The impact of caregiving on the roles and valued activities of stroke carers: A systematic review of qualitative studies

OBJECTIVE

To understand the experiences of informal carers and the impact of role and activity changes on their health and wellbeing.

METHODS

A systematic search of CINHAL, MEDLINE, Embase, APA PsycInfo, and Web of Science was conducted. Studies were eligible if they included informal stroke carers (≥18 years), used a qualitative methodology, explored the roles and valued activities of stroke carers, and were published in English. The 10-item Critical Appraisal Skills Programme checklist for qualitative studies was used to assess methodological quality. The results of the included studies were thematically synthesised.

RESULTS

A total of 36 qualitative studies were included and four overarching themes were identified: (1) Life adjustment; (2) Changing role and identity; (3) Changing activities: From meaningful to purposeful; and (4) Understanding and supporting carers.

CONCLUSION

The sudden nature of stroke requires major readjustment in the carers life that has implications on their relationships, roles, and activities, subsequently impacting on their health and wellbeing. Health professionals and researchers should collaborate with stroke carers to identify their valued activities and implement realistic strategies to maintain these activities. Future interventions designed for carers should implement education about the importance of participating in valued activities and strategies to maintain these activities.

Web-based interventions on the resilience of informal caregivers: a systematic review and meta-analysis

Informal caregivers play an increasingly important role in the provision of care services, especially for the ageing population. At present, the evidence on the resilience of the Internet to family caregivers is still limited. The purpose of this study was to evaluate the factors related to the resilience of the Internet to family caregivers. We searched retrieved randomized controlled trials (rct) of the effects of Internet interventions on resilience in informal caregivers from the beginning of the database to 1 November 2022. A preliminary search identified 3348 studies, 5 of which met the inclusion criteria. The studies involved 482 participants from four countries. Our results show that compared to the control group, internet intervention can effectively improve the resilience level of caregivers [SMD = 0.65, 95%CI(0.04，1.26), P ≤ 0.05]. In our study, Web-based interventions can significantly improve the adaptability of informal caregivers. In addition, our research also pointed out many resources that can be used, such as online learning, online answers and online psychological counseling provided for caregivers through the Internet, which can effectively reduce their burden of care and thus improve their resilience. In the future, these findings can be used to develop projects to improve the resilience of caregivers through personalized Internet intervention, so as to meet the care needs of patients.

Exploring challenges affecting resilience in carers of stroke survivors: a qualitative descriptive study

PURPOSE

To develop an intervention to build resilience in carers of stroke survivors this study aimed to understand these carers' (1) Challenges that adversely affect their resilience, and (2) suggestions for a relevant intervention to build resilience.

METHODS

Individual semi-structured interviews were used. Participants included carers of stroke survivors (stroke duration > six months). Transcripts were analysed using the General Inductive Approach. This study followed guidelines of Consolidated criteria for Reporting Qualitative research (COREQ).

RESULTS

Four themes were identified that affected resilience: (1) carer psychosocial outcomes, (2) stroke's sudden and unexpected impact, (3) financial stressors, and (4) carer exclusion in care planning. Carers suggested an intervention comprising information sharing and training in coping skills, positive communication, problem-solving, and connection with "people who have gone through this" to improve resilience. Most supported a group, monthly delivery of the intervention.

CONCLUSION

These findings provide direction for a suitable intervention. Further, they suggest that stroke rehabilitation could be improved by adopting a family-centered model of care so that carers can be included as active partners in care process. Protecting carers from the negative impact of caring role on their resilience may sustain their ability to provide long-term care for the stroke survivor.IMPLICATIONS FOR REHABILITATIONThe provision of informal care to stroke survivors can be associated with significant emotional consequences, withdrawal from social activities, and poor quality of life for the carers.The abruptness of stroke presentation along with its long-term nature can negatively affect the resilience of informal carers.Exploration of challenges affecting carer resilience is important to develop interventions to build resilience in carers of stroke survivors.Integrating interventions focusing on carers' resilience as part of the stroke rehabilitation process is imperative to ensure well-being of carers and sustainability of the care provided to the stroke survivor.

Information, involvement, self-care and support-The needs of caregivers of people with stroke: A grounded theory approach

BACKGROUND

Globally, stroke is a leading cause of death and disability, with most care undertaken by caregivers who are generally family and friends without prior experience of care. The lack of experience or unpreparedness results in feelings of uncertainty, burnout, anxiety, burden, etc. Hence, it is necessary to identify the needs of caregivers to better support them in their caregiving journey and improve the quality of care delivered.

