A qualitative study of specialist nurse support for stroke patients and care-givers at home

Information provision for stroke survivors and their carers

BACKGROUND

A stroke is a sudden loss of brain function caused by lack of blood supply. Stroke can lead to death or physical and cognitive impairment and can have long lasting psychological and social implications. Research shows that stroke survivors and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

The primary objective is to assess the effects of active or passive information provision for stroke survivors (people with a clinical diagnosis of stroke or transient ischaemic attack (TIA)) or their identified carers. The primary outcomes are knowledge about stroke and stroke services, and anxiety.

SEARCH METHODS

We updated our searches of the Cochrane Stroke Group Specialised Register on 28 September 2020 and for the following databases to May/June 2019: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) and the Cochrane Database of Systematic Reviews (CDSR; 2019, Issue 5) in the Cochrane Library (searched 31 May 2019), MEDLINE Ovid (searched 2005 to May week 4, 2019), Embase Ovid (searched 2005 to 29 May 2019), CINAHL EBSCO (searched 2005 to 6 June 2019), and five others. We searched seven study registers and checked reference lists of reviews.

SELECTION CRITERIA

Randomised trials involving stroke survivors, their identified carers or both, where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone, or where the comparison was between active and passive information provision without other differences in treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We categorised interventions as either active information provision or passive information provision: active information provision included active participation with subsequent opportunities for clarification and reinforcement; passive information provision provided no systematic follow-up or reinforcement procedure. We stratified analyses by this categorisation. We used GRADE methods to assess the overall certainty of the evidence.

MAIN RESULTS

We have added 12 new studies in this update. This review now includes 33 studies involving 5255 stroke-survivor and 3134 carer participants. Twenty-two trials evaluated active information provision interventions and 11 trials evaluated passive information provision interventions. Most trials were at high risk of bias due to lack of blinding of participants, personnel, and outcome assessors where outcomes were self-reported. Fewer than half of studies were at low risk of bias regarding random sequence generation, concealment of allocation, incomplete outcome data or selective reporting. The following estimates have low certainty, based on the quality of evidence, unless stated otherwise. Accounting for certainty and size of effect, analyses suggested that for stroke survivors, active information provision may improve stroke-related knowledge (standardised mean difference (SMD) 0.41, 95% confidence interval (CI) 0.17 to 0.65; 3 studies, 275 participants), may reduce cases of anxiety and depression slightly (anxiety risk ratio (RR) 0.85, 95% CI 0.68 to 1.06; 5 studies, 1132 participants; depression RR 0.83, 95% CI 0.68 to 1.01; 6 studies, 1315 participants), may reduce Hospital Anxiety and Depression Scale (HADS) anxiety score slightly, (mean difference (MD) -0.73, 95% CI -1.10 to -0.36; 6 studies, 1171 participants), probably reduces HADS depression score slightly (MD (rescaled from SMD) -0.8, 95% CI -1.27 to -0.34; 8 studies, 1405 participants; moderate-certainty evidence), and may improve each domain of the World Health Organization Quality of Life assessment short-form (WHOQOL-BREF) (physical, MD 11.5, 95% CI 7.81 to 15.27; psychological, MD 11.8, 95% CI 7.29 to 16.29; social, MD 5.8, 95% CI 0.84 to 10.84; environment, MD 7.0, 95% CI 3.00 to 10.94; 1 study, 60 participants). No studies evaluated positive mental well-being. For carers, active information provision may reduce HADS anxiety and depression scores slightly (MD for anxiety -0.40, 95% CI -1.51 to 0.70; 3 studies, 921 participants; MD for depression -0.30, 95% CI -1.53 to 0.92; 3 studies, 924 participants), may result in little to no difference in positive mental well-being assessed with Bradley's well-being questionnaire (MD -0.18, 95% CI -1.34 to 0.98; 1 study, 91 participants) and may result in little to no difference in quality of life assessed with a 0 to 100 visual analogue scale (MD 1.22, 95% CI -7.65 to 10.09; 1 study, 91 participants). The evidence is very uncertain (very low certainty) for the effects of active information provision on carers' stroke-related knowledge, and cases of anxiety and depression. For stroke survivors, passive information provision may slightly increase HADS anxiety and depression scores (MD for anxiety 0.67, 95% CI -0.37 to 1.71; MD for depression 0.39, 95% CI -0.61 to 1.38; 3 studies, 227 participants) and the evidence is very uncertain for the effects on stroke-related knowledge, quality of life, and cases of anxiety and depression. For carers, the evidence is very uncertain for the effects of passive information provision on stroke-related knowledge, and HADS anxiety and depression scores. No studies of passive information provision measured carer quality of life, or stroke-survivor or carer positive mental well-being.

AUTHORS' CONCLUSIONS

Active information provision may improve stroke-survivor knowledge and quality of life, and may reduce anxiety and depression. However, the reductions in anxiety and depression scores were small and may not be important. In contrast, providing information passively may slightly worsen stroke-survivor anxiety and depression scores, although again the importance of this is unclear. Evidence relating to carers and to other outcomes of passive information provision is generally very uncertain. Although the best way to provide information is still unclear, the evidence is better for strategies that actively involve stroke survivors and carers and include planned follow-up for clarification and reinforcement.

An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT

BACKGROUND

There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS).

DESIGN

A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care.

SETTING

Nineteen NHS study centres.

PARTICIPANTS

Patients with a new stroke who received early supported discharge and their informal carers.

INTERVENTIONS

Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge.

MAIN OUTCOME MEASURES

The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers' strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years.

RESULTS

A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval -0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: -£311 (95% confidence interval -£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective.

CONCLUSIONS

EXTRAS did not improve stroke survivors' performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective.

FUTURE WORK

Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45203373.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.

Pharmacological, psychological and non-invasive brain stimulation interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that influences recovery yet often is not detected, or is inadequately treated. This is an update and expansion of a Cochrane Review first published in 2004 and previously updated in 2008.

