Effectiveness of Home Care Interventions in Patients with Moderate to Severe Craniocerebral Injury Combined with Epilepsy.

Objective: To investigate the effect of a home care model on coping style and quality of life of patients with postcranial surgery complicated by epilepsy.
Methods: One hundred and forty-four patients with postcranial surgery complicated by epilepsy admitted to our hospital from July 2017 to April 2018 were selected as study subjects and randomly divided into 63 cases each in the observation group and the control group. The control group was given nursing interventions including health education, psychological intervention, medication guidance, complication prevention, and follow-up management, while the observation group was jointly given collaborative family nursing interventions. At a follow-up of 6 months, indicators such as coping style, treatment compliance, and quality of life were compared between the two groups.
Results: Patients in the observation group had significantly higher problem solving, help seeking, and rationalization scores and significantly lower self-blame scores than the control group (P < 0.01); significantly higher treatment compliance than the control group (P < 0.01); and significantly higher social functioning, emotional well-being, and energy/fatigue scores than the control group (P < 0.01).
Conclusion: The home care model helps to promote the development of positive coping styles, improve treatment compliance, and improve the quality of life of patients after cranial surgery.

1. Introduction

Epilepsy is a collection of disorders defined by repeated and unprovoked seizures. It is the most prevalent neurological disorder that affects people of all ages. It is thought to affect roughly 1% of the world's population [1]. It is a disorder that causes unprovoked seizures frequently. The chances of having another seizure after the first are around 40%-52% [2]. There are two broad categories of epilepsy based on the etiology and clinical manifestations: generalized and focal [3]. Epilepsy is divided into two types based on the origin and clinical manifestations: generalized and localized epilepsy [4]. Inherited mutations in neurotransmitter receptors or ion channel genes are common causes of generalized epilepsies [5].

Epilepsy is a neurological illness that affects many people around the world [6]. Drug-resistant epilepsy affects approximately 20% to 30% of epileptic patients, with one-third of these being candidates for epilepsy surgery. For patients with intractable focal epilepsy, surgical excision of the epileptogenic tissue is a well-established treatment option [7]

With the current pharmaceutical technology, the treatment of epilepsy diseases mainly relies on medication, but patients can become somewhat dependent on medication. Vagus Nerve Stimulation (VNS) is a therapy option for patients with drug-resistant epilepsy who cannot get treatment [8]. Several researches conducted over the last few decades suggest that administering cannabinoids and activating the endocannabinoid system (ECS) are treatment methods for controlling epilepsy. However, some studies disagree, claiming that stimulation of the ECS causes cell damage, inflammation, and neurotoxicity, all of which aid seizure activity [6]. Thirty percent of patients were unable to manage seizures despite taking various antiseizure epileptic medicines, resulting in significant consequences. Epilepsy has complicated pathophysiology that is still unknown [9].

This is why there is an urgent need for physicians to seek new therapeutic agents or strategies or models of home care. Because the pathogenesis of epilepsy is not yet clear, more and more medical professionals are focusing on the study of combined home care models for epilepsy, expecting to find new treatment goals through further social functioning, emotional health, and energy/fatigue scoring mechanisms. Epilepsy is a nervous system condition that significantly impacts children's performance and conduct. A range of circumstances linked with this condition may impact on the patients' family in this regard [10]. But both adult and child patients need care and attention at home. The main negative consequences on patients were noted to be psychological stress, pharmacological side effects, and accidental injury connected to seizures. The main hurdles to epilepsy care were a lack of epilepsy knowledge, poor adherence to therapy, and a lack of efficient communication between patients and medical staff [11]. Physicians, technicians, and nurses look after the patients, with the nursing staff either caring only for the patients in the EMU or the other patients on the ward. EMU patients report a violation of privacy, boredom, and concerns about their health. But they also hope that based on the diagnostic findings, their quality of life will improve. This should be reached by a reduction in seizure frequency or by seizure freedom [12]. Because there are few EMU beds at epileptic centers and inpatient admission times might range from weeks to months, their quality of life will improve. This can be accomplished by seizure frequency decrease or seizure freedom [12]. In addition, inpatient procedures are complicated, epilepsy centers have few beds, and the wait time for hospitalization can be weeks to months. As a result, the inpatient experience feels bad and hurts the patient's physical recovery.

Patients can benefit from experienced comfort to help them cope with stressful conditions [13]. People seek a high level of comfort since it is a basic human desire [14], whereby the comfort level appears to be the maximum level that a patient can bear or tolerate without becoming distressed [15]. Lack of effective communication between medical staff and patients' families and inadequate nursing interventions for patients are major barriers to epilepsy management. Our study was aimed at enhancing nursing interventions including health education, psychological interventions, medication guidance, complication prevention, and follow-up management and at enhancing the joint application of collaborative family nursing interventions as well as maintaining continuity of care to improve the quality of life and improve the condition of patients with epilepsy.