METHODS

The study employed a grounded theory methodology that utilizes information gathered from literature reviews and social media to represent the needs and create a storyline visually. The storyline is further refined and evaluated using an online survey of 72 participants recruited through online stroke caregiving communities.

RESULTS

The study identified four core categories of needs: (i) Information: sufficient information delivered in layman's terms based on the individual situation of the caregiver and survivor through oral and hands-on demonstrations, (ii) Involvement: inclusion in the decision-making processes at different stages of recovery through face-to-face communication at the hospital, (iii) Self-care: ability to engage in work and leisure activities, (iv) Support: receive support in the form of resources, services and finances from different other stakeholders.

CONCLUSIONS

There is a need to create a caregiver-centered approach in stroke recovery to ensure limited obstruction to care and reduced uncertainty in stroke recovery. Moreover, through the inclusion of caregivers in stroke recovery, it may be possible to reduce the burden of care to the caregiver and ensure the satisfaction of the healthcare system throughout stroke recovery.

Factors impacting the access and use of formal health and social services by caregivers of stroke survivors: an interpretive description study

BACKGROUND

Evidence has shown that family and friend caregivers of stroke survivors are significantly and negatively impacted by caregiving. The negative effects of caregiving may persist over time suggesting that caregivers might benefit from ongoing engagement with supportive services. However, little is known about caregivers' use of formally funded health and social services, or the factors influencing their access to and use of these services. The aim of this study is to increase understanding of the factors that influence stroke caregivers' access and use of formal health and social services, from the perspective of stroke caregivers and healthcare providers.

METHODS

A qualitative study was conducted with stroke caregivers and health providers in Ontario, Canada using interpretive description. In-depth interviews were conducted with caregivers of survivors who experienced a stroke between six months to five years previous and healthcare providers who support caregivers and stroke survivors. All participants provided written informed consent. Interview data were analyzed using constant comparison to identify codes and develop key thematic constructs.

RESULTS

A total of 40 interviews were conducted with 22 stroke caregivers at an average 30-months post-stroke and 18 health providers. Factors that influenced stroke caregivers' access and use of services included: finances and transportation; challenges caregivers faced in caring for their health; trust that they could leave their family member and trust in health providers; limited information pertaining to services and a lack of suitable services; and the response of their social networks to their caregiving situation.

CONCLUSION

Stroke caregivers experience significant challenges in accessing and using formal health and social services. These challenges could be addressed by increasing availability of subsidized community-based supports such as respite and counselling tailored to meet the ongoing needs of caregivers. Systemic change is needed by the health system that readily includes and supports caregivers throughout the stroke recovery continuum, particularly in the community setting.

Prognostication in post-stroke aphasia: Perspectives of people with aphasia on receiving information about recovery

Many people with aphasia (language impairment post-stroke) want to know their prognosis for recovery, yet current understanding of their experience of receiving prognoses is limited. Such insight is necessary to inform clinical practice in formulating and delivering aphasia prognoses, especially given the psycho-emotional distress and secondary adverse effects on recovery associated with conversations about prognosis. We sought an in-depth understanding of the perspectives of people with aphasia in relation to receiving prognoses post-stroke, with the aim of informing an evidence-based approach to aphasia prognostication in clinical practice. Semi-structured interviews, facilitated by communication support strategies, were conducted one-to-one with eight people with aphasia (ranging from mild to very severe) 3-12 months post-stroke. Reflexive thematic analysis was used to analyse the qualitative data, yielding two over-arching themes: (1) How would you know without knowing me?; (2) I need to know, but I don't want to know. Our findings illustrate issues of mistrust within the patient-clinician relationship, and complex emotions relating to hope and post-stroke adjustment. The present insight into the lived experience of receiving aphasia prognoses highlights the need for focused consideration of personal definitions of normalcy, measures for fostering trust, and the role of prognostic uncertainty.

Prognostication in Poststroke Aphasia: Perspectives of Significant Others of People With Aphasia on Receiving Information About Recovery

PURPOSE

Knowing what to expect poststroke is important for many significant others of people with aphasia, yet an understanding of their perceptions and preferences in receiving prognostic information is limited. This knowledge is needed to inform the formulation and delivery of aphasia prognoses as conversations about prognosis can be harmful or helpful depending on their alignment with key stakeholder perspectives. Our preliminary study sought insight into the perspectives of significant others of people with aphasia on receiving prognostic information, with an aim toward informing evidence-based practice in aphasia prognostication.

METHOD

We interviewed seven significant others of people with aphasia, 3-12 months poststroke. The interviews were semistructured, conducted one-to-one, and analyzed qualitatively using reflexive thematic analysis.

