Effects of a physiotherapist-led stroke training programme for nurses

The impact of education/training on nurses caring for patients with stroke: a scoping review

BACKGROUND

Stroke survivors have complex needs that necessitate the expertise and skill of well-trained healthcare professionals to provide effective rehabilitation and long-term support. Limited knowledge exists regarding the availability of specialized education and training programs specifically designed for nurses caring for stroke patients.

AIM

This review aims to assess the content and methods of training for nurses caring for stroke patients, examine its impact on both nurses and patients, and identify key facilitators and barriers to its implementation.

METHODS

We conducted a comprehensive scoping review by reviewing multiple databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, Web of Science, Scopus, ProQuest Dissertations and Theses, Google Scholar, and Cochrane databases. Data extraction and narrative synthesis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.

RESULTS

Seventeen articles were included in this review. We found that education/training not only enhanced patients' self-care abilities, nursing outcomes, and satisfaction, but also had a positive impact on the knowledge, skills, and practices of nurses. The obstacles to education/training included feasibility and cost-effectiveness, while the driving factors were management support and participation, professional education/training, and controlled environment creation.

CONCLUSIONS

This review highlights the crucial role of education/training in enhancing stroke care provided by nurses. Effective education/training integrates various educational methods and management support to overcome implementation barriers and optimize clinical practice benefits. These findings indicate the necessity of universal and consistent stroke education/training for nurses to further improve patient outcomes in stroke care.

Factors Facilitating and Hindering the Use of Newly Acquired Positioning Skills in Clinical Practice: A Longitudinal Survey

Background

After learning new skills, healthcare professionals do not always apply them in practice, despite being motivated. This may be referred to as an intention-behavior gap. One example is the positioning of immobilized and disabled patients in hospitals, nursing homes, or neurorehabilitation clinics. Positioning is crucial to prevent complications such as pressure sores, pneumonia, and deep vein thrombosis. However, it is often not carried out optimally even when professionals have completed education programs. The LiN-method is a positioning procedure involving a special focus on aligning and stabilizing body parts, which has been shown to have advantages over conventional positioning. We assess which factors may facilitate or hinder the use of LiN in clinical practice after participants complete training.

Methods

A longitudinal survey with 101 LiN-course participants was conducted in Germany. Each participant completed a questionnaire directly after the course and 12 weeks later, including a report of the frequency of use in practice. They also completed a questionnaire which surveyed 23 aspects that might facilitate or hinder use of the new skills, covering the workplace, socio-collegial factors, motivation, self-confidence, and mindset.

Results

Most assessed aspects were associated with LiN-use, with the highest correlations found for confidence with the method, perceived ease of application, sufficient time, assessing one's skills as sufficient, remembering the relevant steps, and a work environment open to advanced therapeutic concepts. To reduce data complexity, the questionnaire was subjected to a factor analysis, revealing six factors. A regression analysis showed that four factors predicted use 12 weeks after course completion, in the following order of importance: (1) subjective aspects/confidence, (2) access to materials, (3) work context, and (4) competent support in the workplace.

Conclusion

Numerous aspects are associated with the use of recently acquired clinical or nursing skills, such as LiN. Many of these can be improved by appropriately setting up the workplace. The aspects most associated with use, however, are confidence with the method and self-perceived competence of healthcare professionals. While causality still needs to be demonstrated, this suggests that education programs should support participants in developing confidence and foster a mindset of continuous learning.

The impact of education and training interventions for nurses and other health care staff involved in the delivery of stroke care: An integrative review

OBJECTIVES

The aim of this review was to explore the impact of stroke education and training of nurses and other health care staff involved in the delivery of stroke care.

DESIGN

We performed an integrative review, following PRISMA guidance where possible.

DATA SOURCES

We searched MEDLINE, ERIC, PubMed, AMED, EMBASE, HMIC, CINAHL, Google Scholar, IBSS, Web of Knowledge, and the British Nursing Index from 1980 to 2016.

