of the approach was therefore confirmed.
Ethical considerations This study was approved by the ethics committee of Faculty of Health Sciences, Hokkaido University. We acquired informed, signed consent from the nurses, patient representatives, and research partnership facility managers. We explained (both orally and documented) the purpose of the research, their right to confidentiality, and their right to refuse or decline participation and explained that no disadvantage would result either from participation or from nonparticipation. In addition, if the patient would recover consciousness, get consent by similar procedures. The participant’s names were encrypted and saved. The researchers were nurses with doctoral degrees and were familiar with qualitative and quantitative research.
Results We identified 14 clusters: three clusters related to ‘why’ nurses sat patients with DOC without trunk support and five clusters related to ‘how’ they achieved sitting without trunk support, consistent with the study aims. The contents of each cluster are shown below, according to the following key: italics are used to state the cluster name, and the symbols < and > bound the synonyms.
Why and how nurses sit patients with DOC
1 To raise the patient’s body to assess the recovery of activities of daily living. This cluster comprised 12 synonyms. These included the , , , , and . An example with five synonyms is shown below: is leading to life. When we carry out intervention, there is no clear assessment that they do anything. While doing the , I know their possibility by my hands and arms. Maybe it is my . [Nurse C]
2 To adjust circadian rhythm and encourage the will to sit. This cluster comprised 20 synonyms. These included , , , , , , , and . An example with six synonyms is shown below: I have the idea that the of must be improved first. Patients who are bedridden in a have no sense of day and night. We have a of sleeping at night and getting up in the morning to do , but patients do not perform according to any set . Any patient should be encouraged to wake up in the morning and should be dressed to begin . If the patients sit without trunk support on their own, we should assist their back. This informs them that it is the daytime now and creates a . I think that sitting without trunk support is important to induce the to sit. [Nurse A]
3 To make it easier to breathe. This cluster comprised seven synonyms. These included , , and . An example with six synonyms is shown below: I want to the patient’s and contracture better. If I the patient’s rib cage move more, the risk of , , and will be reduced. In other words, I think that good breathing indicates the body that can move. This means that the good body can not only but also the hand becomes free. Moreover, is . As for me, it
Why nurses sat patients with DOC without trunk support Three clusters were generated to explain the reasons for sitting patients with DOC without trunk support as follows: to raise the patient’s body to assess the recovery of activities of daily living, to adjust circadian rhythms and encourage the will to sit, and to make it easier to breathe. These are now expanded with their synonyms in the following three paragraphs: © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
is surely disagreeable to become busy with . Then, I wish to prepare the patient’s body daily. It is a patient’s body. [Nurse D]
How nurses facilitated sitting without trunk support We generated five clusters to describe the practice of sitting without trunk support for patients with DOC. These were as follows: moving the patient to the prone position to sit
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in safety and comfort, developing postural stability by improving the flexibility of the lower limbs, improving the flexibility of the hip joint, developing trunk balance and encouraging hand use for stability, and terminating sitting practice when symptoms of respiratory failure, heart failure, or excessive tiredness developed. These are now expanded with their synonyms in the following five paragraphs:
4 Developing trunk balance and encouraging hand use for stability. This cluster comprised 19 synonyms. These included , , , , , , , , and . An example with seven synonyms is shown below: I think that muscle can also be by sitting without positively. Also, additional stimulation is pro-
1 Moving the patient to the prone position to sit in safety and comfort. This cluster comprised 11 synonyms. These included , , , , and . An example with 11 synonyms is shown below:
duced by independence and through the . To break down their on purpose, I the patient’s body while sitting. This is meant to be a stimulus for them to their bodies on their own, even if there is risk to postural . [Nurse C]
I am careful about and at all times. I also ensure that the blood pressure is maintained above 60–70 (units). If the blood pressure becomes , approximately 60–70, I would never raise the patient’s body suddenly. In that case, I would gradually place the patient in a head-up position to accustom his or her body to the postural change. If the blood pressure is very , I keep the patient supine in bed and come back to them at another time. [Nurse E]
Discussion We identified three reason clusters (i.e., why) and five practice clusters (i.e., how) related to nursing patients with DOC in a sitting posture without trunk support. The reasons were (1) to raise the patient’s body to assess the recovery of activities of daily living, (2) to adjust their circadian rhythm and encourage the will to sit, and (3) to make it easier to breathe. The practice involved (1) moving the patient to the prone position to sit in safety and comfort, (2) developing postural stability by improving the flexibility of the lower limbs, (3) improving the flexibility of the hip joints, (4) developing trunk balance and encouraging hand use for stability and (5) ensuring safety by terminating the sitting practice when symptoms of respiratory failure, heart failure or excessive tiredness developed. In this study, the main reasons for sitting patients were to assess their readiness for independent living and to prepare them by ensuring optimal breathing and a proper circadian rhythm. The sitting position is a fundamental posture for activities of daily living, including eating meals © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2498–2504
Original article
Why and how nurses sit patients with DOC
and defecating. In patients with hemiplegia due to cerebrovascular disease sequelae, it has been reported that the acquisition of sitting balance is correlated with autonomous living (Cabanas-Valdes et al. 2013). This is consistent with our finding that sitting without trunk support was intentionally developed and considered fundamental for independent living. To date, research among patients with DOC has focused on the activation of brain activity, such as the reaction and level of consciousness induced by stimulation, and has focused on sensory stimulation (Oh & Seo 2003) and sitting without trunk support (Okubo 2011). This study adds a novel perspective that sitting without trunk support facilitates the development of independent living among patients with DOC. This study revealed that hip flexibility is specifically encouraged in the prone position as an initial step to improve sitting balance. Research has shown that, after being bedridden for long periods, rehabilitation needs to be modified to account for the physical disuse states that persist after cognitive recovery (Andrews et al. 1996); failure to do so increases the possibility of fracture through even minor movement (Oppl et al.2014). Due to their cardiorespiratory decline, acute shock can also develop after moving patients to the sitting position (Spaak et al. 2005), which has led to a tendency to restrict movement in patients with DOC in an attempt to reduce any risk (Lavrijsen et al. 2007). Consequently, no clear method of rehabilitation has been established for this patient group (Elliott & Walker 2005). This study failed to clarify the beneficial effects of the prone position and of the interventions that improve hip flexibility. Despite this, if correctly performed while carefully observing circulatory dynamics, this research suggests that sitting without trunk support represents a promising intervention. Importantly, this new skill is based on the
fundamental nursing principle of helping patients gain independence as rapidly as possible.
Conclusion This study used a text-mining method to assess why and how nurses rehabilitate patients with DOC in the sitting posture without trunk support. The core reason for this practice was to provide a foundation for those patients to live independently. The practice therefore focused on identifying patients at risk of fracture and cardiorespiratory deterioration due to disuse syndromes and engaging in physical preparation in the prone position to improve the flexibility of the hip joint. This gives us more practical evidence than previous studies that focused on the role of the intervention in improving the level of awareness among patients.
Relevance to clinical practice The primary goals when nursing patients with DOC are maintaining life, preventing complications, and helping with their activities of daily living. This study provides empirical and practical evidence from nurses who perform novel clinical interventions that specifically promote independent living. Verifying the physiological meaning of this intervention would further contribute to its development as a useful nursing skill and, if implemented, should ultimately help to improve the quality of life of patients with DOC.
Contributions Study design: KM, YH; Data analysis: KM, YH and Manuscript Preparation: KM, YH, SY.
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