OBJECTIVES

The primary objective is to test the hypothesis that pharmacological, psychological therapy, non-invasive brain stimulation, or combinations of these interventions reduce the incidence of diagnosable depression after stroke. Secondary objectives are to test the hypothesis that pharmacological, psychological therapy, non-invasive brain stimulation or combinations of these interventions reduce levels of depressive symptoms and dependency, and improve physical functioning after stroke. We also aim to determine the safety of, and adherence to, the interventions.

SEARCH METHODS

We searched the Specialised Register of Cochrane Stroke and the Cochrane Depression Anxiety and Neurosis (last searched August 2018). In addition, we searched the following databases; Cochrane Central Register of Controlled Trials, CENTRAL (the Cochrane Library, 2018, Issue 8), MEDLINE (1966 to August 2018), Embase (1980 to August 2018), PsycINFO (1967 to August 2018), CINAHL (1982 to August 2018) and three Web of Science indexes (2002 to August 2018). We also searched reference lists, clinical trial registers (World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); to August 2018 and ClinicalTrials.gov; to August 2018), conference proceedings; we also contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing: 1) pharmacological interventions with placebo; 2) one of various forms of psychological therapy with usual care and/or attention control; 3) one of various forms of non-invasive brain stimulation with sham stimulation or usual care; 4) a pharmacological intervention and one of various forms of psychological therapy with a pharmacological intervention and usual care and/or attention control; 5) non-invasive brain stimulation and pharmacological intervention with a pharmacological intervention and sham stimulation or usual care; 6) pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy; 7) pharmacological intervention and non-invasive brain stimulation with placebo plus non-invasive brain stimulation; 8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and 9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy, with the intention of preventing depression after stroke.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) for dichotomous data with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 19 RCTs (21 interventions), with 1771 participants in the review. Data were available for 12 pharmacological trials (14 interventions) and seven psychological trials. There were no trials of non-invasive brain stimulation compared with sham stimulation or usual care, a combination of pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy, or a combination of non-invasive brain stimulation and a pharmacological intervention with a pharmacological intervention and sham stimulation or usual care to prevent depression after stroke. Treatment effects were observed on the primary outcome of meeting the study criteria for depression at the end of treatment: there is very low-certainty evidence from eight trials (nine interventions) that pharmacological interventions decrease the number of people meeting the study criteria for depression (RR 0.50, 95% CI 0.37 to 0.68; 734 participants) compared to placebo. There is very low-certainty evidence from two trials that psychological interventions reduce the proportion of people meeting the study criteria for depression (RR 0.68, 95% CI 0.49 to 0.94, 607 participants) compared to usual care and/or attention control. Eight trials (nine interventions) found no difference in death and other adverse events between pharmacological intervention and placebo groups (RR 1.25, 95% CI 0.32 to 4.91; 496 participants) based on very low-certainty evidence. Five trials found no difference in psychological intervention and usual care and/or attention control groups for death and other adverse events (RR 1.18, 95% CI 0.73 to 1.91; 975 participants) based on very low-certainty evidence.

AUTHORS' CONCLUSIONS

The available evidence suggests that pharmacological interventions and psychological therapy may prevent depression and improve mood after stroke. However, there is very low certainty in these conclusions because of the very low-certainty evidence. More trials are required before reliable recommendations can be made about the routine use of such treatments after stroke.

The role of community-based nursing interventions in improving outcomes for individuals with cardiovascular disease: A systematic review

OBJECTIVE

To examine the role of community-based nursing interventions in improving outcomes for community-dwelling individuals with cardiovascular disease.

DESIGN

A systematic review and narrative synthesis.

DATA SOURCES

Seven electronic databases (MEDLINE, CINAHL, Global Health, LILACS, Africa-Wide Information, IMEMR and WPRIM) were searched from inception to 16 March 2018 without language restrictions.

REVIEW METHODS

We included studies evaluating the outcomes of interventions led by, or primarily delivered by, nurses for individuals with cardiovascular disease in community settings. Study selection, data extraction and risk of bias assessments were performed by at least two independent reviewers.

RESULTS

Twenty-eight studies met the inclusion criteria and were included in this review. Community-based nursing interventions improved outcomes in four key areas: (1) self-care, (2) health, (3) healthcare utilisation, and (4) quality of care. Significant improvements were reported in patients' knowledge and ability to self-manage, severity of disease, functional status, quality of life, risk of death, hospital readmission days, emergency department visits, healthcare costs and satisfaction with care. Facilitators to intervention effectiveness included the use of an individualised approach, multidisciplinary approach, specially trained nurses, family involvement and the home setting. Conversely, barriers to intervention success included limitations in nurses' time and skills, ineffective interdisciplinary collaboration and insufficient intervention intensity.

CONCLUSIONS

The overall evidence is positive regarding the role of community-based nursing interventions in improving outcomes for individuals with cardiovascular disease. However, this review highlights the need for more robust research establishing definitive relationships between different types of interventions and outcomes as well as evaluating the cost-effectiveness of these interventions to aid the development of sustainable policy solutions.

Caring for a cerebral palsy child: a caregivers perspective at the University Teaching Hospital, Zambia

Background

Cerebral palsy is a major cause of disability and most survivors are left with residual disability and are dependent on parents/caregivers for essential care. This study aimed to determine the experiences of parents/caregivers of cerebral palsy children receiving out-patient physiotherapy. A concurrent mixed methods was used to collect data in the present study. The modified caregiver strain index (MCSI-13) was used to detect Disturbed sleep, Inconvenient/Tiresome, Physical strain, Confining, Family changes, Changes in personal plan, Other demands, Emotional adjustments, Upsetting behavior, Patient has changed, Work adjustments, Financial Strain and Feeling Overwhelmed (strain morbidity) in 25 parents/caregivers of CP children. A purposive sample of 25 parents/caregivers was selected for both the quantitative part and qualitative part of the study. The study was conducted at Community Based Intervention Association Out-patients at the University Teaching Hospital in Lusaka, Zambia. The MCSI was used to collect quantitative data and in-depth interviews provided the qualitative data.