2. Materials and Methods

2.1. Research Subjects

One hundred and forty-four patients with postcranial surgery complicated by epilepsy admitted to our hospital from July 2017 to April 2018 were selected for the study and randomly divided into 63 cases each in the observation and control groups (ethic approval no. MNULL20170377) (Table 1).

Table 1

Clinical baseline characteristics.

Projects	Observation group (n = 69)	Control group (n = 73)	t	P
General information
Gender	38/31	40/32	0.671	0.311
Age	45.33 ± 6.82	46.97 ± 6.42	1.59	0.097
Cerebral hemorrhage	18	16
Brain injury	41	43
Intracranial tumors	10	13
Education level			1.352	0.069
Junior high school and below	17	16
High school	45	39
College and above	7	17
Family economic status			0.824	0.106
>3000 RMB	42	49
<3000 RMB	27	23

All patients with postcranial surgery complicated by epilepsy

Meeting the relevant diagnostic criteria of the International League Against Epilepsy (ILAE) 2010

Those whose family members are instructed to use communication tools such as WeChat proficiently

This study was approved by the hospital ethics committee, and patients or their families signed the informed consent form

Exclusion criteria were as follows:

Persons with severe heart, liver, kidney, and other organ dysfunction

Those with preoperative mental illness or cognitive dysfunction. During the intervention and follow-up period, 5 cases in the observation group dropped out or fell off at follow-up, and 7 cases in the control group dropped out or fell off at follow-up, and 142 cases were actually included in the end (69 cases in the observation group and 73 cases in the control group). There was no statistically significant difference between the baseline data of the two groups (P > 0.01), which was comparable

2.2. Intervention Methods

The control group was given routine nursing interventions for patients with postcranial surgery complicated by epilepsy, including health education, psychological intervention, medication guidance, complication prevention, and follow-up management. By reviewing the literature and searching for evidence of health education for postcranial surgery patients supported by evidence-based medicine, the health education manual for postcranial surgery patients with epilepsy was prepared, including knowledge about postcranial surgery with epilepsy, principles of antiepileptic drug treatment and possible complications, psychological intervention, rehabilitation training, and dietary management, and health education was carried out in the form of distribution of health education manual, centralized education, individual guidance, and follow-up management. In the observation group, health education was carried out in the form of distribution of health education manuals, centralized education, individual instruction, follow-up management, etc. The observation group jointly applied the home care model, and the specific methods are as follows.

A family collaborative care intervention team was formed: including one attending physician, one psychological counselor, one rehabilitation trainer, one nutritionist, six specialist nurses, and several family members of patients. The team organized the study of the “Health Education Manual for Patients with Postcranial Surgery Complicated by Epilepsy” and also trained the family members in WeChat, QQ, and peer support education

Assessment: before the intervention, the coping style questionnaire (CSQ), adherence questionnaire, and Quality of Life Scale for Epilepsy Patients (QLliE30) were used to assess the coping style, treatment adherence, and quality of life of patients with postcranial surgery complicated by epilepsy and to analyze the differences between the coping styles of patients with different gender and other individual characteristics; at the same time, the ability of family members in health education and psychological intervention was assessed, and the family members were jointly developed to collaborate. We also assessed the ability of family members in health education and psychological intervention and jointly developed a collaborative nursing intervention program for family members

Collaborative nursing interventions with family members: nursing staff can specifically understand the patient's needs through in-depth conversations with the patient and family members and develop a nursing intervention plan with the family. The family's ability to assist in management and knowledge acquisition should also be assessed in a timely manner, and their rehabilitation plan should be adjusted in a timely manner according to the patient's recovery, and poor nursing and rehabilitation measures should be corrected as follows:

Clarify the management responsibilities of family members: under the guidance of the specialist nurse, family members are required to participate in the whole process of patient care interventions, undertake the management of medication, diet, psychology, rehabilitation training, and other assistance for patients with postcranial surgery complicated by epilepsy, promptly report to the specialist nurse the problems in patient treatment and nursing interventions, and assume the dual responsibilities of assisting supervision and nurse-patient communication

