How nurses in a stroke rehabilitation unit attempt to meet the psychological needs of patients who become depressed following a stroke

Clinical practice guidelines for post-stroke depression in China

Post-stroke depression (PSD) is a very common complication that leads to increased physical disability, poor functional outcome, and higher mortality. Therefore, early detection and treatment are very important. Since there are currently no specific guidelines for this disorder in China, the purpose of this study was to develop PSD guidelines and provide suggestions for clinicians and related workers.

The Effect of a Brief Intervention for Patients with Ischemic Stroke: A Randomized Controlled Trial

BACKGROUND

Depression and anxiety are common after stroke. There is inconclusive evidence of the benefit of psychotherapy for poststroke depression and anxiety. Here, we used a brief intervention, Neuro-Linguistic Programming (NLP) brief therapy plus health education, to evaluate the changes in patients with ischemic stroke.

METHODS

One hundred eighty patients were randomly allocated to receive 4 sessions of NLP plus health education (n = 90) or usual care (n = 90). A set of questionnaires was used preintervention and postintervention as well as at the 6-month follow-up. The primary outcomes were the prevalence of depression and anxiety, and the awareness of stroke knowledge.

RESULTS

More patients in the intervention group achieved remission of depressive (odds ratio [OR], 2.81; 95% confidence interval [CI], 1.41-5.59) and anxious symptoms (OR, 2.19; 95% CI, 1.15-4.18) after intervention. At the 6-month follow-up, we found no differences between groups in both the prevalence of depression and anxiety. After intervention, the intervention group had better awareness rates on most of the stroke knowledge items (P < .05). It also had better quality of life and physical function both after intervention and at the follow-up (P < .05).

CONCLUSIONS

NLP plus health education could reduce depression and anxiety immediately after intervention, but not at the 6-month follow-up. The intervention could also improve the awareness of stroke knowledge and benefit patients on quality of life and physical function.

Using stroke to explore the Life Thread Model: An alternative approach to understanding rehabilitation following an acquired disability

The purpose of this paper is to introduce the Life Thread Model, which incorporates established psychological and social theory related to identity change following an acquired disability. It is supported by a growing body of empirical evidence and can be used to broaden our understanding of service provision in rehabilitation. We suggest that a limited appreciation of social and psychological processes underpinning rehabilitation has led to different agendas for patients and professionals, lack of recognition of power relationships, negative views of disability, and insufficient professional knowledge about the management of emotional responses. The Life Thread Model, based on narrative theory and focusing on interpersonal relationships, has been developed following ten years of empirical research. Using the model, the balance of power between professionals and patients can be recognized. We suggest that positive emotional responses can be supported through (a) endorsing a positive view of self, (b) 'being' with somebody as well as 'doing' things for them; and (c) seeing acquired disability as a time of transition rather than simply of loss. This model highlights the usually hidden social processes which underpin clinical practice in acquired disability. Recognition of the importance of discursive as well as physical strategies widens the possibilities for intervention and treatment.

Patient, carer and staff experience of a hospital-based stroke service

OBJECTIVE

Here, the aim is to study the experiences of patients, carers and staff throughout a hospital stroke care pathway.

DESIGN

Focus groups of patients, carers and staff followed a semi-structured format to elucidate experiences. The groups were recorded, transcribed and subjected to thematic analysis. Analyses were verified by researchers and participants.

RESULTS

Patients and carers produced four overlapping themes: 'information', 'staff attitudes', 'availability of care/treatment' and 'considering the whole person in context'. The carers' group produced two additional themes: 'accommodation of patients' individual needs' and 'burden of care'. Their experiences were complex and multi-faceted; positive views of the whole service co-existed with negative views of some aspects. The staff groups produced six themes: 'specialist service', 'split service', 'availability of care', 'consistency of care', 'staff morale' and 'wish for change'. Positive views of the specialist service were tempered by problems with physical and professional separation, staff shortages and 'hierarchical practice' that reduced collective decision-making.

CONCLUSION

Some of the patients' and carers' perspectives have not been previously reported in the stroke literature, including a desire for individualized treatment, the consideration of wider, non-physical needs and the carers' sense of burden. In addition, the study revealed how staff, carers and patients viewed each other and the service and demonstrated the concordance of their perceptions. However, staff showed little insight into the users' need for information and negative experiences of care. In contrast with previous research, lack of emotional care, poor continuity of care and lack of staff knowledge and skills were not identified as problems.