Results

The median age of the participants was 33.6 years and a range of 27 to 50 years. The study sample consisted of more females (92%) than males (8%). being overwhelmed and inconvenient/tiresome followed by family adjustments and work adjustment 72 and 68% respectively for each were the experiences mostly highlighted by the parents/caregivers in this study. When it came to the needs of the parents/caregivers more than half of them needed help with caring. To this effect participants expressed their perception; one mother had this to say, “…I need someone to help in caring. Sometimes I need to do some other things but can’t, because if I do then no one will remain with the child…”.

Conclusion

This study point out to some evidence that the burden inflicted on those caring for children with cerebral palsy should be addressed if the quality of care for those with cerebral palsy is to be improved.

High-quality Health Information Provision for Stroke Patients

OBJECTIVE

High-quality information provision can allow stroke patients to effectively participate in healthcare decision-making, better manage the stroke, and make a good recovery. In this study, we reviewed information needs of stroke patients, methods for providing information to patients, and considerations needed by the information providers.

DATA SOURCES

The literature concerning or including information provision for patients with stroke in English was collected from PubMed published from 1990 to 2015.

STUDY SELECTION

We included all the relevant articles on information provision for stroke patients in English, with no limitation of study design.

RESULTS

Stroke is a major public health concern worldwide. High-quality and effective health information provision plays an essential role in helping patients to actively take part in decision-making and healthcare, and empowering them to effectively self-manage their long-standing chronic conditions. Different methods for providing information to patients have their relative merits and suitability, and as a result, the effective strategies taken by health professionals may include providing high-quality information, meeting patients' individual needs, using suitable methods in providing information, and maintaining active involvement of patients.

CONCLUSIONS

It is suggested that to enable stroke patients to access high-quality health information, greater efforts need to be made to ensure patients to receive accurate and current evidence-based information which meets their individual needs. Health professionals should use suitable information delivery methods, and actively involve stroke patients in information provision.

Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients

Objective: To adapt the Reintegration to Normal Living Index (RNLI) for postal use with stroke patients.

Design: Reliability was examined using test–retest on 26 stroke patients. Construct validity was tested on 76 patients by examining correlations between the modified RNLI and related scales.

Subjects: Patients at three months to one year post stroke.

Results: All items demonstrated better than chance agreement between test and retest and seven items substantial agreement (kappa= >0.61). The modified RNLI correlated positively with related scales. Patients with stronger reintegration to normal living had better outcomes in anxiety, depression, daily activity and quality of life.

Conclusion: This postal instrument appears reliable and valid and may be a useful outcome measure in stroke studies.

Information provision for stroke patients and their caregivers

BACKGROUND

Research shows that stroke patients and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

To assess the effectiveness of information provision strategies in improving the outcome for stroke patients or their identified caregivers, or both.

SEARCH METHODS

For this update we searched the Cochrane Stroke Group Trials Register (June 2012), the Cochrane Central Register of Controlled trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the NHS Economic Evaluation Database (EED), and the Health Technology Assessment (HTA) Database (The Cochrane Library June, 2012), MEDLINE (1966 to June 2012), EMBASE (1980 to June 2012), CINAHL (1982 to June 2012) and PsycINFO (1974 to June 2012). We also searched ongoing trials registers, scanned bibliographies of relevant articles and books and contacted researchers.

SELECTION CRITERIA

Randomised trials involving patients or carers of patients with a clinical diagnosis of stroke or transient ischaemic attack (TIA) where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and methodological quality and extracted data. Primary outcomes were knowledge about stroke and stroke services, and impact on mood.

MAIN RESULTS

We have added four new trials to this update. This review now includes 21 trials involving 2289 patient and 1290 carer participants. Nine trials evaluated a passive and 12 trials an active information intervention. Meta-analyses showed a significant effect in favour of the intervention on patient knowledge (standardised mean difference (SMD) 0.29, 95% confidence interval (CI) 0.12 to 0.46, P < 0.001), carer knowledge (SMD 0.74, 95% CI 0.06 to 1.43, P = 0.03), one aspect of patient satisfaction (odds ratio (OR) 2.07, 95% CI 1.33 to 3.23, P = 0.001), and patient depression scores (mean difference (MD) -0.52, 95% CI -0.93 to -0.10, P = 0.01). There was no significant effect (P > 0.05) on number of cases of anxiety or depression in patients, carer mood or satisfaction, or death. Qualitative analyses found no strong evidence of an effect on other outcomes. Post-hoc subgroup analyses showed that active information had a significantly greater effect than passive information on patient mood but not on other outcomes.

AUTHORS' CONCLUSIONS

There is evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, the reduction in depression scores was small and may not be clinically significant. Although the best way to provide information is still unclear there is some evidence that strategies that actively involve patients and carers and include planned follow-up for clarification and reinforcement have a greater effect on patient mood.

Patients' experiences with self-referral to in-patient rehabilitation: A qualitative interview study

PURPOSE

To describe objectives, experiences and satisfaction among subjects referring themselves to in-patient rehabilitation.

METHOD

Persons suffering from stroke or multiple sclerosis were invited to refer themselves to a specialised rehabilitation department. Ten patients referred themselves within the study period, of whom two were excluded. The remaining eight underwent qualitative semi-structured in-depth interviews, focusing on the decision of self-referral, the personal goals for the rehabilitation, and the satisfaction with the stay. The interviews were tape-recorded and subjected to content analysis. As an underlying theoretical framework, we applied Antonovsky's Sense of Coherence model.

RESULTS

Half of the patients had not written the application themselves and did not know which grounds had been put forward in the application. Nevertheless, all the patients were able to formulate their personal goals for the rehabilitation stay. These were distributed in three main categories: those who recently had got a progressive disability wanted education and improved knowledge on their disease; those who had had an acute, traumatic change of health status wanted training in order to improve muscular strength or everyday skills; and those who had been disabled for several years wanted inspiration for further life.