RESULTS

Five themes were drawn from the interviews: (a) You don't know what you don't know. (b) Having them alive is the best you can ask for. (c) Recovery in the eye of the beholder. (d) Outcomes don't matter unless they help me help them. (e) It's my prognosis too if I'm living with aphasia.

CONCLUSIONS

A significant other's prognosis-related perceptions and preferences are products of their poststroke reality and may inadvertently shape that of the person with aphasia. In order to facilitate recovery, prognostication practices need to consider the needs of significant others both as providers of care and as requiring care themselves for their first-hand experiences of third-party disability.

Formal Health and Social Services That Directly and Indirectly Benefit Stroke Caregivers: A Scoping Review of Access and Use

Stroke can be a life altering event that necessitates considerable amounts of formal and informal care. The impacts of stroke often persist over time requiring ongoing support for stroke survivors. Family members provide the majority of care and experience many life changes as a result of their caregiving role including social, financial, employment and health impacts. Formal supports such as counselling, respite, and health promotion initiatives that directly benefit caregivers or benefit them indirectly through supporting the stroke survivor, are well-placed to help caregivers manage their caregiving role. However, to date little is known about formal service use by stroke caregivers and the factors that influence their service use. This scoping review provides a critique and synthesis of what is known about stroke caregivers’ access and use of formal services intended to support them. Findings suggest that while services are available, caregivers’ ability to use them are impacted by both facilitators and barriers. Facilitators included: sex, age, and having a higher household income (depending on services used). Barriers included: high cost, poor service quality and deficient knowledge/communication regarding service availability. This review highlights a significant gap in our knowledge of caregivers’ experience in accessing and using formal services.

Geographic distance and social isolation among family care-givers providing care to older adults in Canada

Family care-giving is associated with social isolation, which can lead to adverse health and wellbeing outcomes among family care-givers. The role of geographic distance in care-giver social isolation (CSI) is unclear and has received mixed research findings. Framed by the Ecological Model of Caregiver Isolation, this study examined the relationship between geographic distance and CSI, including the interaction between geographic distance and care-giving intensity for CSI. Linear regression and analysis of covariance were used to test these hypotheses using a sub-set of family care-givers from the 2012 Canadian General Social Survey (N = 2,881). Care-givers living a short distance from receivers reported lower levels of social isolation than co-resident, moderate-distance and long-distance care-givers. Being involved in higher-intensity care-giving as the primary care-giver, undertaking more care-giving tasks and providing care more frequently resulted in higher CSI scores. Long- and moderate-distance care-givers reported greater CSI than co-resident and short-distance care-givers only when providing higher-intensity care-giving. Employing a granulated measure of geographic distance positioned within an ecological framework facilitates an understanding of the nuanced association between geographic proximity and CSI. Furthermore, the identified interaction effects between geographic distance and care-giving intensity on CSI further explicate the complexity of care-giving experiences. The findings are relevant for programmes supporting care-givers in different contexts, especially distance care-givers.

Prognostication in post-stroke aphasia: speech pathologists' clinical insights on formulating and delivering information about recovery

PURPOSE

For people with post-stroke aphasia, "Will I get better?" is a question often asked, but one that is intellectually and emotionally demanding for speech pathologists to answer. Speech pathologists' formulation and delivery of aphasia prognoses is varied and there is limited evidence for optimising practice. We aimed to understand speech pathologists' clinical experiences, reasoning, and support needs in aphasia prognostication.

MATERIALS AND METHODS

Twenty-five Australian speech pathologists working with people with aphasia participated in individual, semi-structured interviews. Their age, level of experience, work setting, and location were maximally varied. Interview responses were analysed qualitatively using thematic analysis.

RESULTS

Five themes were drawn from the interviews: (1) prognostic challenges are shared but not voiced; (2) truth is there's no quick fix; (3) recovery is more than words; (4) the power of words; and, (5) prognostic competence is implicit.

CONCLUSIONS

Speech pathologists use implicit competencies to formulate and deliver aphasia prognoses. A patient-centred, holistic contextualisation of aphasia recovery may enable realistic, optimistic, and constructive conversations about prognosis. These conversations may have therapeutic potential if prognostic uncertainty, emotional adjustment, and conditional outcomes are carefully addressed. Future research should seek to understand the perceptions and preferences of people with aphasia and their significant others.Implications for RehabilitationAphasia prognostication in clinical practice is complex and nuanced, thus increased clinical and research focus is warranted to ensure key stakeholder needs are met.Conversations about prognosis may be more meaningful to people with aphasia if recovery is conceptualised as encompassing impairment, activity, and participation outcomes.Given the implicit competencies required for prognostication, a structured approach to reflective practice and experience-based training may be beneficial.Conversations about prognosis may have therapeutic value, but further research is needed to explore this potential.

