Traumatic brain injury (TBI) is a problem that affects humans on every continent where humans have established societies. According to Levack et al (2010) worldwide there are approximately ten million individuals whose death or hospitalization are caused by TBI annually. This study originated in New Zealand where the government spends one hundred million annually in the acute and post-acute care for those who have experienced TBI and that number grows larger every year. (Levack et al., 2010) In a country the size of the United States that number grows to between nine to ten billion dollars annually. (Levack et al, 2010) Since a large majority of this money is spent on the long term rehabilitation and care of patients, this is the area where if examined and analyzed for best practices and outcome measurements, where the most potential savings can occur.
Especially if those best practices become the standard of care for TBI patients. If medical care is geared from the acute phase care through the post-acute phases then not only can money be saved but patient outcomes can improve as well. Under current medical practice, not all best practices and outcome measures have been identified and this leads to disparate care for patients with TBI depending on factors of where they live to socio economic status of the patient. Purpose and Methodology for Article Selection The study by Levack et al. (2010) has the stated intent “to explore the use of qualitative metasynthesis to inform debate on the selection of outcome measures for evaluation of services provided to adults with traumatic brain injury.” In order to perform this metasynthesis the researchers “Fifteen databases were searched for qualitative research published between 1965 and June 2009, investigating the lived experience of recovery following TBI acquired during adulthood” (Levack et al, 2010) Each article was reviewed by two researchers to locate themes that best described the lived experience of adults post TBI. (Levack et al, 2010)
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This allowed the authors of the study to gather information from as broad a source as possible, but may have the ability to create a situation of information overload for the researchers. That being said, by including research that is almost 50 years old it does allow the researchers to look to the past and gain a complete picture in how TBI has been treated in the age of modern medicine. For this study the authors only looked at qualitative studies, as stated “to be considered a qualitative study, papers needed to explicitly adopt qualitative methods for both data collection and data analysis. Papers that collected quantitative data…were thus not considered.” (Levack et. Al, 2010) They also excluded any studies where the TBI was caused by anything other than “an acute brain injury resulting from mechanical energy to the head from external physical forces where such injury was found to result in confusion, disorientation, loss of consciousness, post-traumatic amnesia or other neurological abnormalities” (Levack et al. 2010)
Any studies that focused on or allowed participants whose TBI was caused by “drug, alcohol or medication use; treatment for other injuries; psychological trauma; psychiatric disorders; or other co-existing medical conditions” were also excluded (Levack et al, 2010).
Originally 1629 papers were identified for possible inclusion in the study, after all papers were examined based on the inclusion criteria identified only 23 papers were included in the final metasynthesis. These 23 papers were published between 1965 and 2009, therefor for the currentness of this study is open to debate since the majority of the papers included research from the last 5 years the inclusion of information almost 50 years old at the time could arguably be deemed irrelevant. However, one could argue that since the focus is on the experience of the adult patient post TBI, that human experience is human experience, whether or not that experience occurred 5 years ago or 50 years ago.
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Framework and Findings While not explicitly stating it in the paper it appears as if the researchers were utilizing the grounded theory frame work to guide their analysis of the topic. This can be gleaned from the fact that a very large amount of initial information, 1629 papers, was gathered a reviewed by multiple researchers. This large amount of information was applied to very selective inclusion criteria and whittled down to 23 articles. (Scott, 2009) In other words only 1.4% of the original gathered information was included after inclusion criteria was applied to the available research. The most significant reason articles were disqualified was that they included quantitative analysis. This key criteria alone accounts for 1367 of the excluded papers. (Levack et al, 2010) Also as stated by Helen Scott (2009) Grounded Theory allows for researchers to “seek out and conceptualise (sic) the latent social patterns and structures of your area of interest through the process of constant comparison.” Levack et al (2009) did just that, in that the main result of their metasynthesis was to identify the eight interrelated themes of:
1) Mind/ body disconnect
2) Disconnect with pre-injury identity
3) Social disconnect
4) Emotional squeallae
5) Internal and external resources
6) Reconstruction of self-identity
7) Reconstruction of a place in the world
8) Reconstruction of personhood
to describe the enduring experience of those who have suffered a TBI in adulthood (Velack et al, 2010).
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The authors of the study however explicitly state that they were hindered by a “paucity of qualitative studies” on the subject of TBI and that their misconception at the outset that there would be an abundance of qualitative studies. However they go on to state that “given that these independently conducted studies consistently identified similar theoretical constructs, we propose that this body of research should be considered increasingly representative of commonly lived experiences following TBI.” It is hard to determine if this statement should be taken at face value or if there is a need to justify this metasynthesis of only 23 articles over approximately 50 years.
Application to Practice How can these findings be applied to practice? If we as medical professionals understand the interrelated themes then we can help guide patients through them from the mind body disconnect that occurs post TBI towards the goal of reconstruction of personhood. A similar idea would be how we view the transition through grief. We know as medical professionals that there are five stages that people will inevitably endure with a loss, however the order of those stages and time spent in each stage will vary from person to person based on their individual resilience and support network. This is very similar to the concepts identified for TBI patients in this study as shown in the flow diagram created by the authors to show the interconnectedness of the 8 themes in what they call the enduring experience of TBI. (Fig 1.)
References
Levack, W., Kayes, N., & Fadyl, J. (2010).
Experience of Recovery and Outcome Following Traumatic Brain Injury: A Metasynthesis of Qualitative Research. Disability & Rehabilitation, 986-999. Retrieved April 22, 2015, from http://library.gcu.edu:2048/login?url=http://search.ebscohost.com.library.gcu.edu:2048/login.aspx?direct=true&db=s3h&AN=50311007&site=eds-live&scope=site
Scott, H. (2009, January 1).
What is Grounded Theory? – Grounded Theory Online; supporting GT researchers. Retrieved April 22, 2015, from http://www.groundedtheoryonline.com/what-is-grounded-theory