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.

Student nurses' use of their interpersonal skills within clinical role-plays

Heron's six-category intervention analysis is a component of many counselling courses and is used extensively by teachers of interpersonal skills within nursing curricula. In addition, researchers have used six-category intervention analysis as a theoretical framework for exploring nurses' perceptions of their interpersonal skills. This study aimed to advance previous research by using Heron's framework to analyse student nurses' actual skills, as deployed in clinical role-plays, and then to compare them to earlier findings. Analysis of the data produced the following rank order of interventions based on Heron's framework: catalytic, prescriptive, supportive, informative, confronting and cathartic. The findings both challenge and support previous findings on nurses' perceptions of their interpersonal skills. The paper discusses these findings and their implications for clinical practice.

The aphasic person's views of the encounter with other people: a grounded theory analysis

Being affected by aphasia influences the total life experience. The aim of this study was to generate a theoretical model, from a nursing perspective, of what aphasic persons (n = 12) experience in encounters with other people. Data were collected through interviews which adopted a biophysical, socio-cultural and psychological approach and then analysed using grounded theory method. Two main categories emerged, namely: 'interaction' and 'support'. Encountered experiences led to: 'a feeling of having ability'; 'a feeling of being an outsider'; and 'a feeling of dejection or uncertainty'. The feeling state was dependent on whether the interaction was 'obstructed' or 'secure' and on whether the support resulted in 'strengthened' or 'impaired' self-esteem. Therefore nurses need to give support that enhances patients' self-esteem and which results in them gaining a positive and realistic view of their aphasia, as well as involving those around them in this perspective. This then will give the possibility for the patient to turn the interaction process from an obstructed into a secure one.

A study of the criteria used by healthcare professionals, managers and patients to represent and evaluate quality care

AIM

To explore the perceptions of and criteria used by healthcare professionals, managers, patients and relatives to represent and evaluate their concept of quality care.

METHODS

A qualitative approach using grounded theory was adopted in this exploratory descriptive study. Data collected by semi-structured interviews from a purposive sample of nurses, doctors, managers (n = 36), patients (n = 34) and relatives (n = 7) from one acute medical ward, were subjected to content, question and thematic analysis, using an inductive categorizing scheme.

FINDINGS

Three categories of criteria relating to Care Resources, Processes and Outcomes were identified by healthcare professionals, managers, patients and relatives. Resource criteria included Human Resources: staff numbers, ratio to patients, skill mix; as well as Environmental/Physical and Financial Resources. Process criteria included Care Functions, Practices and Standards as well as Interpersonal Processes. Outcome criteria were either patient-focused: feeling comfort, happy, informed and satisfied; or health-related: maintenance or progress with health problems and goals.

CONCLUSIONS

The criteria used by healthcare stakeholders in this study were not unusual; virtually all were supported by the literature, a proportion of which was evidence-based. The criteria identified in this study are however consensual, agreed upon by healthcare professionals, managers, patients and relatives as representing their view of quality care. These consensual criteria could be used as unifying constructs for the development and testing of more comprehensive, reliable and valid methods of evaluating quality care which represent its multiple dimensions and perspectives.

Patients' and relatives' experiences and perspectives of 'Good' and 'Not so Good' quality care

AIMS

To explore patients' and relatives' perceptions of care and identify key criteria used to evaluate quality care, via descriptions of actual care experiences.

METHOD

A qualitative approach using Grounded Theory was adopted; data collected by semistructured interviews, from a purposive sample of 34 acute medical patients and 7 relatives, was subjected to question and thematic analysis.

FINDINGS

The nature of the care provided and interpersonal aspects of caring emerged as key quality issues for patients. Good Quality Care was characterized as individualized, patient focused and related to need; it was provided humanistically, through the presence of a caring relationship by staff who demonstrated involvement, commitment and concern. Care described as 'Not so Good' was routine, unrelated to need and delivered in an impersonal manner, by distant staff who did not know or involve patients.

