Stroke nursing care and management in the community: a survey of district nurses' perceived contribution in one health district in England

Revisioning, reconnecting and revisiting: the psychosocial transition of returning home from hospital following a stroke

PURPOSE

This study aimed to investigate and improve understanding of the experiences of patients and their carers during the first month at home following discharge from hospital, thereby enhancing appropriate care from a more informed perspective.

METHOD

In-depth interviews and self-report diaries were used to capture data from 12 patient/carer dyads. Four survivors with marked communication problems were included in this number, two requiring the use of pictures and diagrams to express their views. Interpretative phenomenological analysis (IPA) was used to capture and interpret survivor and carer experiences.

FINDINGS

Three superordinate themes were derived from the data. Stroke survivors and their carers described the first month at home as a very dynamic time, recounting a process that involved revisioning (re-examining their identity and the reality of their new situation, including an awareness of their own mortality), reconnecting (with important relationships and previous activities) and revisiting (their past lives, and the stroke event and hospital experience). These three activities assisted in making and finding sense in their new situation; participants' vision of their lives was revised and revisited as they attempted to reconnect with as much of their past selves and past activities as possible.

CONCLUSIONS

This study contributes to understandings through in-depth individual accounts of the psychosocial transition of returning home. Details of how people make sense of their altered situation can make a valuable contribution to research, and the knowledge base for care provision. Implications for Rehabilitation Supporting people to revision their future can assist with psychosocial transition following a stroke. Assisting patients to reconnect and reintegrate in a way that is meaningful to them is an important part of the rehabilitation support that can be offered by professionals, and can be informed by awareness of their vision of what the future may now hold. Offering people the opportunity to reflect on what has occurred, either verbally or in the form of a diary, can assist adjustment and help people to make sense of their changed situation.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.

A survey to investigate the role of the district nurse in stroke care

The long-term needs of people who have had a stroke and their carers are not being adequately addressed. A stroke care coordinator based in primary care might improve service delivery: the district nurse has been suggested as a possible candidate. A postal survey was conducted with three primary care trusts in Bradford to investigate the current role of the district nurse in stroke care and to examine their potential as stroke care coordinator. District nurses from 24 (59%) teams responded to the survey. Twenty-two (44%) were aware of the national clinical guidelines for stroke and five (10%) had received stroke-related training within the previous year. The district nurses demonstrated insight into the types of longer term problems experienced by people who have had a stroke and their carers. While findings of the survey suggests that they would be a likely candidate for the stroke care coordinator role, there are major educational, training and organizational challenges to implementing this change.

Qualitative studies of stroke: a systematic review

BACKGROUND AND PURPOSE

Qualitative studies are increasingly used to investigate social processes and phenomena influencing health behaviors and service provision. We aimed to identify the scope of published qualitative studies of stroke, consider their relevance to development and delivery of services for people with stroke, and make recommendations for future work.

METHODS

Literature review of published articles was identified by systematically searching online literature databases using keywords from the start of each database until 2002. Articles were reviewed by 2 authors, using a standardized matrix for data extraction. The 2003 European Stroke Initiative recommendations for stroke management were used to categorize the literature for consideration of its contribution to stroke research.

RESULTS

We included 95 articles. Their empirical contribution includes an emphasis on recording the "human" experience of stroke; identification of needs as perceived by patients and their families, differences in priorities between patients and professionals, and barriers to best-quality care. We identified 12 papers that were specifically undertaken to develop or evaluate interventions.

CONCLUSIONS

Qualitative studies have addressed a wide range of issues related to the impact of stroke on individuals and caregivers, and to the organization and delivery of services. Significant problems remain in ensuring the delivery of best-quality stroke care, which such studies have the potential to address. Maximizing this potential requires greater collaboration between nonclinical and clinical scientists, service providers, and users to formulate research questions of interest as well as new research strategies, such as meta-analysis, to pool qualitative research findings and multisited investigations.

An exploration of the contribution of the community nurse to rehabilitation

Effective hospital and community rehabilitation services are increasingly recognised as a means of meeting the changing pattern of health and social care need. While the district or community nurse has the potential to play a central part in community rehabilitation provision, this role has received relatively scant attention in the literature. This paper describes research findings on community nurses' perceptions of their role and potential contribution to rehabilitation. As part of a wider, 2-year, qualitative investigation of the role of the nurse in rehabilitation, fieldwork was undertaken with both district and community staff nurses. This comprised focus group discussions and interviews with staff recruited as a consequence of the follow-up of patients' experiencing rehabilitation. The findings indicate that community-based nurses contributed to patient rehabilitation by making assessments, referring on to other members of the multi-professional team, advocating for and liaising with other services, helping people to adapt, teaching and motivating patients and carers, supporting and involving families, and providing technical care. A number of challenges to community-based nursing roles were apparent, including feelings of exclusion, lack of recognition, a lack of time for rehabilitation and paucity of referrals for rehabilitation. Greater clarity and recognition is needed of the community-based nursing contribution to rehabilitation, and there is a need to ensure that community nursing assessments contribute to patients' rehabilitation goals and the promotion of independent living.

Identifying priorities for strengthening and developing the nursing contribution in a field of practice: A case study in stroke care

Building on earlier work, this paper describes a coordinated and systematic method for identifying priorities for nursing development within a field of practice. The nursing contribution in stroke care serves as a case study, the primary aim of which was to establish priorities for research and development in stroke care from a nursing perspective. The initiative was a partnership between the Royal College of Nursing and the Stroke Association, supported by the Royal College of Physicians.

