Who's in control after a stroke? Do we disempower our patients?

From recovery to regaining control of life - the perspectives of people with stroke, their carers and health professionals

Aim: To understand how people with stroke and carers adapt over time, and how health professionals support transition to home.Method: A multi-perspective, prospective, qualitative, longitudinal study was conducted using in-depth semi-structured interviews one and six months after inpatient discharge. Twenty-four participants (eight triads, including people with stroke, carers and health professionals) were included. Thematic and narrative analysis facilitated identification of cross-cutting themes according to individual trajectories post-stroke.Findings: A major theme: "regaining control of life" suggested a shift in perspective after six months at home. Four sub-themes help to understand the triads' perspectives over time: i) importance of team involvement; ii) differences in perceived roles within the triad; iii) differences in expectations and collaboration within the triad and iv) planning a different future. People who were involved in supporting adaptation and rehabilitation processes were reported differently between triads and over time, showing the complexity of interrelations. A reduction in professional involvement was matched by changes in participants' goals and expectations.Conclusion: Findings suggest the importance of a dyadic perspective and a gradual increase in people with stroke and carers' active engagement. Professionals' approach throughout rehabilitation should be modified according to people with stroke and carers' changing needs and expectations.IMPLICATIONS FOR REHABILITATIONDivergence in perspectives about priorities and goals between the person with stroke their carers and healthcare professionals can lead to the creation of different agendas within rehabilitation.An open dialogue and decision-making process that involves both the person with stroke and carers is highly recommended for the identification of shared rehabilitation goals and to support ongoing recovery post discharge.A tailored approach to rehabilitation is required which focusses on shared priorities and includes individual or collective support for the person with stroke and their carers.Ongoing consultation about the desires of the person with stroke about rehabilitation, priorities and goals is important in order to tailor the professional approach to the stage individuals are at with their coping and adjustment post stroke.

Transitions in the Embodied Experience After Stroke: Grounded Theory Study

BACKGROUND

The body is central to the practice of physical therapy, but clinical theory largely neglects the body as a concept. A better understanding of the embodied experience could enhance delivery of physical therapy.

OBJECTIVES

The purpose of this study was to gain an in-depth understanding of embodiment for people after stroke while transitioning from the hospital to the home.

DESIGN AND METHODS

Seven people with stroke, aged 66 to 89 years, were interviewed 1 month after discharge from a stroke rehabilitation unit. Interviews were analyzed using grounded theory methods, and a theoretical model was developed.

RESULTS

Two main themes in the embodied experience of stroke were: (1) "a divergent body-self," where participants referred to an objective physical body, separate from their sense of self, and (2) "a cohesive body-self," reflecting a sense that "it's all me." The theme "a divergent body-self" included subthemes of a body that was "strange," "unpredictable," and "effortful." In contrast, the theme "a cohesive body-self" comprised the subthemes "freedom," "control," and "self-identity," reflecting experiences of bodily movement, personal independence, and self-identity. Participants fluxed between these perspectives, within moments and over time, with these perspectives influenced by "anchors," including their environment, knowledge, and attitude.

CONCLUSIONS

The bodily experience of stroke is intimately connected with a person's sense of self. A person's social and physical environment, as well as his or her personal attributes, can serve to "anchor" that person more comfortably within his or her embodied experience of stroke. Theory that acknowledges the integral connection between body and self could enhance physical therapist practice. This study supports the need for physical therapists to be adequately informed to integrate the embodied experience in their practice when working with people after stroke.

The Language of Recovery: How Effective Communication of Information Is Crucial to Restructuring Post-Stroke Life

BACKGROUND

Providing appropriate and effective information to people with stroke and their families has been identified as a key component to successful practice. Researchers continue to focus on "lack of information" as being the lack of specific technical medical information rather than the communication of practical knowledge and how people use that knowledge to restructure life after stroke. To meet patients' expectations and achieve better outcomes in stroke, professionals need access to communication theory, research, and training.

OBJECTIVES

Improve stroke communication systematically.