CONCLUSIONS

Empirical evidence was found which support these findings, which are in opposition of the received view that patients place greater emphasis on the technical aspects of care tasks. The quality issues identified as important by patients and relatives in this study are not always evaluated in care audits. Those responsible for evaluating health care quality might consider combining traditional (professional/technical) audit criteria with those used by health care users to achieve a more comprehensive evaluation.

Older adults' descriptions of hope after a stroke

This descriptive, qualitative study explored the phenomenon of hope and associated factors in older adults who have experienced a stroke. The research questions were (a) What are the patterns of hope manifested by older adults after a stroke? and (b) What are the factors associated with their patterns of hope after the stroke? Participants were a convenience sample of nine stroke survivors who were participating in a stroke support group. Patterns of hope they described were positive anticipation, active participation, forward moving process, inner sense/strength, faith in God, continuing to hope, relative comparison, life-sustaining realistic possibilities, connectedness, previous abilities, and mobility. Factors associated with hope patterning were family connectedness, spiritual connectedness, and goal achievement. Implications for nursing practice included the life-sustaining value of hope, benefits of stroke survivors telling their stories and knowing study results, the delicate balance between caregiver involvement and burden, and the influence of spirituality. Recommendations for further research focus on longitudinal investigations of stroke survivors' experiences, the relation between hope and stroke recovery, and outcome studies of stroke survivors who use hope-fostering strategies.

Intermediate care for older people: Using action research to develop reflective nursing practice in a rehabilitation setting

The importance of developing intermediate care options for older people is gaining increasing prominence in the UK with the promotion of new health and social care partnerships. Consequent changes in practice and values are demanded from staff. An action research approach provides a process of generating information linked to dialogues which facilitate such changes. This article draws on a case study of nursing staff working with older people in a newly‐defined rehabilitation setting in a Welsh community hospital. The action research cycle reported, focused on a series of collaborative interventions aimed at bringing about such changes in thinking and practice from a ‘doing for’ to an ‘enabling’ rehabilitative style of nursing. Three questionnaires and a round of group interviews were successively undertaken with a group of 49 staff, with planning and discussion sessions taking place between each data collection round. The process highlighted differing assumptions between different grades of nursing staff and between nurses and therapists about the nature of the rehabilitative process and how far it could be integrated with nursing care. The article discusses how the action research process supported a shared change in perspective that progress needed to be made to work in an integrated rehabilitative way. Participative approaches, such as action research, should be drawn on if the positive and cost‐effective benefits of rehabilitation for older people are to be more actively realised.

Development of health care delivery systems that are sensitive to the needs of stroke survivors and their caregivers

The life-altering event of a stroke has long-term effects not only on stroke survivors but also on their caregivers, health care professionals, and health care delivery systems. The nurse administrator is faced with an obvious challenge to organize nursing systems to meet the multiple needs of the stroke survivor. The article presents data on the perceived needs of stroke survivors and their caregivers that provide direction and assistance to nursing administrators in organizing nursing services to address these perceived needs.

The nursing care of stroke patients in nursing homes. Nurses' descriptions and experiences relating to cognition and mood

Registered nurses working in nursing homes often care for stroke patients with impaired cognition and mood disorders. Understanding the behaviour of these patients often puts great demands on nurses. This study illuminates registered nurses' descriptions and experiences of stroke patients and the nursing care given in nursing homes, with a focus on cognition and mood. Registered nurses responsible for the care of stroke patients in nursing homes were asked to describe the individual patient's state of health and the nursing care given. Patients' cognition and mood have been selected for this article. A qualitative content analysis was used to group the text into categories. Registered nurses' descriptions showed great complexity and variation in patients' disabilities, as well as uncertainty about understanding these patients and the appropriate nursing care. Registered nurses described the need for further education in stroke care, and adequate resources for patient activity training, as well as meeting patients' psychosocial and communicative needs.

