Challenges and Strategies in Implementing an Environmental Management Protocol for Agitated Patients in Neurorehabilitation

Background and/or Objectives: To investigate changes in neurorehabilitation staff’s self-perceived effectiveness, confidence, and frequency using environmental management strategies to reduce agitation in patients experiencing post-traumatic amnesia (PTA) after moderate to severe traumatic brain injury (TBI).

Design: Pre-post design

Setting : 25-bed inpatient neurorehabilitation unit specializing in brain injury care

Participants : 124 interdisciplinary staff members (OLD protocol: n=67; NEW protocol: n=57)

Interventions: NEW "Stop Light" protocol was introduced through expanded onboarding, quarterly Elevate Your Expertise (EYE) sessions, behavioral skills days, and weekly nursing safety meetings. Previous OLD low stimulation protocol was limited to one-time training and communicated through a single-page guideline.

Main Outcome Measures: Pre- and post-surveys utilized to assess staff self-perceived effectiveness, confidence, and frequency of protocol application, and perceived effectiveness in managing agitation (5-point Likert scales from 1 for “No confidence” to 5 for “High confidence”, for frequency from 1 for “Never” to 5 for “Always”, for effective from 1 for “Never” to 5 for “Always”)

Results: The NEW protocol significantly improved perceived effectiveness in managing impulsive (p=0.002) and restless (p < 0.001) behaviors, with 81.4% and 88.4% of users rating it as effective most of the time or always. However, no significant improvements were noted in staff confidence regarding protocol comprehension, application, or education of caregivers (p>0.05).

Conclusions: Despite improvements in agitation management, challenges in staff confidence and protocol accessibility persist. Future strategies will focus on reinforcement training, real-time coaching, and enhanced accessibility of protocol resources to optimize implementation and patient outcomes.