CONCLUSIONS

Patients may put forward other reasons to apply for rehabilitation than health personnel. Does the Sense of Coherence Model seems applicable to describe these reasons.

A clinical trial of an individualised intervention programme for family caregivers of older stroke victims in Taiwan

AIM AND OBJECTIVE

To explore the long-term effects of a discharge-preparation programme targeting Taiwanese family caregivers of older patients with stroke.

BACKGROUND

Little is known about the effects of interventions for caregivers of patients with stroke in Asian and Chinese families.

DESIGN

A randomised experimental design was used.

METHOD

Participants included 158 older patients with stroke (72 in the experimental group and 86 in the control group) and their family caregivers. A caregiver-oriented intervention programme was designed to increase caregiver preparedness, to enhance caregiver perception of balance between competing needs and to satisfy specific needs during the transition between hospitalisation and discharge. Long-term outcomes were measured by caregiver's health-related quality of life, quality of care, stroke patient's self-care ability, patient's health-related quality of life and service utilisation. Longitudinal data were analysed by the generalised estimating equation approach.

RESULTS

During the 12 months following discharge of older patients with stroke, caregivers in the experimental group provided significantly better quality of care (beta = 0.45; p = 0.03) than the control group. Between the sixth-twelfth months following discharge, patients in the control group were more likely to be institutionalised than those in the experimental group (chi(2) = 5.11; p = 0.03).

CONCLUSION

Using a sample from Taiwan, this intervention programme succeeded in improving quality of care provided by family caregivers to older patients with stroke and in decreasing the likelihood of their institutionalisation.

RELEVANCE TO CLINICAL PRACTICE

Older Chinese patients with stroke and their family caregivers can benefit from an individualised programme that prepares caregivers for patient discharge. Similar programmes may be applicable to other countries with Chinese populations.

Interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent depression and improve physical and psychological outcomes in patients with stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group (October 2007) and the Cochrane Depression Anxiety and Neurosis Group (February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006), Applied Science and Technology Plus (1986 to May 2006), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), BIOSIS Previews (2002 to May 2006), General Science Plus (1994 to September 2002), Science Citation Index (1992 to May 2006), Social Sciences Citation Index (1991 to May 2006), SocioFile (1974 to May 2006) ISI Web of Science (2002 to February 2008), reference lists, trial registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or psychotherapy against standard care (or attention control) to prevent depression in patients with stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality. Primary analyses were the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow up. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Fourteen trials involving 1515 participants were included. Data were available for 10 pharmaceutical trials (12 comparisons) and four psychotherapy trials. The time from stroke to entry ranged from a few hours to seven months, but most patients were recruited within one month of acute stroke. The duration of treatment ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or other endpoints. A significant improvement in mood and the prevention of depression was evident for psychotherapy, but the treatment effects were small.

AUTHORS' CONCLUSIONS

A small but significant effect of psychotherapy on improving mood and preventing depression was identified. More evidence is required before recommendations can be made about the routine use of such treatments after stroke.

Information provision for stroke patients and their caregivers

BACKGROUND

Research shows that stroke patients and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

To assess the effectiveness of information provision strategies in improving the outcome for stroke patients and/or their identified caregivers.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched May 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), CINAHL (1982 to March 2007), PsycINFO (1974 to March 2007), Science Citation Index and Social Science Citation Index (1981 to March 2007), Assia (1987 to March 2007), Index to UK theses (1970 to March 2007), Dissertation Abstracts (1961 to March 2007), ongoing trials and research registers, bibliographies of retrieved papers, relevant articles and books, and the Journal of Advanced Nursing. We also contacted researchers for additional information.

SELECTION CRITERIA

Randomised trials involving patients or carers of patients with a clinical diagnosis of stroke or transient ischaemic attack (TIA) where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and methodological quality and extracted data. Primary outcomes were knowledge about stroke and stroke services, and impact on mood.

MAIN RESULTS

Seventeen trials involving 1773 patient and 1058 carer participants were included. Eight evaluated a passive and nine an active information intervention. Meta-analyses showed a significant effect in favour of the intervention on patient and carer knowledge, one aspect of patient satisfaction, and patient depression scores. There was no significant effect on number of cases of anxiety or depression in patients, carer mood or satisfaction, or death. Qualitative analyses found no strong evidence of an effect on other outcomes. Post-hoc subgroup analyses showed that active information had a significantly greater effect than passive information on patient mood but not on other outcomes.

AUTHORS' CONCLUSIONS

There is evidence that information improves patient and carer knowledge of stroke, aspects of patient satisfaction, and reduces patient depression scores. However, the reduction in depression scores was small and probably clinically insignificant. Although the best way to provide information is still unclear there is some evidence that strategies that actively involve patients and carers and include planned follow up for clarification and reinforcement have a greater effect on patient mood.

Family carers in stroke care: examining the relationship between problem-solving, depression and general health

AIMS AND OBJECTIVES

The purpose of this article is to describe the problem-solving abilities of Hong Kong family carers looking after a stroke patients at home and report the relationships between their perceived problem-solving abilities with their depression level, general health status, and the functional recovery of stroke patients.

BACKGROUND

Previous research on supportive interventions for caregiving in stroke care suggests that enhancing carers' problem-solving abilities is useful. Nevertheless, not much is known about the relationship between carers' problem-solving abilities and their physical and psychosocial health and there is notably little work that has been done with the Chinese population.

DESIGN

A cross-sectional and correlational design was used.

METHODS

A convenience sample of 70 family carers, who were the main carers of stroke patients at home, during the first three months poststroke was recruited to complete a self-report questionnaire.

RESULT

Significant correlations were found between the family carers' global perceived problem-solving abilities and higher level of depressive symptoms (r = 0.35, P = 0.01) and poorer perceived health (r = 0.50, P = 0.01) as measured using the Center for Epidemiological Studies - Depression Scale and General Health Questionnaire. Among the three subscales of the Problem-Solving Inventory, problem-solving confidence showed the highest correlation with these variables. The functional ability of the stroke patients as measured using the Modified Barthel Index (MBI) was not associated with any variables.