METHOD

This article will examine stroke communication using a three-part framework: 1. Utilize theory to clearly conceptualize how communication influences stroke outcome. 2. Identify components and mechanisms of communication content to positively influence stroke outcome. 3. Develop goals and strategies for putting content skills into stroke communication practice.

CONCLUSION

Relatively little is known about the content and structure of informal communication transactions between stroke survivors, families, and health care professionals and how they accommodate (or resist) realignment of identity after stroke. The professional discourse attempts to ensure realistic expectations of recovery whereas stroke survivors and families complain about the negative discourses, how possibilities for life after stroke are presented, and the hopelessness that this creates. More research is required into how these different discourses affect outcomes.

Elderly peoples' experience of nursing care after a stroke: from a gender perspective

AIM

This paper is a report of a study conducted to explore, from a gender perspective, older people's experiences of nursing care after a stroke.

BACKGROUND

Little attention has been given to gender differences in nursing care. The majority of people who have a stroke are older. Improving knowledge of the gender perspectives of older men and women regarding nursing care after stroke is crucial.

METHOD

This was a qualitative study based on interviews with five women and five men between 66 and 75 years of age, who had received nursing care at a ward for stroke rehabilitation. The data were collected in 2006. Qualitative content analysis of the interviews was carried out.

FINDINGS

A main theme and five categories, all common to both men and women, were identified. The main theme, to promote recovery of the body, encompassed the categories. There were, however, gender differences in how the nursing care received was experienced. The ways patients experienced nursing care seemed to be linked with their lives as women and men before they had the stroke. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ.

CONCLUSION

Nurses need to increase their awareness and knowledge concerning the similarities and gender differences in the experiences and needs of older people, both men and women.

Characteristics of physiotherapy sessions from the patient's and therapist's perspective

PURPOSE

The purpose was to explore, describe and compare the characteristics of physiotherapy sessions with patients after stroke from two perspectives: the patients' and the physiotherapists', in relation to observed behaviour.

METHODS

A qualitative, descriptive, comparative approach was used. Nine patients and 10 physiotherapists participated. Data from observations and semi-structured interviews were used.

RESULTS

Six themes were identified: setting and attaining goals, focusing on motor activity, finding the optimal training strategy, facilitating active patient involvement, making use of environmental factors and adjusting to the structural reorganization of the rehabilitation services. The physiotherapists and the patients made similar descriptions in some of the themes but differed in some. The physiotherapists expressed what they perceived to be their lack of scientific knowledge, while the patients trusted their physiotherapists' competence. The physiotherapists wanted to take the patients' personal experiences into account in the sessions, which was not obvious to the patients.

CONCLUSION

Differences in physiotherapists' and patients' descriptions of characteristics of physiotherapy sessions have to be taken into consideration in the rehabilitation of stroke patients. In order to empower the patient to take a more active part in the rehabilitation process, there is a need to explore how to incorporate the patients' personal experiences and knowledge into the rehabilitation process.

Patients, doctors, and therapists perceptions of professional roles in spinal cord injury rehabilitation: Do they agree?

Spinal cord injury is a devastating condition, requiring extensive rehabilitation from a range of health care professionals. However, it is unclear if patients view the professionals' input into their rehabilitation in the same way as those professionals. This paper presents findings from a qualitative study into patient participation in spinal cord injury rehabilitation. The aim of the part of the study reported here was to identify whether there is agreement between health care professionals and patients perceptions of professional roles in spinal cord injury rehabilitation. Results are presented from semi-structured interviews conducted with five doctors, five physiotherapists, three occupational therapists and 20 patients in a spinal cord injury unit in England. Findings suggest considerable agreement between professionals and patients about the role those professionals play in their rehabilitation. Physiotherapists are perceived to be key to rehabilitation, occupational therapists focus on hand function but physiotherapists and occupational therapists complement each other. Doctors coordinate the team yet reduce their input as patients move out of the acute phase into rehabilitation. There are some tensions but the early input of these professionals into patients' rehabilitation may help to develop understanding of roles. Congruence between patients and professionals may mean that patients have realistic expectations and encourage a more equal relationship between them.