Problems and Needs of Caregivers and the Multidisciplinary Team regarding Transitional Care for Survivors of Severe Traumatic Brain Injury: A Qualitative Descriptive Study

The needs and support for survivors of severe traumatic brain injury and their caregivers after hospital discharge are in high demand. Although care transition interventions have demonstrated improvement in outcomes, little is known about care transition practice for survivors of such brain injury as experienced by multidisciplinary team members and caregivers in Thai community settings. This study aimed to describe the problems and needs in caring for survivors of traumatic brain injury during the hospital-to-home transition as perceived by the multidisciplinary team and caregivers. A qualitative descriptive study was conducted in one of the tertiary hospitals in Southern Thailand. The researcher collected data through in-depth interviews with seven caregivers of survivors of traumatic brain injury and focus group discussions with 11 multidisciplinary team members. Content analysis was used for data analysis. The multidisciplinary team and caregivers identified problems and needs related to the demands of care and the needs of the caregivers. “Lack of adequate preparation, learning resources and self-confidence” was identified as a main theme. Four sub-themes included: 1) inadequate discharge preparation, 2) low self-confidence in patient care at home, 3) lack of adequate learning resources and communication channels for caregiving at home, and 4) limited time on home visits after discharge. “Consistent support with accessing appropriate resources” was reported as the most common need. Four sub-themes included 1) adequate discharge planning within the caregiver’s context, 2) simple self-learning resources available at home, 3) alert and rapid response using technology for two-way communication, and 4) adequate supplies and network support of primary care after discharge. Caregivers and the multidisciplinary team require additional support from routine practice. This necessitates a co-designed discharge program in the transitional period that incorporates the specific needs and problems of the care setting. Future nursing research needs to develop a transitional nursing support model to enhance caregivers' capabilities in providing effective patient care at home.