CONCLUSION

Findings of this study suggest that perception of confidence is a key factor in appraisal of problem-solving among Chinese family carers, which raises questions for future research about the impact of cultural influences on designing and measuring interventions.

RELEVANCE TO CLINICAL PRACTICE

The study has implications for nursing and health care practice and for developing interventions targeted at building self-confidence among Chinese carers.

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.

Expanding the role of the stroke nurse: a pragmatic clinical trial

AIMS

This paper reports a study evaluating whether expanding a specialist nursing role to provide outreach education and support to stroke patients and carers after discharge from hospital is effective in promoting recovery.

BACKGROUND

Building therapeutic relationships with patients and carers is a key component of the nursing role in stroke rehabilitation, although this is limited by the constraints of service organization.

METHODS

A pragmatic randomized controlled trial was undertaken. Patients with a diagnosis of stroke were randomized to receive continued support from a stroke nurse (n = 87) or usual care and follow-up (n = 89) after discharge from hospital. Patients were recruited from two hospitals in the north-west of England from November 1999 to April 2001. Patient dependence (Barthel Index), general health (Nottingham Health Profile), activities of living (Frenchay Activity of Living Index), depression (Beck Depression Inventory) and carer strain (Carer Strain Index) were assessed at 3 and 12 months after stroke.

RESULTS

The continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health at 12 months (median difference 42.6, P = 0.012), and in particular reduced negative emotional reaction (P = 0.037) and perceived social isolation (P = 0.002). In addition, the intervention reduced carer strain at 3 months (P = 0.045), and reduced deterioration in physical dependence from 3 to 12 months (P = 0.049).

CONCLUSION

The provision of continued intervention from a stroke nurse after discharge from hospital, focusing on education and support, has tangible benefits for patients and carers.

Supporting Family Caregivers in Stroke Care

BACKGROUND AND PURPOSE

Teaching effective problem-solving skills to family caregivers of patients with chronic disease has been shown to be useful for promoting physical and psychosocial well-being. However, the use and effectiveness of problem solving for supporting caregivers in stroke care has not been reviewed. This article aims to identify and review studies that have examined the effectiveness of teaching problem solving skills to caregivers in stroke care, highlight gaps in the evidence base, and recommend avenues for additional research.

METHODS

A structured review of literature identified from nursing, medicine, and psychology databases from 1970 to 2004 was conducted. Eleven articles reporting the development or evaluation of effective problem-solving interventions for caregivers of patients with stroke were critically appraised using recognized quality criteria.

RESULTS

The results of this review show that the strength of evidence for problem-solving interventions for caregivers of stroke patients is limited. Because some studies used small samples and varied methods and interventions, making a comparison was difficult. Caregivers' problem-solving abilities were rarely measured, and the theoretical concepts and framework underpinning most studies were unclear.

CONCLUSIONS

Evidence from the review suggests a need to additionally study the link between theoretical concepts of effective problem solving and outcomes using standardized measures and to examine also the processes involved in implementing the intervention using multimethod designs, including both quantitative and qualitative approaches.

An exploration looking at the impact of domiciliary and day hospital delivery of stroke rehabilitation on informal carers

OBJECTIVES

To explore the impact of two methods of post-hospital stroke rehabilitation on both carers' perceptions of the health services offered and their quality of life.

SETTING

East Dorset Health Authority.

SUBJECTS

Forty-six informal carers were recruited from a sample of 106, initially identified from stroke patients participating in a larger randomized controlled trial.

DESIGN

Qualitative methods.

METHODS

Semi-structured interviews were used at baseline and six months to explore carers' perception of a good therapy, the advantages and disadvantages of the different services and their fulfilment with the services. In-depth thematic analysis was carried out to explore the impact of the two different methods of service delivery on carers' quality of life.

RESULTS

Day hospitals provided carers with respite opportunities, whilst domiciliary stroke teams provided carers with better educational opportunities to be involved in therapy. No qualitative difference was found in the impact that the different services had on carers' quality of life, which were influenced by factors such as the degree of disruption that caring had on their lives, the loss of a shared life and the availability of social support. Ultimately, carers saw the services as providing benefit for survivors and not themselves.

CONCLUSIONS

Domiciliary stroke teams provided informal stroke carers with skills that could help improve postdischarge stroke rehabilitation amongst stroke survivors. Informal carers also benefited from the respite elements of day hospital. A mixed model using both domiciliary care and day hospital care, could provide carers with the benefits of education, convenience and respite.

Postdischarge nursing interventions for stroke survivors and their families

BACKGROUND

The physical, cognitive, and emotional sequelae of stroke underscore the need for nursing interventions across the continuum of care. Although there are several published studies evaluating community interventions for stroke survivors, the nursing role has not been clearly articulated.

AIM

The aim of this paper is to report a study to describe, using a standardized classification system, the nursing interventions used with stroke survivors during the initial 6 weeks following discharge home.

METHODS

In the context of a randomized controlled trial, two nurse case managers provided care to 90 community-dwelling stroke survivors who were assigned to the intervention arm of the trial. The nursing documentation was analysed, using the Nursing Intervention Classification (NIC) system, to identify and quantify the interventions that were provided.

FINDINGS

Stroke survivors received, on average, six different interventions. There was a trend for those who were older, more impaired, and who lived alone to receive more interventions. The most commonly reported interventions included those directed towards ensuring continuity of care between acute and community care, family care, and modifying stroke risk factors. The study was limited to the nursing documentation, which may represent an underestimation of the care delivered.

CONCLUSIONS

The NIC system was useful in capturing the interventions delivered by the nurse case managers. Nursing interventions are often not clearly articulated and less often use standardized terminology. Describing nursing activities in a standard manner will contribute to an increase in nursing knowledge and to evidence-based practice.