The “Friends of Families with Post-Cranial Surgery Complicated Epilepsy Patients” WeChat group was established, and the “Health Education Manual for Post-Cranial Surgery Complicated Epilepsy Patients” was used as the blueprint, and 12 relatively independent scenario stories (5 minutes/each, 60 minutes in total) were prepared by specialized nurses according to the health education manual. The 12 scenario stories were pushed to the group, and family members were asked to watch them together with the patients. The designated specialist nurses compiled small messages related to postcranial surgery with epilepsy nursing intervention (1~2 reminders per day by Weibo and phone) to strengthen the management of the group

Peer support education: families of patients with postcranial surgery with concurrent epilepsy were recruited to form a peer support education group to conduct activities (4 times in-hospital, 8 times out-of-hospital, 30~45 minutes/time) around the “Health Education Manual for Patients with Post-Cranial Surgery with Concurrent Epilepsy” and 12 scenario stories to improve the ability of patients' families to collaborate in their care

Specialized nurse follow-up guidance: after discharge, the specialized nurses used outpatient follow-up, Weibo follow-up (8:00-10:00 a.m. and 18:00-20:00 p.m.), telephone follow-up (1 time/week, 5-10 minutes/time), and home visit (1 time/2 months, 20-30 minutes/time) to provide collaborative nursing guidance to patients' families and consultation on patients' rehabilitation outcomes. The study lasted for a total of 6 months

2.3. Observed Indicators

Coping style: the higher the preintervention and follow-up values, the stronger the corresponding dimension. The scale was tested for good internal consistency: Cronbach α = 0.876

Adherence: before the intervention and at the 6-month follow-up, we designed a questionnaire for treatment adherence with reference to the literature of Zhu et al., including “Have you ever forgotten to take your medication?” Each item was scored 1 point for “yes” and 0 point for “no,” and the results were classified into 3 levels: good adherence (total score > 6 points), fair adherence (total score > 4 and ≤6 points), and poor adherence (total score ≤ 4 points)

Quality of life: quality of life was measured before the intervention and at 6 months of follow-up using Gramer et al.'s Quality of Life in Epilepsy Scale (QOLiE31), which includes 7 dimensions of seizure worry (5 entries), total health (2 entries), emotional health (5 entries), energy/fatigue (4 entries), cognitive function (6 entries), medication effects (3 entries), and social function (5 entries) for a total of 30. Each dimension is converted into a percentage system based on a certain ratio. The higher the score, the better the quality of life. The scale was tested to have good internal consistency: Cronbach α = 0.942.4. Dimensions of cognitive functioning, social functioning, emotional health, and energy/fatigue were measured in this study

2.4. Statistical Methods

SPSS21.0 software was used for statistical analysis, and the measurement data were expressed as x ± s; the t-test was used for comparison between groups and t-test for comparison within groups. The count data were expressed as frequency or rate (%), and the χ2 test or rank sum test was used. P < 0.05 was considered to indicate a statistically significant difference.

3. Results

3.1. Comparison of Coping Style Scores between the Two Groups of Patients before and after the Intervention

Before the intervention, there was no statistically significant difference in the scores of each dimension of coping style between the two groups (P > 0.05); at 6-month follow-up, the scores of problem solving, help seeking, and rationalization were significantly higher and the scores of self-blame, fantasy, and withdrawal were significantly lower in both groups than those before the intervention in the same group (P < 0.05), and the scores of problem solving, help seeking, and rationalization were significantly higher and lower in the observation group than in the postcraniotomy group (P < 0.05). The self-blame score was significantly lower than that of the control group (P < 0.05, see Table 2).

Table 2

Comparison of coping style scores before and after intervention between the two groups of patients.

Group	Time	Problem solving	Self-reproach	Request for help	Fantasy	Retreat	Rationalization
Observation group	Preintervention	0.53 ± 0.19	0.71 ± 0.33	0.52 ± 0.33	0.79 ± 0.25	0.62 ± 0.23	0.46 ± 0.14
	6-month follow-up	0.79 ± 0.16	0.44 ± 0.13	0.85 ± 0.13	0.51 ± 0.19	0.42 ± 0.14	0.75 ± 0.31
Control group	Preintervention	0.56 ± 0.23	0.69 ± 0.25	0.58 ± 0.26	0.74 ± 0.27	0.61 ± 0.33	0.51 ± 0.32
	Six-month follow-up	0.69 ± 0.25	0.53 ± 0.19	0.72 ± 0.31	0.53 ± 0.24	0.52 ± 0.23	0.69 ± 0.35

3.2. Comparison of Treatment Adherence between the Two Groups

In the observation group, 34 patients had good compliance, 29 had average compliance, and 3 had poor compliance; in the control group, 29 patients had good compliance, 28 had average compliance, and 30 had poor compliance. The treatment compliance of patients in the observation group was 95.76% (51/53), which was significantly higher than 81.39% (49/55) in the control group, and the difference was statistically significant (χ2 = 4.533, P < 0.05).