Preventing avoidable hospital admission of older people

The National Service Framework for Older People (Department of Health, 2001) stresses the importance of preventing unnecessary hospital admissions for older people. Such admissions arise when there is inadequate health and social support available in the community to meet the needs of this age group. This article reports on a study designed to evaluate the effectiveness of a programme of enhanced primary care support intended to reduce the risk of hospital admission for people aged 75 years and above. Nineteen patients out of a possible 322 in one GP practice were judged by GPs and district nurses to be "at risk" of avoidable hospital admission. All at-risk patients were visited by a GP or district nurse to review their needs for enhanced support, six patients subsequently accepting a referral for additional support. No statistically significant difference in the number of hospital admissions in the intervention group was observed compared with a group of patients with similar demographic characteristics but deemed not to be at such high risk, suggesting that the intervention might have been effective in reducing the number of avoidable hospital admissions.

A description of the nursing role in stroke rehabilitation

A theoretical description of the nursing role in stroke rehabilitation remains elusive in the literature. The United Kingdom strategy for health service development will increasingly require nurses from all clinical specialities to collaborate with other health care professionals and stakeholders to evaluate the services they provide. In stroke rehabilitation, an understanding of the contribution that nursing makes is essential, if that collaboration is to be effective. This paper details a study undertaken to describe the nature of the nursing role in stroke rehabilitation, and the factors that shape this role. A reflective enquiry was used to enable the collection of data grounded in the realities of clinical practice. Study participants were qualified nursing staff (n=13) working in a rehabilitation unit in the north-west of England. A total of 35 in-depth reflections were obtained for analysis. Three role categories were identified in the data: the nurse as care giver, facilitator of personal recovery and care manager. Sub-categories of nursing intervention were identified within each category, together with anticipated outcomes and contextual features that shaped the category. The results of the study were verified by a purposive sample of nursing staff from the rehabilitation unit.

Exploring the role of the district nurse in rehabilitation

This article reviews the available literature to examine the district nurse's contribution to rehabilitation of the older patient in the community. It is argued that policy and demographic changes indicate that there is a demand for nursing care in the home that enables individuals and their carers to live with chronic health problems and develop strategies that maintain and improve their health. The ways in which district nurses incorporate an understanding of patient rehabilitation within their work is discusses. It is suggested that although there is an expectation that district nurses can and should be involved in planning and supporting rehabilitation for their patients, the process is often poorly defined, hampered by contextual problems and dependent on the cooperation and support of others. Furthermore, in specific areas of care such as cardiac rehabilitation and services for those recovering from stroke, there would appear to be an increase in specialist nurses who either undertake or coordinate the rehabilitation process for patients. This raises questions regarding how district nurses should develop their skills in rehabilitation and what strategies could be adopted to develop patterns of work that ensure collaboration and development rather than overlap and duplication.

Community nursing and stroke: a reassessment of the issues

Recent research has highlighted the difficulties that stroke patients and carers experience in navigating a recovery path through a complex array of service providers. Many of these difficulties relate to continuing recovery from stroke at home, often when professional help is decreasing. A study by Gibbon (1994) demonstrated a potential role for community nurses in helping patients and carers to cope with the aftermath of stroke. This article reassesses the issues that affect the capacity of community nurses to develop this role. A focus group conducted with community nursing students identified a number of barriers to the expansion of service provision for this patient group, including workload pressures, training and management support. Understanding of the problems faced by stroke patients and their carers in the current organization of continuing care and rehabilitation is required to support expansion of nursing practice in this area.

The scope for community based intervention in stroke rehabilitation

The aftermath of stroke is commonly managed in the community, often exclusively by the GP. However, a significant proportion of community stroke patients have considerable impairments and disabilities which often go undetected and consequently untreated by the primary healthcare team. This article describes and quantifies the disabilities experienced by stroke patients living in the community and reviews the evidence for community rehabilitation. The roles of the occupational therapist and community nurse in the management of stroke rehabilitation are discussed. The authors conclude that an opportunity exists for better collaboration between the occupational therapist and the community nurse.

An exploratory study of nurses' perceptions of their role in neurological rehabilitation

The role of the nursing profession in the multidisciplinary specialty of neurological rehabilitation has not been clearly defined in the United Kingdom. A qualitative exploratory study was performed in a highly specialized neurological rehabilitation unit. Nine registered nurses having at least 1 year of experience in this setting were interviewed in a semistructured manner. Transcripts of the interviews were subjected to a theme analysis. Three main themes emerged in relation to the role of the nurse. The first theme referred to actions directly related to patient care. This theme included four concepts: the promotion of patient independence, routine tasks, the management of patient care, and counseling. The second theme involved the organizational issues that influence practice. Nurse opinions and views of their roles formed the third theme. The subjects' views identified skills specific to neurological rehabilitation nursing and areas for further exploration.

Stroke. 1: A paradigm case in nursing rehabilitation

This is the first of two articles which consider rehabilitation following a stroke. Although stroke is a major cause of morbidity and mortality in the UK there have been relatively few studies describing its long-term effects. Despite relatively good functional recovery, in many cases a number of stroke survivors still experience 'long-term misery'. This article argues for an expanded range of outcomes in stroke rehabilitation and for greater attention to be paid to the psychological needs of stroke survivors and their carers. Areas of deficit in stroke rehabilitation are described, as is the currently poorly developed nursing role.