Informal carers' experience of caring for stroke survivors

BACKGROUND

Stroke is the third most common cause of death in industrialized countries and a major cause of adult disability. However, the burden of caring for stroke survivors usually rests with family members who have neither chosen nor volunteered for the role of 'carer'.

AIMS

This paper reports on a study which aimed to describe the experience of caring for a stroke survivor at one year after stroke in Scotland.

STUDY DESIGN

Semi-structured, taped interviews were conducted with 90 carers of stroke survivors one year after stroke and the data analysed using NUD*IST. The interviews were part of a larger study, which included the administration of a range of valid and reliable multidimensional instruments to both carers and stroke survivors. The interview prompt schedule had been developed and tested in a previous study.

FINDINGS

Although a medical emergency, stroke was not always diagnosed or treated as such by either the public or general practitioners. Initially most carers found that they lacked the knowledge and skills to care for the stroke survivor at home and so they had to learn how to obtain the information and assistance required. Carers had to adapt to the changes that stroke effected in the stroke survivor and seek alternative ways of securing the resources they needed for managing their lives. They thought that they had not been prepared adequately for the caring role or assessed satisfactorily in terms of whether they could manage given their skill level, age and/or health status.

CONCLUSIONS

A public health campaign to educate and inform that stroke is a medical emergency is required if stroke disability is to be minimized. The use of new technologies should be considered in facilitating carers' learning how to care. There is a need to test alternative models of stroke follow-up in multi-centre studies that are holistic and place the carer-stroke survivor at the centre of care.

Outreach nurse support after stroke: a descriptive study on patients' and carers' needs, and applied nursing interventions

OBJECTIVE

To describe the number and types of problems mentioned by successfully contacted home-dwelling stroke patients and their carers, and nursing interventions applied.

DESIGN

In this multicentre quantitative study in the Netherlands, stroke patients and carers received outreach nurse support consisting of three telephone contacts and one home visit within six months after discharge. Standardized checklists describing a wide range of potential problems were used to record problems and interventions.

SUBJECTS

A sample of 173 patients admitted for a stroke and discharged home, and 148 carers.

RESULTS

Of 173 patients, 166 (96%) were contacted and 162 mentioned in total 1419 problems. Physical problems were mentioned most frequently (92%; 153/166), followed by emotional problems (60%; 99/166). The proportion of patients with problems decreased from 94% (142/151) at the first contact to 74% (108/145) at the last contact. Of 148 carers, 118 (80%) were contacted and 84 mentioned 266 problems. 'Psychosocial burden' was mentioned most frequently (45%; 53/118). Proportions of carers with problems were 56% (54/96) at the first contact and 37% (26/70) at the last contact. Of 864 interventions to patients, stroke nurses most frequently applied 'supportive listening' (55%; 471/864) and 'reassuring or encouraging' (12%; 107/864), and of 258 interventions to carers 45% (115/258) were 'supportive listening' and 17% (43/258) 'informing'.

CONCLUSIONS

Almost all patients and most carers were contacted. Though the number of needs decreased during the consecutive contacts, many patients and carers still raised problems during the last contact. Nurses most frequently applied the intervention 'supportive listening'.

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.

A review and commentary of the social factors which influence stroke care: issues of inequality in qualitative literature

Stroke is the third most common cause of death in the UK and a major cause of adult disability. Stroke services have long been criticised for being deficient and there is evidence that some aspects of care provision vary across different population groups. While there is information about the patterns of service provision, questions remain about processes which might underlie these variations. The present paper sought to assess how well the processes which might lead to inequity in the delivery and uptake of stroke services are currently understood by reviewing the qualitative literature in the area. The review was carried out by systematically searching online literature databases, using keyword and bibliographical searches, within a particular time frame. In total, 55 articles were reviewed, including studies related to primary and secondary clinical care, as well as social care. Articles focused on both professionals' and patients' perspectives. The review reports the cultural factors and processes which have been identified as possible causes of barriers to professionals' delivering stroke services, as well as issues which influence patients' uptake of services. Issues identified in the literature were categorised into four broad thematic areas: conceptualisations of stroke illness and ageing, socio-economic factors, resource allocation and information provision. These themes are then revisited through the hypothesis that the concept of social and personal identity could cast new light on our understanding of how inequity in stroke care provision might arise. It is argued that the ways in which professionals and patients view themselves and each other influences their interaction, and in turn, the delivery and demand for services. Finally, the authors suggest areas where further research is warranted.

A qualitative study of stroke patients' and carers' perceptions of the stroke family support organizer service

OBJECTIVE

To investigate stroke patients' and carers' perceptions of the family support organizer (FSO) service in order to highlight its value for potential purchasers and to help shed light on findings from randomized controlled trials.

DESIGN AND SUBJECTS

Twenty semi-structured interviews were undertaken with a subsample of stroke patients and their primary informal carers after completion of nine-month outcome assessments as part of a randomized controlled trial.

SETTING

Community stroke services in North Nottinghamshire, UK.

RESULTS

Interviewees who received the service reported that the presence of an FSO was valuable in many respects, including helping to claim benefits, as a source of information on stroke, and providing continuity between stroke services. Emotional support was only described by a few. Interviewees who did not receive the service described feelings of isolation and being let down by other stroke services after discharge. They also reported problems accessing information. Help needed to address the practical problems after stroke was commonly reported. For those who did not receive the FSO service, access to support appeared to be found through other channels.

CONCLUSION

The FSO service appeared to be an information service. In order to evaluate community stroke services, a mixture of qualitative and quantitative outcome measures are necessary.

Outcome, functional recovery and unmet needs following acute stroke. Experience of patient follow up at 6 to 9 months in a newly established stroke service

OBJECTIVE

To assess outcome at six months post stroke and the unmet needs and adherence to the secondary prevention advice among survivors living at home.

SETTING

Stroke Rehabilitation Unit (SRU), Hairmyres Hospital and patients homes.

SUBJECTS

Survivors living at home who had been managed in the SRU.