REVIEW METHODS

Any intervention studies were included if they focused on the education or training of nurses and other health care staff in relation to stroke care. Articles that appeared to meet the inclusion criteria were read in full. Data were extracted from the articles, and the study quality assessed by two researchers. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance.

RESULTS

Our initial search identified 2850 studies of which 21 met the inclusion criteria. Six studies were randomised controlled trials, and one was an interrupted time series. Fourteen studies were quasi-experimental: eight were pretest-posttest; five were non-equivalent groups; one study had a single assessment. Thirteen studies used quality of care outcomes and eight used a patient outcome measure. None of the studies was identified as having a low risk of bias. Only nine studies used a multi-disciplinary approach to education and training and nurses were often taught alone. Interactive education and training delivered to multi-disciplinary stroke teams, and the use of protocols or guidelines tended to be associated with a positive impact on patient and quality of care outcomes.

CONCLUSIONS

Practice educators should consider the delivery of interactive education and training delivered to multi-disciplinary groups, and the use of protocols or guidelines, which tend to be associated with a positive impact on both patient and quality of care outcomes. Future research should incorporate a robust design.

Challenges of collecting data in the clinical setting

Undertaking a piece of research in the clinical setting is often far more difficult than it appears from descriptions in textbooks. This paper describes some of the challenges faced in the course of completing a non-participant observational study that examined how health promotion practice was carried out by hospital-based nurses in an acute setting. The challenges included deciding which observational role to adopt, whether to use structured or unstructured observations, which observational position to adopt, how long observation sessions should be and how to deal with ethical issues when the researcher is also a nurse. It is concluded that the answers to some dilemmas and challenges are not always found in the literature and that decisions taken often depend on the researcher's morality and pure common sense.

A study to assess the effect of nursing interventions at the weekend for people with stroke

Objective: To examine whether additional therapy provided by nurses at the weekend improved the physical outcome for people with stroke on a stroke rehabilitation unit.

Design: A single blind randomized controlled trial.

Setting: A 16-bed stroke rehabilitation unit in the north of England.

Subjects: Forty-one people with stroke were randomized by means of minimization to intervention and control groups.

Interventions: The intervention group received additional exercise at the weekend provided by the nursing staff and the control group received their usual care. Both groups received usual care during weekdays.

Main outcome measures: The Motor Assessment Scale (MAS), the Barthel Index (BI) and length of stay in hospital.

Results: No significant differences were found between the groups in terms of MAS and BI at discharge but there was a borderline significant difference between the groups on unconditional testing in terms of length of stay in hospital and on the stroke unit ( p = 0.05 and p = 0.07 respectively). However, these findings were in favour of the control group. On conditional testing (adjusting for BI on admission and age) these differences disappeared ( p = 0.14 and p = 0.15) for length of stay in hospital and on the stroke unit respectively.

Conclusions: The present study indicates that an increase in one-to-one input by nurses for people with stroke did not lead to a measurable difference in outcome in this small study.

Effect of recommended positioning on stroke outcome at six months: a randomized controlled trial

Objective: To evaluate the effect on patient outcome of a teaching package for nurses designed to improve the positioning of stroke patients.

Design: Cluster randomized controlled trial with six-month follow-up.

Setting: Ten stroke rehabilitation hospital units located within one UK inner city region. These were randomized to control or intervention group.

Subjects: A sample of 120 patients admitted within four weeks of a first stroke and with a hemiplegia. No eligible patient refused to participate. Eighty-three (69%) completed the study.

Intervention: All nursing staff on the intervention units received a group teaching package to improve their clinical practice in patient positioning.

Main outcome measure: Rivermead Mobility Index (RMI) at six months post stroke. Patient's position was recorded using an established observational tool.

Results: After the teaching there was some evidence of better positioning in the intervention than the control group (difference in percentage of correct positions per patient 4.9%, 95% confidence interval (CI-0.1% to 9.9%, p-0.055). There was no evidence of differences between the two groups in any of the outcome measures at six months although there was a trend towards increased elbow flexor tone in the control group.

