Community nursing has a critical role to play.
- A gap exists for patients with a traumatic brain injury, as well as their caregivers, in accessing and receiving continued support after returning home.
- Nurses serve as key players in discharge planning and implementation during the acute and rehabilitative phases of recovery.
- Nurses have the expertise and creativity to help to fill the identified gap in care for these patients living in rural setting.
Patients with traumatic brain injury (TBI) experience varying symptoms depending on injury severity. Navigating reentry into the community and achieving the highest level of independence requires interdisciplinary planning and implementation. Nurses serve as a key component of this plan and have the potential to fill gaps for patients who experience barriers to subacute care.
The Brain Injury Association of America highlights the importance of competent, early planning for community reentry, which can mean different things for different patients. The unique experience of each patient—which can range from severe neurobehavioral effects, complex medical needs, and neuroendocrine dysfunction to mobility challenges and sleep disorders—creates a challenging discharge plan for the healthcare team. According to Comley-White and colleagues, studies show that only 26% to 45% of those with a severe TBI reintegrate back into their community easily. More specifically, patients in rural communities face a scarcity of resources.
At the point of community reintegration, social workers or community health professionals typically begin to manage care. However, patients living in rural areas may lack access to these healthcare experts. That’s where nurses, who serve in various roles within rural communities, can help fill gaps in care.
Lack of resources
Many rural areas experience a general lack of resources, which can create care gaps. These gaps can prove especially difficult for a patient with a TBI because of its varied presentation and need for specialized care. Brown and colleagues reported that all-cause mortality from TBI is 23% higher in rural areas compared with urban regions. Much of this mortality rate results from an inability to implement current guidelines due to poor availability of resources.
After the acute and rehabilitative stage of TBI recovery has ended, subacute rehabilitative programs extend into the community reintegration period. These programs help promote as much patient independence as possible, facilitate ongoing rehabilitation, and ensure a smooth transition back into the community setting. They also assist in establishing care and educating caregivers regarding ongoing medical or psychosocial needs the patient may have or develop as a result of the TBI. Many of these outpatient programs run as extensions of larger rehabilitative centers, which primarily exist in urban regions. Ultimately, a patient discharged to a rural community is left with a care gap.
Other community resources include networks of support groups and long-term residential facilities that specialize in ongoing rehabilitation for those with TBI. Lack of these resources to assist in community reintegration can prove devastating for patients from the acute or inpatient rehabilitative setting to the home setting in rural regions. The journey to healing can change rapidly for patients with a TBI. Lack of appropriate community support and resources can lead to rehospitalizations and caregiver burnout.
Rather than the large and specialized facilities common in urban and higher-income areas, rural communities typically have home health nursing care, independent or satellite hospitals or clinics, rehabilitative nurses, and skilled nursing facilities. Nurses serve as critical members of the healthcare teams that already exist within rural communities. With appropriate training and preparation, they can help fill this gap in care for patients with TBI.
Patient cost burden
Because most subacute programs and specialized rehabilitative services exist in larger urban centers, they require travel for the patient. Travel time and expense, as well as time away from work for caregivers, can become burdensome. This cost creates a barrier to access of appropriate post-acute care.
Brown and colleagues note that the estimated lifetime healthcare costs for a patient with a TBI is $396,000. Despite charitable support for housing, time away from work to travel to urban facilities increases that financial burden.
Typically, case management collaborates with nursing staff to identify and coordinate community resources and connect patients and families with these liaisons. However, with specialized education and cross-training, existing community nurses can create structures of care and support for patients and their families within their own community. Such community structures not only offer improved reintegration but also alleviate costs.
Complex patient needs
Although the brain’s plasticity gives it an uncanny ability to heal, the trauma to neurons deeply impacts various aspects of a patient’s life. Social, professional, and family structure changes can lead to patient isolation, a primary concern for patients with TBI.
Although isolation can occur due to geographical location or altered social structures, it also can result from shame, symptomology, or mental illness triggered by the injury. Patients experience high levels of neurologic fatigue and develop chronic seizure disorders and neuroendocrine conditions, which may impact work performance or activities of daily living. These complications require long-term medication management with antiepileptics, hormone replacement, or drugs to treat neurobehavioral and sleep disorders.
