Transformation of the Relationship: The Experience of Primary Support Persons of Stroke Survivors

Mothers of Children with Acquired Disabilities: Using the Subjective Voice to Inform Parent/Professional Partnership

This article presents findings from a phenomenological dissertation that interviewed mothers of young children who acquired permanent disabilities. Mothers' accounts provide a rich source of information to professionals about the subjective and interpersonal experiences that accompany unexpected acquired disability in a young child. Their stories reveal the complex interplay of emotions that occur in the immediate aftermath of acquired disability and all along the continuum of the child's care. Mothers also identify qualities and barriers that influence their satisfaction with parent/professional relationships. The article highlights the value of an integrated model for theory and practice based on mothers' earned wisdom.

Coherence in the Urban Family Caregiver Role with African American Stroke Survivors

Expressions of coherence by urban caregivers in African American family systems are the focus of this ethnographic study. The profound changes that can accompany stroke may create considerable stress for families caring for the affected person. Coherence, a sense of mutuality, and differences in functioning among family members were discovered in this study to be important for maintaining stability within the family. Through coherence, family caregivers felt connected and this helped them survive in stressful times related to caring situations. The findings aid in defining coherence as an interpersonal process and place it in a family system context.

Defining and measuring patient-centred care: an example from a mixed-methods systematic review of the stroke literature

BACKGROUND

  Involving patients in the determination of their care is increasingly important, and health-care professionals worldwide have recognized a need for clinical outcome measures and interventions that facilitate patient-centred care delivery in a range of settings.

AIM

  A mixed-methods review was conducted, which aimed to identify stroke-specific patient-centred outcome measures and patient-centred interventions.

SEARCH STRATEGY

  Databases searched included MEDLINE and PsycINFO; search strings were based on MeSH terms and keywords associated with the terms 'stroke' and 'patient-centred'.

DATA EXTRACTION AND ANALYSIS

  Descriptive statistics were used to report quantitative data; thematic analysis was also performed in the included studies.

MAIN RESULTS

  Three patient-centred outcome measures (Subjective Index of Physical and Social Outcomes, Stroke Impact Scale, Communication Outcome after Stroke scale) and four interventions were identified. Key elements of intervention design included delivery in people's own homes, involvement of families and tailoring to individual needs and priorities. Thematic analysis enabled description of three broad themes: meaningfulness and relevance, quality, and communication, which informed the development of a definition of patient-centred care specific to the specialty of stroke.

CONCLUSIONS

  It is important for health-care professionals to ensure that their practice is relevant to patients and families. The review identified three stroke-specific patient-centred outcome measures, key elements of patient-centred interventions, and informed the development of a definition of patient-centred care. These review-derived outputs represent a useful starting point for health-care professionals, whatever their specialty, who are working to reconcile tensions between priorities of health-care professionals and those of patients and their families, to ensure delivery of patient-centred care.

Needs, priorities, and desired rehabilitation outcomes of family members of young adults who have had a stroke: findings from a phenomenological study

PURPOSE

This study explored the experience of stroke from the perspective of family members of young adults who have had a stroke. Gaining understanding of the short, medium and long-term needs and desired rehabilitation outcomes of family members assisted identification of appropriate family-centred multidisciplinary rehabilitation interventions.

METHOD

A qualitative approach based on Merleau-Ponty's existential phenomenology enabled exploration of family members' experience of stroke. Eleven family members, including parents, spouses, children and siblings, participated in 24 interviews over 2 years. A subsequent iterative process of critical reflection was used to identify family-centred needs, priorities and associated rehabilitation outcomes.

RESULTS

Within a thematic framework, family members' experience was conceptualised as Disruption of Temporal Being. Against this overarching theme or (back)ground, figural themes were identified: Uncertainty, Disrupted and Altered Relationships, and Situatedness. In addition, sixteen short, medium and long-term effects of stroke were identified along with associated family-centred needs and rehabilitation outcomes.

CONCLUSION

An empathetic understanding of the experience of stroke from the perspective of family members, combined with research evidence and professional expertise enables the multidisciplinary rehabilitation team to deliver tailored interventions based on identified needs and priorities, and negotiation of mutually agreed goals.

IMPLICATIONS FOR REHABILITATION

• Following stroke in a young adult, families' needs, priorities and associated rehabilitation outcomes change over time; rehabilitation services should reflect this dynamic process. • To deliver family-centred care, rehabilitation professionals need to develop a deeper understanding of the experience of families affected by stroke, gained from qualitative research findings and from their own reflective practice. • Gaining understanding of the experience of family members of young adults who have had a stroke will enable health professionals to consider how they may improve practice and enhance service provision to ensure delivery of effective, family-centred interventions. • The table of family-centred needs and outcomes can be used by members of the multidisciplinary stroke rehabilitation team in conjunction with their own knowledge, experience and resources to inform family-centred practice.