Conclusions: A teaching intervention to improve patient positioning made no significant impact on outcome at six months post stroke. However, following the teaching there was only a slightly higher incidence of recommended patient positioning within the intervention group. Thus, a teaching package may not be powerful enough to enable any effect on patient outcome to be measured.

Effects of therapeutic positioning on vital parameters in patients with central neurological disorders: a randomised controlled trial

AIMS AND OBJECTIVES

To investigate the effects of positioning on heart rate, breathing frequency and blood pressure in postacute, severely disabled patients with central neurological disorders.

BACKGROUND

Positioning patients is part of the regular nursing routine in the care for severely disabled patients. Positioning can be done in a conventional way or in Lagerung in Neutralstellung (Engl.: positioning in neutral), which has recently been shown to have better effects on the passive range of motion and comfort than conventional positioning. While it is thought that positioning influences vital parameters, so far no study has investigated this for a clinically relevant observation period, and no study has compared different positioning concepts in this respect.

DESIGN

A multicentre, randomised, controlled, single-blind clinical trial.

METHODS

Two hundred and eighteen patients were randomly assigned to positioning in neutral or conventional positioning. For two hours, they were lying in one of five positions (supine, 30° and 90° side lying on the right or left side) according to the respective positioning concept. Heart rate, breathing frequency and blood pressure were measured before and after positioning in a supine lying position (i.e. not positioned according to any concept). It was investigated if the interventions influence vital parameters and whether there are differences between positioning in neutral and conventional positioning, or between the different positions.

RESULTS

In neither of the groups did heart rate, breathing frequency and blood pressure change significantly after the intervention compared to before (p ≤ 0·01).

CONCLUSION

Positioning does not influence heart rate, breathing frequency and blood pressure when patients are lying for a clinically feasible length of two hours.

RELEVANCE TO CLINICAL PRACTICE

This study shows that nurses can apply both positioning concepts according to their patients' preferences or to address problems like pressure sore prevention. There is no risk of influencing basic vital parameters.

The Mauk Model for Poststroke Recovery: assessing the phases

Despite the estimated 795,000 strokes occurring in America annually (American Heart Association, 2009), few practical models guide nurses when they provide quality care to stroke survivors. The Mauk Model for Poststroke Recovery is a theoretical framework concerning six phases of poststroke recovery. The purpose of this article is to discuss a pilot study detailing the ways in which nursing students used the Mauk model to identify these phases of stroke recovery via patient case examples. A sample of 30 volunteer nursing students read five case studies and determined the phase of stroke recovery. Descriptive statistics about sample characteristics and frequencies were calculated using SPSS 14 for Windows. Nearly 57% (n = 17) of the students rated all of the case studies to the correct phase. Ways in which the model might be clarified and used as a valuable tool when assessing the phase of stroke recovery are described.

Physical activity in hospitalised stroke patients

The aim of this paper was to examine the amount and type of physical activity engaged in by people hospitalised after stroke. Method. We systematically reviewed the literature for observational studies describing the physical activity of stroke patients. Results. Behavioural mapping, video recording and therapist report are used to monitor activity levels in hospitalised stroke patients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6%-69.3%), alone (median 53.7%, IQR 44.2%-60.6%) and in their bedroom (median 56.5%, IQR 45.2%-72.5%). Approximately one hour per day is spent in physiotherapy (median 63.2 minutes, IQR 36.0-79.5) and occupational therapy (median 57.0 minutes, IQR 25.1-58.5). Even in formal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear more common in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels are low in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance our ability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventions to increase physical activity after stroke need to be tested further.

Presenting a successful stroke education model to meet the Joint Commission's Disease-Specific Care Certification

Obtaining Joint Commission Disease-Specific Care Certification can be challenging for healthcare organizations. This article outlines the methodology for developing and implementing a comprehensive educational plan for a 560-bed academic teaching hospital. This information is valuable to any staff development educator who is leading the way to achieve Joint Commission Disease-Specific Care Certification.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico

OBJECTIVE

Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care.