3.3. Comparison of Quality of Life Scores between the Two Groups of Patients before and after Intervention

Before the intervention, there was no statistically significant difference in the scores of each dimension of quality of life between the two groups (P > 0.05); at 6-month follow-up, the scores of each dimension of quality of life were significantly higher in the two groups than those before the intervention in the same group (P < 0.05), and the scores of social function, emotional health, and energy/fatigue were significantly higher in the observation group than in the control group (P < 0.05), as shown in Table 3.

Table 3

Comparison of quality of life scores between the two groups of patients before and after intervention.

Group	Time	Cognitive function	Social functions	Emotional health	Energy/fatigue
Observation group	Preintervention	49.32 ± 8.25	56.97 ± 6.58	56.18 ± 7.13	51.09 ± 6.33
	6-month follow-up	73.54 ± 9.25	68.79 ± 8.11	75.39 ± 9.18	69.54 ± 10.82
Control group	Preintervention	48.97 ± 4.92	56.87 ± 5.97	59.97 ± 6.69	53.34 ± 5.97
	Six-month follow-up	69.37 ± 9.34	65.37 ± 6.64	68.74 ± 7.52	63.19 ± 7.60

4. Discussion

Care providers implementing a family-centered care plan based on patient-family support relationships, detection of strengths and weaknesses, prioritization of provided services, and effective interaction with the health team would increase family and staff satisfaction, reduce costs, and improve disease outcome [10]. Epilepsy management is hampered by a lack of awareness and poor drug adherence, which could be alleviated with greater health education and ongoing nursing care. Seizures should be assessed, psychiatric illnesses should be screened for, and appropriate psychological therapy should be provided [11].

The establishment of long-term and maintained interactions between a patient and a care provider, including information continuity, management continuity, and relationship continuity, is referred to as continuity of care [16]. However, there are significant variances amongst the centers. Differences in patient-healthcare-professional relationships, nurses' caring behavior, and the ward environment's person-centeredness could contribute [17, 18]. Epilepsy specialist nurses might be sent in to counsel young children on their options, perhaps reducing worry, fear, and discomfort [19].

The perspective of bedside nurses, in particular, is critical in informing the design of ward and its impact on patient comfort [20]

Our experiment took 144 cases of patients with postcranial surgery complicated by epilepsy as the study subjects. We randomly divided them into 63 cases each in the observation group and the control group. The control group was given nursing interventions, including health education, psychological interventions, medication guidance, complication prevention, and follow-up management. In contrast, the observation group was jointly given family collaborative nursing interventions. The follow-up management was six months, and the indexes of coping style, treatment compliance, and quality of life were compared between the two groups. First, the joint application of the home care model in the observation group was determined, including the formation of a family collaborative care intervention group to assess the coping style, treatment compliance, and quality of life of patients with postcranial surgery complicated by epilepsy and to assess the ability of family members in health education and psychological intervention and to develop a family collaborative care intervention plan jointly. We also conducted a collaborative family care intervention program. We confirmed our conjecture from three aspects. First, in terms of coping style, the problem solving, help seeking, and rationalization scores of postcranial surgery patients in the observation group were significantly higher than those in the control group, and the self-blame scores were significantly lower than those in the control group. The patients in the observation group had healthier and more effective coping styles. Then, treatment compliance of patients in the observation group was significantly higher than that of the control group. Finally, the quality of life of the observation group was significantly higher than that of the control group, and patients were emotionally healthier. Overall, our study confirms that the home care model helps promote the development of positive coping styles in postcranial surgery patients, improves treatment compliance, improves patients' quality of life, and helps patients recover better.

5. Limitation

There are some limitations in our study. Data were basically collected for the purpose of psychometric testing of the EMUCQ and not for identifying influential variables. All EMUs have different safety measures and restrictions for patients. Patients can move freely and even go to the terrace in some units, which have soft floors and rubber tiles [21]. So in nursing interventions, many variables would not be judged. Our study shows that the experience of comfort with combined home and hospital care interventions is highly individualized and can only be explained to a limited extent so individualized care in which families and nurses must be aware that other factors, such as the situation in the individual's environment, may influence the patient's recovery. In subsequent research centers, we also need to expand the study population as well as consider more extrinsic factors.

6. Conclusion

Overall, our study demonstrates that the home care model helps promote the development of positive coping styles in postcranial patients, improves treatment compliance, improves patients' quality of life, and has a positive impact on the recovery of epilepsy disorders.