A Mixed Methods Study of the Experience of Transition to the Community of Working-Aged People with Non-Traumatic Brain Injury

Background and aims: The ‘transition’ phase from hospital to home following brain injury is well established as a critical period of adjustment for individuals and their families. There is, however, a lack of knowledge about the experience of transition following nontraumatic brain injury (e.g., stroke, aneurysm) for individuals of working age. The purpose of this study was to explore the transition experiences of individuals with nontraumatic brain injury using mixed methods approach.

Methods: Six individuals with nontraumatic brain injury were recruited from a larger study using maximum variation sampling criteria. Individuals participated in semistructured interviews at 6-months postdischarge and completed quantitative measures of psychosocial outcomes predischarge and at 6-months postdischarge. Results: Qualitative content analysis of interviews identified three themes: (1) changes in role performance, (2) support and services and (3) coping with life after brain injury. The transition experience was characterised by loss of valued roles including driving and work, identified as major barriers to regaining independence postdischarge. Informal support provided by family and friends were relied on, while formal supports were accessed infrequently. Life post-injury presented a number of challenges including adjusting to changes in physical and cognitive abilities and a fear of reinjury. Qualitative data were supported by an overall trend of improved functioning on the quantitative measures over the 6 months.

Conclusions: Key life circumstances of working age adults with nontraumatic brain injury influence the transition experience. Clinically, the findings support the need for individualised, structured transition services pre- and postdischarge for this group.

The long-term experience of family life after stroke

Stroke is a life-threatening and disabling illness known to have a significant impact on families. The purpose of this study was to illuminate the long-term experience of family life after stroke of stroke survivors and their spouses and children, particularly regarding marital and parent-child relationships. Thirty-seven narrative interviews were conducted with stroke survivors and their spouses and adult children who were minors at onset of the illness. A qualitative approach inspired by Gadamer's hermeneutic and van Manen's phenomenological understanding of lived experience was used. The analysis revealed four themes: the family as a lifebuoy, absent presence, broken foundations, and finding a new marital path. Lack of communication and altered roles and relationships endangered marital equilibrium and parent-child relationships after stroke. This study highlighted the need for professional family support as families were unprepared for the life changes that occurred. Nurses and other healthcare workers should examine family relationships and communication patterns and view the family as a unit composed of unique persons with different needs. Further research on the experiences of stroke survivors' children seems urgent.

Young adults' experience of stroke: a qualitative review of the literature

Stroke is a life-threatening event that has a devastating impact on young adults and their families. The author conducted a systematic review of the qualitative literature to explore the experience of stroke from the perspective of young adults. Four primary research 'papers' were analyzed using the Qualitative Assessment and Review Instrument; 60 findings were extracted from the papers and merged into 13 categories, from which three synthesized findings were developed - disorientation, disrupted sense of self, and roles and relationships. Many of the effects of stroke are 'invisible' but have significant impact on social participation, including the ability to return to work and to enjoy an active social life. Young adults feel the same and yet different following stroke, which may have a profound effect on relationships. Effective communication between patients, families and health professionals is crucial to all aspects of recovery.

Stress experienced by stroke survivors and spousal caregivers during the first year after discharge from inpatient rehabilitation

PURPOSE

This study describes levels of stress in stroke survivors and spousal caregivers and identifies predictors of stress in couples during their first year at home.

METHOD

The Perceived Stress Scale (PSS) was administered to 159 stroke survivors and caregivers at discharge and at 3, 6, 9, and 12 months. Other variables tested included stroke survivor function (FIM), health status, mutuality, stroke impact (SIS), caregiver coping (F-COPES), support (MOS Social Support Survey), and preparedness. Repeated measures analyses of PSS scores were conducted with linear mixed models for stroke survivors and caregivers.

RESULTS

PSS scores for stroke survivors and caregivers were positively correlated (p<.01). Scores decreased significantly over the year, but caregivers had higher scores initially and decreased less. Stroke survivor function was a significant predictor of stress for both survivors and caregivers. Preparation was the most powerful predictor of stress in caregivers, whereas mutuality was the strongest predictor for stroke survivors. Good health, social support, and coping were associated with less stress.

CONCLUSIONS

Stress is increased by poor function and mediated by internal and external buffers including health, the dyadic relationship, coping ability, and social support. More research using a dyadic research approach is needed to better understand stress within couples.

Informal primary carers of stroke survivors living at home-challenges, satisfactions and coping: a systematic review of qualitative studies

PURPOSE

To summarize qualitative studies from the last decade that focus on experiences of caring for stroke survivors and to describe challenges, satisfactions and coping strategies.

METHODS

A systematic review of qualitative studies identified from English language medicine, nursing and psychology databases from 1996-2006 was undertaken.

