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The role of specialist nursing in complex brain injury – perspective from a specialist nurse

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Charlie Oliver is Ward Manager on Allitsen – part of St Andrew’s specialist neurobehavioural brain injury pathway. Charlie and her team care for and support people with complex cognitive, behavioural and physical healthcare needs as a result of their brain injury.

NR Times caught up with Charlie to find out more about the importance of multidisciplinary working within this context and how providing dignity for her patients is key to her team’s nursing approach.

Allitsen is one of four specialist wards here at St Andrew’s.

The ward accepts transfers and step-down from our admission wards, but also has people come to us directly.

We specialise in supporting patients with complex brain injuries, significant physical needs and who tend to have longer-term management needs.

Defining timelines for a patient’s progress can be difficult if they’ve had a significant brain injury.

There can be huge psychological issues and a lot of attendant comorbidities. Nothing is linear with brain injury.

Some of our patients are living with dysphagia following their brain injury and some require PEG feeding. All require extensive physical care.

Providing a good quality of life for patients is central to mine and my team’s approach, so we work very hard on nurturing therapeutic relationships and building on those to support patient rehabilitation.

Also key is the support from the wider specialist MDT and our patients receive frequent input from Neuro Specialist Physiotherapists, the Speech and Language team and Specialist Dietitians.

Ensuring dignity for people following a brain injury is a guiding principle for us 

Maintaining a person’s dignity is central to everything we do, particularly when it comes to caregiving and patient interaction.

It’s not just a core value; it’s a guiding principle that impacts how we design care plans, conduct conversations and manage our patients’ physical and emotional environment.

This is especially important when working with people who have significant brain injuries.

They may not recognise when they need to go to the toilet, for example, and that can be really frightening to anyone if you can’t comprehend what personal care entails.

In these situations, it’s all about that communication and a slow process of building trust.

One of our patients is bed-bound and incontinent and he can be very aggressive during personal care because he doesn’t understand what’s happening.

But thanks to our nursing team following a consistent approach when delivering personal care, and with a lot of input from SLT, he’s starting to recognise and is able to communicate when he needs to go to the toilet.

We’re trying to build on that by encouraging him to tell us when he needs to go so we can use the commode, rather than him having to rely on incontinence pads.

He’s now not so aggressive and is able to spend periods of time in communal spaces with others, and he responds particularly well when the PAT dogs visit.

We will find a way to get him where he needs to be. It just takes time. Nothing ever happens quickly.

Being able to adapt to people’s needs is crucial 

It’s about being adaptive to the needs and preferences of the particular person.

One gentleman doesn’t like to shower, but he’ll happily sit in the bath for ages. So we’ll put some music on and make it really nice for him so he can enjoy the experience.

It’s really important that we get this right.

Staying clean and fresh is not only good for mental health, but supporting and communicating with people whilst providing personal care also helps us as a nursing team to build a positive therapeutic relationship.

We do whatever we can to support people in getting the best out of their life.

We work with another individual who’s only got the functional use of one arm.

While there’s nothing we can do to give him the use of that arm back, it’s important that we find ways to adapt things for him and show them that there’s still quality of life to be had.

Over time, he’s gone from needing four people to help him get up in the morning to just one. He can mobilise using a specialist wheelchair, giving him back independence and a sense of autonomy.

He’s also relearning to walk with the aid of a walk stand in tailored 1:1 sessions with our brilliant physio team.

This is huge progress for a man who was once bed-bound and reliant on hoists to perform even basic personal hygiene.

Even if a person’s presentation following their brain injury doesn’t change a huge amount, it’s still about promoting their independence as much as possible.

Managing risk whilst supporting people with a complex brain injury

Risk management is one thing St Andrew’s excels at and we can provide the higher level of support needed to get patients to a point where they no longer present with those risks.

This is because my team wears many hats. We can manage the physical, mental and neurological health at the same time, always with the patient at the centre of everything.

One of our most recent success stories was a gentleman who had originally been in an older adults unit.

His family felt he required more specific neuro-rehabilitation although the initial baseline assessments weren’t favourable when he came to us.

When he arrived he was very confused, he was aggressive and was a high falls risk. He needed three people for personal care and wasn’t able to recognise his family in pictures.

Because of his presentation he couldn’t immediately attend structured physiotherapy sessions so we placed a priority on encouraging functional physiotherapy during the day.

This including encouraging him to stand for increasing periods during personal care and in the shower and taking short steps.

Three months on and he’s a completely different guy, he’s really found his feet and can walk laps around the ward which is an amazing achievement.

Image by Paul Michael Hughes Photography T 07790819111 UK E pmh@paulmichaelhughes.com W www.paulmichaelhughes.com

His family who visit every other week have been surprised by the change.

We had another patient with frontal lobe damage who was quite disinhibited. There was a lot of physical and sexual aggression as a result of his injury.

The man required 4:1 hoisting when he came to Allitsen and he was very reluctant to engage with people.

We placed a lot of emphasis on getting him into his wheelchair. He worked with physio and we encouraged him to attend all mealtimes out of his bed.

Over time, his appetite improved, he gained weight and his core strength built from sitting up in the chair rather than laying in bed.

He’s now starting to walk and takes trips into the local town in his wheelchair on the bus, which he really looks forward to.

He also meets up with old friends in town which has been hugely liberating for him and given him that sense of self.

It’s really important to us that we do absolutely everything we can to give our patients the best possible quality of life, whatever their circumstances.

Another gentleman, who was 65, started to become unwell around January last year. He was losing weight and enduring severe stomach pain without any obvious cause.

He was eventually diagnosed with terminal cancer.

The cancer was very aggressive. From diagnosis to his passing was about 12 weeks.

But during that time, the MDT and nursing team went above and beyond to do everything they could to give him the best quality of life possible.

He made a bucket list. Everything that he could possibly do was ticked off before he died.

Staff would come in on their days off to see him and do whatever they could to support him.

Key members of the team took him on a day trip to his hometown that he always talked about but hadn’t been to since he was 20 years old.

That was one of his life goals and he said as much before he passed away.

While we couldn’t discharge him as he’d wished, everyone on the team did everything they possibly could for him.

I’ve seen the same with other patients who’ve become sick or passed away.

We really do care about our patients on this unit and we do everything we can to give them the best quality of life possible.

You can find out more about St Andrew’s specialist neurobehavioural brain injury services HERE 

To discuss a complex brain injury referral t: 0800 434 6690 e: SAH.admissions@NHS.net

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