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

Development and evaluation of tools and an intervention to improve patient- and carer-centred outcomes in Longer-Term Stroke care and exploration of adjustment post stroke: the LoTS care research programme

Background

Evidence-based care pathways are required to support stroke patients and their carers in the longer term.

Aims

The twofold aim of this programme of four interlinking projects was to enhance the care of stroke survivors and their carers in the first year after stroke and gain insights into the process of adjustment.

Methods and results

We updated and further refined a purposely developed system of care (project 1) predicated on a patient-centred structured assessment designed to address areas of importance to patients and carers. The structured assessment is linked to evidence-based treatment algorithms, which we updated using a structured protocol: reviewing available guidelines, Cochrane reviews and randomised trials. A pragmatic cluster randomised controlled trial evaluation of the clinical effectiveness and cost-effectiveness of this system of care was undertaken in 29 community-based UK stroke care co-ordinator services (project 2). In total, 15 services provided the system of care and 14 continued with usual practice. The primary objective was to determine whether the intervention improved patient psychological outcomes (General Health Questionnaire-12) at 6 months; secondary objectives included functional outcomes for patients, outcomes for carers and cost-effectiveness, as measured through self-completed postal questionnaires at 6 and 12 months. A total of 800 patients and 208 carers were recruited; numbers of participants and their baseline characteristics were well balanced between intervention and control services. There was no evidence of statistically significant differences in primary or secondary end points or adverse events between the two groups, nor evidence of cost-effectiveness. Intervention compliance was high, indicating that this is an appropriate approach to implement evidence into clinical practice. A 22-item Longer-term Unmet Needs after Stroke (LUNS) questionnaire was developed and robustly tested (project 3). A pack including the LUNS questionnaire and outcome assessments of mood and social activity was posted to participants 3 or 6 months after stroke to assess acceptability and validity. The LUNS questionnaire was re-sent 1 week after return of the first pack to assess test–retest reliability. In total, 850 patients were recruited and the acceptability, validity and test–retest reliability of the LUNS questionnaire as a screening tool for post-stroke unmet need were confirmed. This tool is now available for clinical use. An in-depth qualitative investigation was undertaken with 22 patients (and carers) at least 1 year after stroke (project 4) to gain further insights into the experience of adjustment. This included initial semistructured interviews, limited observations and solicited diaries with a follow-up interview 3–4 months after the initial interview and highlighted a range of different trajectories for post-stroke recovery.

Conclusions

The programme has been completed as planned, including one of the largest ever stroke rehabilitation trials. This work highlights that successfully addressing the needs of a heterogeneous post-stroke population remains problematic. Future work could explore stratifying patients and targeting services towards patients (and carers) with specific needs, leading to a more specialised bespoke service. The newly developed LUNS questionnaire and the qualitative work will help inform such services.

Trial registration

Current Controlled Trials ISRCTN67932305.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. The Bradford Teaching Hospitals NHS Foundation Trust received additional funding for project 2 in the submitted work from the Stroke Association, reference number TSA 2006/15. The initial development work for the LUNS tool and the Longer-Term Stroke care (LoTS care) trial carried out before the start of the programme grant was funded by the Stroke Association, reference number TSADRC 2006/01.

Managing pain in advanced cancer: a survey of United kingdom general practitioners and community nurses

CONTEXT

General practitioners (GPs) and community nurses (CNs) have a central role in palliative care. With health policy focusing more and more on enabling patients to die at home, primary health care professionals are increasingly responsible for symptom management of patients near the end of life.

OBJECTIVES

1) To investigate GPs' and CNs' training and knowledge in palliative care and 2) to identify the characteristics of GPs and CNs with lower levels of palliative care knowledge.

METHODS

A postal questionnaire was sent to all GPs and CNs in two areas of the U.K. A panel of doctors and nurses with palliative care expertise rated the response categories with regard to correctness and questions with regard to importance for their professional group. These weightings were combined and applied to answers to assess knowledge levels.

RESULTS

Response rates were 54% and 35% for GPs and CNs, respectively. Respondents reported receiving training in most areas of palliative care throughout their careers, with the exceptions of syringe driver use and bereavement care. High levels of knowledge concerning pain management and syringe driver use were found, with no significant differences in the overall knowledge between the professions. Some important gaps were identified for future educational focus. Regression analyses did not identify characteristics that explained the variation in knowledge scores.

CONCLUSION

Both groups had a high level of knowledge concerning key issues in pain management and syringe driver use that should equip them well for their central role in palliative care. Recommendations for the focus of future education sessions are made.

An exploratory study of anxiety in carers of stroke survivors

AIMS AND OBJECTIVES

To investigate anxiety in informal carers of stroke survivors in the first three months after discharge.

BACKGROUND

Informal carers, also called caregivers, play a vital role in supporting stroke survivors. However, caring for stroke survivors can have adverse consequences amongst carers such as burden, stress and reduced quality of life. Emotional distress is also commonly reported but anxiety has received less attention than depression.

DESIGN

Prospective, longitudinal, descriptive study.

METHOD

Forty-five carers completed the Hospital Anxiety and Depression Scale on two occasions - within one month and at three months after discharge from stroke and rehabilitation units.

RESULTS

Carers were more likely to have scores indicating anxiety than depression. In the first month, half the carers (51·1%) scored in the cut-off for anxiety and a third were in the cut-off for depression (31·1%). At three months, the picture was very similar with nearly identical proportions in the anxious and depressed categories (48·9% and 28·9%, respectively). Changes in numbers of cases of anxiety and depression and in mean anxiety scores were non-significant but there was a significant decrease in depression scores (p=0·048). Fourteen carers (31·1%) at one month and eleven (24·4%) at three months fell into both anxious and depressed categories.

CONCLUSIONS

Anxiety is a relatively neglected emotional outcome in stroke carers. Our study suggests anxiety is an important issue very early in caring whilst other research suggests it remains prevalent for many months. Given the significant role carers play in rehabilitation of stroke survivors, greater recognition of their emotional state is required. Further, longitudinal research with larger sample sizes from a range of geographical areas and improved understanding of factors associated with anxiety is needed.

RELEVANCE TO CLINICAL PRACTICE

Nurses working in the community are ideally placed to identify and support carers suffering from anxiety.