RESULTS

Seventeen qualitative studies fitting the inclusion and exclusion criteria, mostly from the USA, were identified. All used carer interviews. These studies corroborate the quantitative research, commonly describing difficulties including emotional responses, uncertainty and associated information and training needs. However, compared with quantitative research, qualitative studies provide a more detailed, complete picture of carers' experiences and identify additional areas including role and relationship changes, positive outcomes and coping strategies.

CONCLUSIONS

Qualitative studies add significantly to our understanding of carers' experiences. Caring for stroke survivors is often challenging but focusing on the difficulties and not drawing attention to successful management strategies and satisfaction reported by carers, limits understanding and reduces the chances of providing appropriate support. Future qualitative research should consider the implications of the timing of collection more carefully and should move away from simple content or thematic analysis which tends to emphasize similarities amongst carers and should now focus on understanding carer diversity. Acknowledging this diversity should maximize the chances of providing appropriate support.

Understanding the practical and theoretical development of social rehabilitation through action research

AIM

This paper aims to present and reflect on the process of practical and theoretical change in an action research project in which the issue of social rehabilitation was developed.

BACKGROUND

Action research is a useful method to change and advance practice. Consequently, grounded knowledge, which forms the basis of the practical change, is developed. 'Social rehabilitation' was the field of clinical practice which needed enhancement as the literature lacked nurse-led social rehabilitation programmes in the neurology field.

DESIGN

This was a cyclic action research project.

METHODS

The project took place in a highly specialised hospital in Spain and aimed to promote social life of neurological patients and relatives through the planning, implementation and evaluation of a nurse-led social rehabilitation programme based on individual needs. In this project, which lasted 30 months, multiple triangulation of sources and methods was applied. Thirty-seven nurses participated and 22 and 18 patients and their relatives constituted a baseline and an intervention group, respectively.

RESULTS

Several issues were carefully treated in this action research project to develop practical and theoretical knowledge about social rehabilitation: the validity and reliability of the project, the work organisation of the wards, the nurses' attitudes towards new care, the researcher-participant relationship and the controversial role of professionals in social rehabilitation.

CONCLUSION

The nurses' emancipation in the process of practice change led to practical and theoretical assimilation of social rehabilitation. Intensive work on practitioners' attitudes and the provision of empirical evidence were key interventions to foster controversial roles and enhance services.

RELEVANCE TO CLINICAL PRACTICE

Details about the process of change of nursing practice in response to clients' needs have been provided. Some reflections about how to integrate social care and knowledge about social rehabilitation in clinical daily practice are made.

Spousal Caregiving for Stroke Survivors

Caregiving for a spouse who has survived a stroke has multidimensional implications for both the partner and the spousal caregiver. A phenomenological study was conducted to examine the experiences of spousal caregivers for stroke survivors. Eight spouses who met the inclusion criteria participated in the study. van Manen's (1997) approach was used to examine the spousal caregivers' experiences. Data were collected through audiotapes from semistructured interviews. The interviews were transcribed to form textual descriptions of the caregivers' experiences. Six interrelated themes emerged through data analysis: experiencing a profound sense of loss, adjusting to a new relationship with a spouse, taking on new responsibilities, feeling the demands of caregiving, having to depend on the support of others, and maintaining hope and optimism. This study contributes to healthcare providers' understanding and knowledge of spousal caregivers for stroke survivors, and supports the need for continued research in this area.

How Stroke Survivors and Primary Support Persons Experience Nurses in Rehabilitation

The role of nursing in rehabilitation has been studied from various perspectives. This study explored experiences with nursing care in rehabilitation from the perspective of stroke survivors and their primary support persons (PSP). The sample consisted of six stroke survivors and seven primary support persons. Through in-depth phenomenological interviews, participants related the experiences with nursing care that stood out for them. The experience was conceptualized as a two-dimensional continuum from helpful to adversarial, with none of the participants articulating a therapeutic presence from nurses. Implications for nursing are explored.

Family caregiver expectations and management of the stroke trajectory

Less than 20% of stroke survivors enter rehabilitation or long-term care facilities after their stroke. Stroke recovery is extremely variable and the resulting uncertainty places a heavy burden on the survivors' family caregivers. According to the trajectory framework, chronic conditions have a defined course that can be shaped and managed. This grounded theory study, part of a larger research project, explored the expectations of family caregivers of the stroke trajectory and their management strategies. Thirteen family caregivers of stroke patients in a sparsely populated area participated in semi-structured interviews. The caregivers were without ideas about what the recovery of their loved ones would be like and had difficulty making projections about the trajectory. They used several strategies, however, in attempts to manage the stroke trajectory. They constructed a positive recovery, reconstituted family life, maintained family routines, created a safety net, and redoubled self-reliance. The findings have implications for how nurses support family caregivers of stroke survivors.