RESULTS

Of 572 consecutive patients with confirmed acute stroke, 301 were managed in the SRU and 179 of these were reviewed at home between 6 and 9 months post acute stroke incident. One hundred and thirty seven (76%) survivors at home were living with a carer. Sixty-eight (38%) had had no personal contact with their General Practitioner since discharge from hospital, although 83 (46%) had attended or were attending day hospital. Thirty-two individuals (18%) had resumed smoking. One hundred and forty nine survivors (83%) still required assistance with daily living tasks. One hundred and fifteen patients (64%) required medication advice. One hundred and forty one (79%) had health concerns. Eight subjects had returned to paid employment. Issues raised by survivors included a feeling of being abandoned by the healthcare system, poor access to professional psychological support and a fear of further stroke.

CONCLUSION

There is a need for continuing patient education, improved support for stroke survivors and more active involvement of Primary Care Services in the care of stroke patients following hospital discharge.

Evaluation of cognitive assessment in stroke rehabilitation

OBJECTIVE

To assess the effect of cognitive assessment on the functional outcome of stroke patients and quality of life for both patients and their carers.

DESIGN

A multicentre, single-blind, randomized controlled trial.

SETTING AND PARTICIPANTS

Two hundred and twenty-eight stroke patients were recruited from hospital wards in three UK centres.

INTERVENTIONS

Patients were screened for cognitive impairment and randomly allocated to either routine care (116 patients) or routine care plus a detailed cognitive assessment (112 patients).

MAIN OUTCOME MEASURES

Outcome was assessed three and six months after recruitment by an independent assessor blind to the intervention on Extended ADL, Cognitive Failures Questionnaire, General Health Questionnaire-28 for patients and carers and Carer Strain Index.

RESULTS

There was no significant difference between the two groups in patients' functional outcome, perceived cognitive ability, level of psychological distress or satisfaction with care. There was a trend for the assessment group to have lower levels of carer strain (p = 0.06).

CONCLUSIONS

The provision of information about cognitive assessment in stroke rehabilitation may decrease carer strain.

Stroke: an exploration of the experience of informal caregiving

OBJECTIVE

To explore the experience of caregiving in informal carers of stroke patients.

DESIGN

The research approach was qualitative. Data were collected one year after the stroke occurred using a semi-structured interview. The audio-taped interviews were transcribed and following this process were analysed thematically using constant comparative procedures.

SETTING

West of Scotland.

SUBJECTS

Twenty-two informal carers of stroke patients.

RESULTS

The results are presented under the headings: Preparation for discharge/feelings about discharge; The early weeks/months at home; A year of caring; and The future. The main themes identified within these broad areas were as follows: physical preparation; emotional support; the supply of information and advice; and the provision of appropriate services (both social and health service provision).

CONCLUSIONS

The data gathered in this small-scale study suggest that the physical and emotional toll associated with caregiving was great. Unfortunately, the help and support provided by the health and social services was often inadequate, inappropriate and poorly tailored to their individual needs. There was little evidence of a seamless flow of care between the secondary and primary care settings.

Information provision for stroke patients and their caregivers

BACKGROUND

The provision of information has been recommended as a key component of service provision after stroke. However, research suggests that patients' understanding of stroke and associated issues remains poor. We determined to undertake a systematic review of information provision strategies for patients and their carers after stroke.

OBJECTIVES

To examine the effectiveness of an information and/or education strategy to improve the outcome of stroke patients and/or their identified caregivers.

SEARCH STRATEGY

Relevant trials were identified in the Cochrane Stroke Group Specialised Trials Register (last searched: June 2000). Additional intervention-based search strategies were developed for: The Cochrane Controlled Trials Register (CENTRAL/CCTR) Medline; Embase; CINAHL; ISI citation index; Science and Social Science Citation Indexes; ISI Web of Science Service; Aslib Index to UK theses; Dissertation Abstracts International, ASSIA and Psychlit/PsycINFO. We also searched the Journal of Advanced Nursing, bibliographies of retrieved papers, relevant articles and books.

SELECTION CRITERIA

Two or three investigators independently assessed trials and abstracts identified for eligibility, methodological quality and other participant characteristics.

DATA COLLECTION AND ANALYSIS

Data were extracted independently using piloted data extraction forms. The primary outcomes were knowledge about stroke and stroke services, and impact on health, specifically mood.

MAIN RESULTS

We identified 152 abstracts, of which 36 studies were potentially relevant to this review. The current analysis includes nine completed trials, a further eight studies are ongoing. Of the nine trials, three evaluated a programme of lectures and the remaining trials evaluated the provision of information. There is some evidence that information combined with educational sessions improved knowledge and was more effective than providing information only. Information provision only had no effect on mood, perceived health status or quality of life for patients or carers. Two trials used an objective measure of satisfaction and no significant differences were found between groups. One trial reported that information and education sessions for carers improved 'family functioning'.

REVIEWER'S CONCLUSIONS

The results of the review are limited by the variable quality of the trials and the wide range of outcome measures used. The general effectiveness of information provision has not been conclusively demonstrated. Future work should address the expressed needs of patients and carers and seek to identify appropriate teaching strategies which can be successfully implemented within clinical practice.

Stroke rehabilitation: benefits of educational initiatives

The supportive education of stroke survivors and their carers has been identified as a key area of interest to rehabilitation nurses. The Audit Commission recommends the widespread use of stroke units within the NHS (Audit Commission, 2000). The aim of this review is to determine the authority of available evidence and to discuss how such evidence might influence practice. The literature tended to assume that education had a positive effect on the outcome of rehabilitation. Various education interventions were attempted, including information-giving through the use of written material as well as more supportive and facilitative approaches. Factors that may affect the ability to learn or absorb information were identified and attempts have been made to evaluate the effect of educational interventions.

Family support for stroke: a randomised controlled trial

BACKGROUND

Attention is currently focused on family care of stroke survivors, but the effectiveness of support services is unclear. We did a single-blind, randomised, controlled trial to assess the impact of family support on stroke patients and their carers.