Neurobehavioral sequalae, commonly identified by the patient’s caregivers as “personality changes,” can range from irritability, impulsivity, and affective instability to diagnosable mental health disorders. Those with TBI also are at high risk for developing substance use disorders and may require care from a mental health specialist or psychiatrist. Mental illnesses that can occur post-injury include depression, anxiety, and bipolar disorder, which require complicated medication regimens. The intricacy of these complications and treatments can result in a disbanding of the patient’s social structure.
The patient’s inability to interact socially for extended periods due to TBI complications and treatment side effects also may inhibit their ability to engage in fulfilling social activities with peers and family. These losses, also known as ambiguous loss, can prove especially challenging. They require specialized care and monitoring, which may not exist in rural communities. (See Mild to moderate TBI.)
Mild and moderate TBI
Not all patients with a traumatic brain injury (TBI) require inpatient hospitalization and rehabilitation. Providers in rural settings have the resources to diagnose and manage concussions (mild TBI) and moderate injury. However, as we learn more about the complexities of chronic traumatic encephalopathy (CTE), mild TBI may require more complex care.
CTE is most common among athletes who participate in impact sports, rodeo professionals, and others who experience repeated head trauma throughout their lives. Although each individual impact doesn’t result in a severe TBI, the accumulation of mild injuries over time can result in debilitating neurologic and neuropsychologic complications. As a result, the weight of care for these patients moves from the acute setting to the community setting and necessitates the availability of knowledgeable care teams.
Most patients residing in higher-income or urban areas have access to the resources and support to accommodate increasingly complex needs. In the rural setting, home health nurses, nursing facilities, and clinics must fill that need.
However, nurses within the community can provide a line of support. They can receive training and education to identify these social and neurologic complications, implement ordered pharmacologic and supportive interventions, and assess treatment efficacy.
Caregiver support
Nursing care offers a holistic approach to addressing the needs of patients, families, and caregivers. The complexities of TBI symptoms require caregivers to not only assist the patient with medical needs but also help manage the psychological and social disparities that occur. A study by Mehran and colleagues shows that caregiver burden grows as patient need complexity increases and cognitive ability decreases.
Isolation not only impacts patients with a TBI but also those who care for them. According to a meta-analysis by Ikiugu and colleagues, caregivers named the effects of social isolation on their well-being as a key concern. Nurses within rural communities (in nursing homes and as part of home care) can support caregivers experiencing increased burdens and challenges to their mental well-being.
Nursing implications
Nurses with knowledge of the needs and long-term impact of TBI can offer services and expertise to patients living in rural areas. For example, after identifying available resources (or lack thereof), nurses can work with case management and public health professionals to create intentional spaces for support. These spaces could range from nonprofits to a simple monthly support group, not only for individuals with TBI but also for caregivers, families, and friends who’ve experienced the ambiguous loss of the functional norm.
This extended participation with the patient would require a level of proactive nurse involvement with the patient’s care during the post-acute and rehabilitative phase. Some considerations include ensuring a friendly space that can accommodate symptomatic sequalae associated with social settings and stamina (such as limited distractions and frequent breaks for neurological rest).
Activities provided in the space could include allowing patients to tell their stories, share experiences, or discuss emotions they find difficult to process with those who haven’t experienced a TBI. A separate space for caregivers would allow for interaction and discussion about the dissolution of social and familial structures secondary to TBI.
Appropriate training and curriculum developed and implemented by and for nurses working in rural areas can help support the care they provide. The Association of Rehabilitation Nurses points to home care rehabilitation nurses as advocates for these patients. Educational sessions with guest speakers and subject matter experts could help establish a larger knowledge base for patients, families, and healthcare professionals. These simple yet effective strategies offer an opportunity to create a support system and practical resources to meet patient needs.
Care journey support
As nurses, we know that caring for patients with severe injuries or chronic illness doesn’t end at the hospital or rehab doors. It extends into the community as the patient attempts to reintegrate into a meaningful life. In addition, wellness stretches beyond physiological health; it includes social, spiritual, and emotional needs.
The patient with TBI faces many challenges as they begin the journey to rejoin their community. The nurse–patient relationship and care structure serve as pivotal strengths in the rural setting. In addition to being accessible to patients, nurses can use their problem-solving skills and creativity to develop community spaces that support patients throughout their care.