DESIGN

A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004.

PARTICIPANTS

Stroke patients.

METHODS

Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter.

RESULTS

One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.

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.

Stroke education for healthcare professionals: making it fit for purpose

TITLE

Stroke education for healthcare professionals: Making it fit for purpose.

RESEARCH QUESTIONS

1. What are healthcare professionals' (HCPs) educational priorities regarding stroke care? 2. Do stroke care priorities vary across the primary and secondary sectors? 3. How do HCPs conceive stroke care will be delivered in 2010?

STUDY DESIGN

This was a two-year study using focus groups and interviews for instrument development, questionnaires for data collection and workshops to provide study feedback. Data were collected in 2005-06.

STUDY SITE

One Scottish health board.

INCLUSION CRITERIA

All National Health Service healthcare professionals working wherever stroke care occurred.

POPULATION AND SAMPLE

Participants were drawn from 4 university teaching hospitals, 2 community hospitals, 1 geriatric medicine day hospital, 48 general practices (GPs), 12 care homes and 15 community teams. The sample comprised 155 doctors, 313 nurses, 133 therapists (physiotherapists, occupational therapists, speech and language therapists), and 29 'other HCPs' (14 dieticians, 7 pharmacists, 2 podiatrists and 6 psychologists).

RESULTS

HCPs prefer face-to-face, accredited education but blended approaches are required that accommodate uni- and multidisciplinary demands. Doctors and nurses are more inclined towards discipline-specific training compared to therapists and other healthcare professionals (HCPs). HCPs in primary care and stroke units want more information on the social impact of stroke while those working in stroke units in particular are concerned with leadership in the multidisciplinary team. Nurses are the most interested in teaching patients and carers.

CONCLUSIONS

Stroke requires more specialist stroke staff, the upskilling of current staff and a national education pathway given that stroke care is most effectively managed by specialists with specific clinical skills. The current government push towards a flexible workforce is welcome but should be educationally-sound and recognise the career aspirations of healthcare professionals.

The training and education of nurses working in stroke care

The National Clinical Guidelines for Stroke (2004) recommend that patients are cared for by staff who have expertise in stroke rehabilitation and access to relevant educational programmes. However, they provide only limited information as to the content and delivery of such programmes and recommend that such decisions are made at a local level. This must inevitably lead to the duplication of efforts and variations in standards and content across national services. This literature review hopes to identify how the content and delivery of educational programmes for nurses on stroke units meet the needs of their role, impact on their practice and influence patient outcomes. It is expected that the findings will be valuable in the development of ongoing training programmes and may contribute to a cohesive approach at national level.

Development of complex interventions in stroke care: a systematic review

BACKGROUND AND PURPOSE

Stroke care is complex, requiring input from professionals, patients and carers. Identifying and developing appropriate intervention components to meet these complex needs is difficult. The Medical Research Council (MRC) Framework for developing and evaluating 'complex' (nonpharmacological) interventions aims to improve intervention development. This study uses the Framework to review complex interventions in stroke care.

METHODS

Systematic review with multiple search strategies (electronic databases, recent journals, gray literature) was used. The MRC Framework was used to guide the search strategy and assess study quality. 'Complex interventions' were defined as educational/psychosocial interventions to change knowledge, beliefs or behaviors.

RESULTS

Sixty-seven studies were included: 39 randomized controlled trials (RCT) and 28 other designs. Complex interventions targeted healthcare professionals (17), and patients, carers and the general population (21 targeting primary or secondary prevention; 30 targeting adjustment and recovery after stroke). Compared with recovery studies, primary and secondary prevention studies were significantly less likely to have been evaluated in RCTs. Interventions evaluated in RCTs were significantly less likely to influence primary outcomes (26%) compared with other designs (44%). Theoretical grounding to support intervention choice was reported in 40 studies but only 14 were theoretically 'well developed'; 21 RCTs listed multiple primary outcome measures, with 10 listing 5 or more. Of these only 3 reported considering statistical power before recruitment and none was sufficiently powered.