METHODS

Patients with acute stroke admitted to hospitals in Oxford, UK, were assigned family support or normal care within 6 weeks of stroke. After 6 months, we assessed, for carers, knowledge about stroke, Frenchay activities index, general health questionnaire-28 scores, caregiver strain index, Dartmouth co-op charts, short form 36 (SF-36), and satisfaction scores, and, for patients, knowledge about stroke and use of services, Barthel index, Rivermead mobility index, Frenchay activities index, London handicap scale, hospital anxiety and depression scales, Dartmouth co-op charts, and satisfaction.

FINDINGS

323 patients and 267 carers were followed up. Carers in the intervention group had significantly better Frenchay activities indices (p=0.03), SF-36 scores (energy p=0.02, mental health p=0.004, pain p=0.03, physical function p=0.025, and general health perception p=0.02), quality of life on the Dartmouth co-op chart (p=0.01), and satisfaction with understanding of stroke (82 vs 71%, p=0.04) than those in the control group. Patients' knowledge about stroke, disability, handicap, quality of life, and satisfaction with services and understanding of stroke did not differ between groups. Fewer patients in the intervention group than in the control group saw a physiotherapist after discharge (44 vs 56%, p=0.04), but use of other services was similar.

INTERPRETATION

Family support significantly increased social activities and improved quality of life for carers, with no significant effects on patients.

Investigating recovery from stroke: a qualitative study

A recent randomized controlled trial evaluated the effects of specialist nurses providing information, advice and support to caregivers and patients at home during the first year after a stroke. Reported here are the results of a complementary study which used qualitative methods to examine the experience of patients and caregivers during the year of recovery after a stroke. We used semi-structured interviews with a purposively selected sample of 30 patients and 15 caregivers at the end of a randomized controlled trial (13-16 months post-stroke). Patients and caregivers provided vivid descriptions of the recovery process. Recovery was perceived in terms of the degree of congruence patients identified between their lives before, and after, stroke. Patients therefore had individual and personal yardsticks for measuring their recovery. In conclusion, further research and interventions must consider the diverse, complex, dynamic and highly personal character of stroke recovery. Traditional outcome measures are too simplistic to capture patients' and caregivers' experiences. There do not appear to be single or simple solutions to the problems of facilitating psycho-social adjustment.

Unpacking the 'black box' of a nurse-led stroke support service

OBJECTIVES

To describe in detail the nature of the specialist nurse interventions; to increase understanding of the principal problems facing stroke patients and their care-givers in the first year following stroke and to demonstrate how these problems may change over time; and to investigate the value of qualitative research methodologies within the context of a randomized trial.

METHODS

Specialist nurses providing support in the year following stroke were asked to maintain comprehensive written records of their involvement with all patients and care-givers participating in a randomized controlled trial. Qualitative methods were used to examine the problems faced by stroke patients and their care-givers, and the actions taken by nurses in response.

RESULTS

Specialist nurses commenced 120 records. As 19 patients died or left the area during the year-long interventions, we obtained 101 complete records. The problems encountered by stroke patients and their care-givers were numerous, diverse, complex and changed over time. Initially, practical difficulties were noted; over time, these were accompanied by growing numbers of psychological needs. The nurses responded by providing information, advice, support and monitoring using a flexible, individualized approach. The nurses also collaborated or liaised with 17 other professional groups and provided direct support to care-givers.

CONCLUSION

The need for many stroke patients and their care-givers to be professionally supported during the stages of stroke adjustment, for at least the first year and probably beyond, was emphasized by this study.

Randomized controlled trial of a comprehensive stroke education program for patients and caregivers

BACKGROUND AND PURPOSE

We report the findings of a randomized controlled trial to determine the effectiveness of a multidisciplinary Stroke Education Program (SEP) for patients and their informal carers.

METHODS

Two hundred four patients admitted with acute stroke and their 176 informal carers were randomized to receive an invitation to the SEP or to receive conventional stroke unit care. The SEP consisted of one 1-hour small group educational session for inpatients followed by six 1-hour sessions after discharge. The primary outcome measure was patient- and carer-perceived health status (SF-36) at 6 months after stroke. Knowledge of stroke, satisfaction with services, emotional outcome, disability, and handicap and were secondary outcome measures.

RESULTS

Only 51 of 108 (47%) surviving patients randomized to the SEP completed the program, as did 20 of 93 (22%) informal carers of surviving patients. Perceived health status (Short Form 36 [SF-36] health survey) scores were similar for SEP patients and controls. Informal carers in the control group scored better on the social functioning component of the SF-36 than the SEP group (P=0.04). Patients and informal carers in the SEP group scored higher on the stroke knowledge scale than controls (patients, P=0.02; carers, P=0. 01). Patients in the SEP group were more satisfied with the information that they had received about stroke (P=0.004). There were no differences in emotional or functional outcomes between groups.

CONCLUSIONS

Although the SEP improved patient and informal carer knowledge about stroke and patient satisfaction with some components of stroke services, this was not associated with an improvement in their perceived health status. Indeed, the social functioning of informal carers randomized to the SEP was less than in the control group.

Recovering from stroke: a qualitative investigation of the role of goal setting in late stroke recovery

This article examines the role of goal setting in the continuing relationship between specialist nurse and patients recovering from stroke. The nurse intervention was intended to ease the patient through the stages of recovery from stroke, focusing on emotional and social recovery rather than physical function. Literature on the use of goals in the nursing process is discussed. The article uses data from contemporary nurse records and from interviews with nurses and with patients and caregivers. The data from each of these elements were subjected to content analysis and were then synthesized using a grounded theory approach to interpret their significance. The perspective of patients and caregivers provides an additional insight into the use and limitations of goal setting which is largely developed in the literature from a nursing perspective. Nurses were found to have different interpretations of the use of goal setting. Some used it explicitly in their relationships with patients, whilst others used the concept to inform their actions whilst being less explicit and more informal. In all cases they demonstrate the tension between establishing and supporting progress towards realistic recovery goals and recognizing the limitations now placed on stroke victims.