Jillian Craft is an instructor at Texas Tech University Health and Science Center School of Nursing in Abilene.
American Nurse Journal. 2025; 20(3). Doi: 10.51256/ANJ032539
References
Association of Rehabilitation Nurses. What does a home care rehabilitation nurse do? rehabnurse.org/about/roles/home-care-rehabilitation-nurse
Brain Injury Association of America. Brain injury rehabilitation. biausa.org/brain-injury/about-brain-injury/treatment/brain-injury-rehabilitation
Brain Injury Association of America. Community-based treatment. biausa.org/brain-injury/about-brain-injury/treatment/community-based-treatment
Brown JB, Kheng M, Carney NA, Rubiano AM, Puyana JC. Geographical disparity and traumatic brain injury in America: Rural areas suffer poorer outcomes. J Neurosci Rural Pract. 2019;10(01):10-5. doi:10.4103/jnrp.jnrp_310_18
Centers for Disease Control and Prevention. Health disparities in TBI. Published April 29, 2024. cdc.gov/traumatic-brain-injury/health-equity
Comley-White N, Mudzi W, Gouws H. Community reintegration of people with traumatic brain injury in South Africa. Brain Inj. 2022;36(9):1187-95. doi:10.1080/02699052.2022.2111027
Doig E, Prescott S, Pick V, et al. Normalising interdisciplinary role-based goal setting in inpatient brain injury rehabilitation: Reflections and recommendations of clinicians. Disabil Rehabil. 2023;45(4):673-83. doi:10.1080/09638288.2022.2040612
Harrison AL, Hunter EG, Thomas H, Bordy P, Stokes E, Kitzman P. Living with traumatic brain injury in a rural setting: Supports and barriers across the continuum of care. Disabil Rehabil. 2016;39(20):2071-80. doi:10.1080/09638288.2016.1217081
Howlett JR, Nelson LD, Stein MB. Mental health consequences of traumatic brain injury. Biol Psychiatry. 2021;91(5):413-20. doi:10.1016/j.biopsych.2021.09.024
Ikiugu MN, Feldhacker M, Schneider J, Wangberg R. Mental health and well-being of informal caregivers for adults with traumatic brain injury: A meta-analysis. Ann Int Occup Ther. 2021;4(4):e236-42. doi:10.3928/24761222-20210601-03
Kreutzer JS, Mills A, Marwitz JH. ambiguous loss and emotional recovery after traumatic brain injury. J Fam Theory Rev. 2016;8(3):386-97. doi:10.1111/jftr.12150
Lorenz LS, Doonan M. Value and cost savings from access to multi-disciplinary rehabilitation services after severe acquired brain injury. Front Public Health. 2021;9:753447. doi:10.3389/fpubh.2021.753447
Marklund N, Bellander B‐M, Godbolt A, Levin H, McCrory P, Thelin EP. Treatments and rehabilitation in the acute and chronic state of traumatic brain injury. J Intern Med. 2019;285(6):608-23. doi:10.1111/joim.12900
Mehran Ilaghi, Gharib F, Pirani A, et al. The burden of traumatic brain injury on caregivers: Exploring the predictive factors in a multi-centric study. BMC Psychol. 2024;12:150. doi:10.1186/s40359-024-01652-6
Oberholzer M, Müri RM. Neurorehabilitation of traumatic brain injury (TBI): A clinical review. Med Sci. 2019;7(3):47. doi:10.3390/medsci7030047
Palm S, Rönnbäck L, Johansson B. Long-term mental fatigue after traumatic brain injury and impact on employment status. J Rehabil Med. 2017;49(3):228-33. doi:10.2340/16501977-2190
Pierre K, Dyson K, Dagra A, Williams E, Porche K, Lucke-Wold B. Chronic traumatic encephalopathy: Update on current clinical diagnosis and management. Biomedicines. 2021;9(4):415. doi:10.3390/biomedicines9040415
Salas CE, Rojas-Líbano D, Castro O, et al. Social isolation after acquired brain injury: Exploring the relationship between network size, functional support, loneliness and mental health. Neuropsychol Rehabil. 2021;32(9):2294-2318. doi:10.1080/09602011.2021.1939062
Key words: traumatic brain injury, rural nursing, rural healthcare, community health
