Michele Paterson, RGN, ONC.
Spinal Nurse Specialist, Queen Elizabeth Spinal Injuries Unit, GlasgowAdvances in knowledge around spinal cord injuries and the technology available to patients and professionals mean specialist units must constantly evolve to respond to patients' needs.
Advances in knowledge around spinal cord injuries and the technology available to patients and professionals mean specialist units must constantly evolve to respond to patients' needs.
Queen Elizabeth National Spinal Injuries Unit provides immediate care and long-term follow-up of any patient in Scotland with a traumatic spinal cord injury.
Based in the Southern General Hospital, Glasgow, the unit has 48 beds - 12 high-dependency and 36 rehabilitation - and takes a multidisciplinary approach.
Rehabilitative care is a continual education process. Hammell (1995) defines it as a programme of interventions that empower individuals with spinal cord injuries to achieve satisfaction in productive activity and personally fulfilling, socially meaningful and functionally effective interactions with the world.
Before they can be empowered, patients have to learn a host of new skills and absorb new information about maintaining their health. Education plays a key role in successful rehabilitation. For adult patients this can be achieved by adhering to the principles of adult learning. Knowles (1990) believes there are five key principles:
- Adults need to know why they need to learn something
- They should take responsibility for their own learning (self-directed learning)
- Previous life experiences and prior learning influence learning
- Readiness to learn relates to need to know
- Adult motivation to learn is largely internally focused - for example, on perceived quality of life and self-esteem.
Ley (1979) suggests that, for information to be retained, it needs to be stated three times, in different ways, and then backed up in writing.
So how do we provide education for clients within the spinal injuries unit?
People have different ways of learning, so we use a varied and flexible range of teaching styles.
Individual education - Education is provided on an individual basis by each discipline, using the goal-planning process. Rehabilitation is patient-centred and adaptable to suit individual needs (Zedjlik, 1992).
Eade (1995) states that goal-planning 'challenges the individual to give life a pre-planned direction by employing specific exercises and strategies'. It involves patients making decisions in prioritising the goals they need to achieve. Giving them control encourages patients to think in a more structured way about their situation and needs (Hammell, 1995). In the long term, it involves more than simply relearning physical tasks that make them independent. They also need to regain the ability to make decisions and prepare for reintegration into the community.
All humans need something to aim for. Goals give meaning to the actions needed to achieve them.
Groups - Weekly group educational sessions are held on a 10-week rolling programme, with different topics covered each week and delivered by the multidisciplinary team (Box 1).
A final 'free' session allows patients to discuss issues they wish to raise. Former inpatients are invited to speak about their experiences. Sessions last 45 minutes to an hour and use a range of formats such as discussions, slide and video presentations.
Group learning has many uses. Structured educational sessions at a set time of day each week emphasise education as an essential part of the rehabilitation programme.
Patients have a forum to ask questions they may not want to ask when on their own. It allows the group to discuss issues and share ideas. An attendance record is kept and patients are actively encouraged to turn up. Evaluations take place at the end of the programme. Patients' views are ascertained through discussion, as not all would be able to fill in forms (Smith, 1999). New talks have been added to the programme following patient feedback.
Relatives - Spinal cord injury affects families as well as the patient. Families can greatly influence the success of patients' rehabilitation. Family support helps patients adjust to their situation, increasing motivation and building confidence (Hoeman, 1996).
Gordon (1998) states that information can reduce feelings of helplessness and isolation among families and patients and increase patients' ability to remember and adhere to treatment plans. With patients' consent, family members are encouraged to take part in their loved one's care. Formal group sessions can reinforce understanding of what is being carried out and why.
Following the patient group programme, we run a relatives' information day for family members and carers, which is a condensed version of what the patient receives. Feedback has shown that relatives find this useful. It develops their knowledge of spinal cord injury and increases their confidence. It allows them to get to know key staff members and their roles. They can also meet staff informally to discuss issues of concern, providing a means of peer support (Smith, 1999). Again, evaluations are carried out at the end of the day.
Written information - Written material can reinforce the information and be used for reference later (Smith, 1999). Many patients might only read it following discharge (Raisbeck, 2000). The spinal unit has produced a series of booklets, written by staff with patient input and advice. These are also available on our spinal website, which can be accessed at: www.show.scot.nhs.uk/spinalunit
While in hospital patients are often distressed and overwhelmed. They may be in denial or find that there is just too much information to take in at once. They may not be fully ready to learn for some time.
Many aspects of rehabilitation, such as decision-making and problem-solving, are only fully explored after discharge. Patients often feel anxious and unsure of their capabilities. Only when they have had time to reflect do they think of questions that they need answers to.
The spinal injuries unit at Queen Elizabeth offers lifelong follow-up. Patients receive an annual review at the outpatient clinic. They often raise questions in this consultation, although 20 minutes does not always allow time to provide education.
A community liaison service is also provided. The team receives many phone calls from patients, some discharged years ago, and from carers and district nurses seeking advice on aspects of spinal cord injury management. People are also starting to email for advice.
The team now runs a number of outreach clinics throughout Scotland to enable us to review patients locally (Box 2). These are unique in the UK. Clinic frequency depends on the number of people with spinal injuries in the area.
It is difficult for patients to keep up with the changes in management, products and services available. Our spinal roadshow refresher days aim to help patients do this.
The project started in June 2002 with a roadshow in Aberdeen. All patients and their families in the region were invited to attend an update on spinal injury care. A comments section enabled them to propose topics to discuss on the day.
Four speakers from the unit travelled to Aberdeen - two nurses, a physiotherapist and an occupational therapist (pictured above). A speaker from the voluntary organisation Spinal Injuries Scotland was also invited, as were representatives from companies producing relevant products.
We decided not to hold the roadshow in the local hospital as we felt it would be too clinical. Instead, we chose a hotel in the centre of Aberdeen.
The day was attended by 40 patients, families, carers and district nurses, and feedback was positive. Patients appreciated that we had travelled to see them as opposed to them having to travel 150 miles to Glasgow, and hoped that we would repeat the day.
A subsequent roadshow in Wick was attended by 22 people and has been repeated. To ensure roadshows are cost-effective, they are run alongside regular outreach clinics.
Although in their infancy, our roadshows have proved a success so far. They have allowed the dissemination of up-to-date information to a large group of people and provided patients with an informal gathering to share information and experiences. They also allow members of the multidisciplinary team to network with other professionals locally and establish links with other agencies.
Eade, D. (1995)Strategies for a balanced life. Clinicians Reference Guide 4 (supplement): 13-16.
Gordon, G.H. (1998)Educating and enlisting patients. Journal of Clinical Outcomes Management 5: 4, 45-50.
Hammell, K.W. (1995)Spinal Cord Injury Rehabilitation. Therapy in Practice. London: Chapman and Hall.
Hoeman, S. (1996)Rehabilitation Nursing: Process and Application (2nd edn). London: Mosby.
Knowles, M. (1990)The Adult Learner: A neglected species (4th edn). Houston, Tx: Gulf.
Ley, P. (1979)Memory for medical information. British Journal of Social Clinical Psychology 18: 2, 245-255.
Raisbeck, E. (2000)The write stuff. Nursing Standard 14: 37, 19-20.
Smith, M. (1999)Rehabilitation in Adult Nursing Practice. London: Churchill Livingstone
Zejdlik, C.P. (1992)Management of Spinal Cord Injury (2nd edn). Sudbury, Ma: Jones and Bartlett.