Neurological rehabilitation nursing: a review of the research

Neurological rehabilitation is increasingly seen as a specialist form of rehabilitation requiring specialist nursing knowledge. However, as in many areas of nursing, nurses in this field recognize that there is a need to increase their knowledge base to ensure that they provide the best and most up-to-date quality care for their patients and their families. To achieve high levels of competence, neurological rehabilitation nurses need to be aware of the existing body of research in this field so that they can make sound decisions regarding their practice and future research endeavours. This review aims to validate the existing knowledge base in this area by identifying and critically analysing research conducted in the area of neurological rehabilitation nursing during the decade 1988-1998 and by identifying any gaps and weaknesses that may be addressed by future research. Studies were included in the review if they examined an aspect of rehabilitation nursing, were concerned predominately with the neurological patient and were conducted in an in-patient setting. Research with a medical focus was not included and only research published in English was reviewed. Relevant research located examined the following areas: (1) the role of the rehabilitation nurse; (2) specific problems concerning the neurological rehabilitation patient; (3) specific nursing interventions; (4) rehabilitation nursing practice; (5) the delivery of rehabilitation programmes and team working; and (6) the family of the rehabilitation patient. The review concludes that research in this speciality remains limited both in quantity and quality. Most of the studies lack rigour and, because they were conducted at a single site, their generalizability to other clinical sites may be limited.

Coping strategies used by hospitalized stroke patients: implications for continuity and management of care

This paper describes findings from an English study into the perceptions of multi-professional practice given by stroke patients, their informal carers and hospital staff. Unstructured interviews were conducted with nine stroke patients and eight informal carers. Case studies were developed from the interview data which formed the basis of a questionnaire designed to ascertain the aims of care for the case studies and the location of professional responsibility for meeting these aims. This was returned by 31 respondents from a range of professional backgrounds. The findings indicate that patients and carers sought out relationships with staff and other patients in order to gain information to help them understand their uncertain futures. Professional staff were reluctant to pass specific information on to patients as it might be misleading in each individual case. The uncertainty surrounding individual recovery means that supportive relationships initiated by patients and carers may need to be recognized and nurtured.

Psychological care in nursing education and practice: a search for definition and dimensions

Despite a wealth of literature from the medical and nursing arenas pointing to the significance of psychological care in illness, there appears to be little consensus on definition, description and dimensions of the concept. A literature review and analysis of textbook content was conducted to explore the nature of the concepts of psychological need and care which might inform nurse educationalists in the preparation of appropriate teaching and learning programmes. Preliminary findings indicate that there is little consensus upon definition or description and, with the exception of information-giving, upon the dimensions or components of psychological care, despite the fact that student nurses are prepared to meet the same nationally prescribed learning outcomes by pursuing broadly the same guidelines for educational content. It is suggested that this has particular implications for nursing lecturers with a responsibility for teaching the philosophy and practice of holistic care.

Stroke patients' perceptions of hospital nursing care

While nursing remains uncertain about the nature of its role in stroke rehabilitation, recent research by social scientists re-affirms its importance. This study explored a small number of stroke patients' perceptions of hospital nursing care in order to illuminate the meaning of the role in practice. Informants' early experiences of nursing care in general medical and care of the elderly assessment wards were dominated by having the necessary done, while nursing in the Stroke Rehabilitation Unit was characterized by a do it yourself approach. These two concepts are explored in detail and related to the existing literature, suggesting some specific areas for practice development and research.

Psychiatric consultation-liaison nursing: revisiting the role

With their special training and assessment skills, psychiatric consultation-liaison nurses have a long history of making important contributions to patient care and staff development. This article reviews how psychiatric consultation-liaison nurses have traditionally approached and implemented the nursing consultation process. Issues facing psychiatric consultation-liaison nurses are discussed. Opportunities such as focusing on subspecialization; expanding practice settings; dealing with organization-based, rather than patient-based mental health issues; and entering intra- and entrepreneurial practice are also explored.

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.

Student nurses perceptions of their interpersonal skills: a re-examination of Burnard and Morrison's findings

Heron's six category intervention analysis is a component of many counselling courses and is used extensively by teachers of interpersonal skills within nursing curricula. The popularity of this framework has generated a number of studies which have attempted to offer empirical support for the theory. The aim of this study was to re-evaluate some of these findings. Utilising an earlier research instrument, a set of findings are offered and comparisons made with previous work. Our findings suggest that student nurses perceive themselves to be most skilled in the use of supportive, prescriptive and cathartic interventions and least skilled in the use of informative, catalytic and confronting interventions. A discussion of the new findings and their implications is offered.