CONCLUSIONS

Few complex interventions in stroke care have been adequately developed or evaluated. This may explain failures to demonstrate efficacy. In future, greater attention is needed to theoretical development and methodological quality.

Towards rehabilitative handling in caring for patients following stroke: a participatory action research project

AIM OF THE STUDY

This study aimed to facilitate nurses to take ownership of their moving and handling practice.

OBJECTIVES

To (i) facilitate nurses in sharing their insights in moving and handling patients following stroke, (ii) enable nurses to identify facilitators of safer moving and handling practice, and (iii) empower nurses in collaboration with physiotherapists to direct changes in their practice.

BACKGROUND

Traditional top down moving and handling training has had variable impact on nursing practice. A moving and handling incident in a stroke unit demonstrated that there were professional development needs for staff in the stroke unit in relation to their moving and handling practice in the care of patients following stroke.

METHODS

An insider participatory action research approach was utilized. Data were analysed from focus group meetings, brainstorming sessions, observational studies, and from written reflective accounts.

FINDINGS

Peer pressure, communication, rehabilitative handling awareness, teamwork between nurses and physiotherapists, equipment and environmental issues were affecting moving and handling practice. Nurses identified that equipment, environment, communication and teamwork strategies would facilitate them in using rehabilitative moving and handling practice. Nurses in collaboration with physiotherapists directed changes in their practice. Participant staff members felt involved and valued, and reported changes in understanding, in their handling practice, and enhanced teamwork.

CONCLUSION

Participatory action research creates a supportive environment, where those directly involved in moving and handling patients can investigate and direct changes in their practice. Thus it is a significant vehicle for delivering professional development in moving and handling practice. Relevance to clinical practice. Professional development initiatives in moving and handling practice must incorporate processes that enhance inter-disciplinary teamwork and value and utilize the views and experiences of the staff who move and handle patients.

Caring for patients with hemiplegia in an arm following a stroke

The patient's arm affected by hemiplegia is a common problem following a stroke. The term hemiplegia is a limited physiological description of the effects of a stroke on a patient's limb. Any nurse involved in the care of stroke patients must possess essential knowledge on the pathophysiology of hemiplegia and its subsequent treatment and care management programmes. This article reviews the stroke literature for patients with arms affected by hemiplegia. It describes common complications that may arise and subsequent preventive care management strategies that need to be considered. Finally it discusses why success in rehabilitation and recovery programmes need to be considered from the patient's perspective and measured in the context of the patient's experiences and feelings of well-being.

What do nurses and therapists think about the positioning of stroke patients?

BACKGROUND

At present, there are a number of different positioning strategies for stroke patients, but these are mainly based on clinical experience rather than research. Prior to developing a study to evaluate the effect of positioning on outcome after stroke, it was important to establish if nurses in our hospital had given much thought to the positioning of stroke patients.

AIM OF THE STUDY

This study aimed to explore whether nurses working on the stroke unit at a Scottish teaching hospital held different views on the positioning of conscious and unconscious stroke patients to nurses working on other wards with stroke patients and therapists.

METHODS

Questionnaires on various aspects of patient positioning were sent to 150 nurses and 25 therapists working in five specialities where stroke patients are cared for in a large teaching hospital.

FINDINGS

Overall, the majority of nurses and therapists (74%) believed that the best position for conscious stroke patients was sitting in a chair. Also, 80% of them believed that the best position for unconscious stroke patients was lying on the nonparetic side. There was less of a consensus between nurses and therapists working in the five specialities as to whether it was appropriate for conscious or unconscious stroke patients to lie on their paretic side, lie supine or sit propped-up in bed in either a 30 or 70 degrees angle.

CONCLUSIONS

The lack of consensus between nurses working in the five specialities is probably because at present there is little research to guide nursing practices for the positioning of stroke patients. Therefore, research to confirm which positions improves or hinders outcome after stroke is essential. Indeed, positioning is a simple inexpensive strategy, which could have a substantial public health impact, as stroke is so common.