Experiences and views of receiving and delivering information about recovery in acquired neurological conditions: a systematic review of qualitative literature

OBJECTIVE

To review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information.

DESIGN

Systematic review of qualitative studies.

DATA SOURCES

MEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies.

RESULTS

Searches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it's not what you say, it's how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty.

CONCLUSIONS

Our findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients' and families' information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.

Design and Usability Testing of the Stroke Caregiver Support System: A Mobile-Friendly Website to Reduce Stroke Caregiver Burden

PURPOSE

The purpose of this study was to design a mobile-friendly, Internet-based website, modeled on previously described websites for Alzheimer caregivers, to equip stroke caregivers and potentially reduce caregiver burden.

DESIGN

A mixed-methods study was performed to design and test the usability of the Stroke Caregiver Support System (SCSS).

METHODS

An iterative, user-centered design approach was employed in three phases: (I) Focus Groups, (II) Structured Interviews, and (III) Usability Testing. Phase I and Phase II provided information for the development of the SCSS website, whereas Phase III helped in gathering data regarding the usability and efficacy of the newly implemented SCSS website.

FINDINGS

Qualitative data on caregiving and the content and design of the SCSS were obtained from focus groups and interviews. In the usability test, the nine caregivers who completed Phase III (78% women, mean age = 46, SD = 17) exhibited a high level of burden and depressive symptoms (median [Q1, Q3] Zarit burden score = 18 [16, 23], Center of Epidemiologic Studies-Depression Scale = 15 [8, 17]). Caregivers conveyed the usability of the SCSS but also expressed several needed improvements.

CONCLUSIONS

Participants reported the value of the SCSS, but further refinements are needed to maximize its usability and potential efficacy.

CLINICAL RELEVANCE

The SCSS has potential to reduce caregiver burden in stroke.

Gender Differences in Longitudinal Associations Between Intimate Care, Resiliency, and Depression Among Informal Caregivers of Patients Surviving the Neuroscience Intensive Care Unit

BACKGROUND/OBJECTIVE

Informal caregivers (e.g., family and friends) are at risk for developing depression, which can be detrimental to both caregiver and patient functioning. Initial evidence suggests that resiliency may reduce the risk of depression. However, gender differences in associations between multiple psychosocial resiliency factors and depression have not been examined among neuroscience intensive care unit (neuro-ICU) caregivers. We explored interactions between caregiver gender and baseline resiliency factors on depression symptom severity at baseline through 3 and 6 months post-discharge.

METHODS

Caregivers (N = 96) of neuro-ICU patients able to provide informed consent to participate in research were enrolled as part of a prospective, longitudinal study in the neuro-ICU of a major academic medical center. Caregiver sociodemographics and resiliency factors (coping, mindfulness, self-efficacy, intimate care, and preparedness for caregiving) were assessed during the patient's hospitalization (i.e., baseline). Levels of depressive symptoms were measured using the Hospital Anxiety and Depression Scale at baseline, 3 months, and 6 months post-discharge.

RESULTS

Baseline depressive symptoms predicted depressive symptoms at both 3- and 6-month follow-ups, with no difference at any time point in rates of depression by gender. At baseline, greater levels of coping, mindfulness, and preparedness for caregiving were individually associated with lower levels of concurrent depression regardless of gender (ps < 0.006). The main effect of baseline coping remained significant at 3-month follow-up (p = 0.045). We observed a trend-level interaction between gender and baseline intimate care, such that among male caregivers only, high baseline intimate care was associated with lower depression at 3-month follow-up (p = 0.055). At 6-month follow-up, we observed a significant interaction between caregiver gender and baseline intimate care, such that male caregivers reporting high intimate care reported lower symptoms of depression than females reporting high intimate care (p = 0.037).

CONCLUSIONS

Results support implementation of psychosocial resiliency interventions for caregivers of patients admitted to the neuro-ICU early in the recovery process. Male caregivers may particularly benefit from strategies focused on increasing intimate care (e.g., physical and emotional affection with their loved one) and quality of the patient-caregiver dyadic relationship.

mHealth applications to support caregiver needs and engagement during stroke recovery: A content review

Caregiving in stroke results in severe physical, psychological, and social impacts on the caregiver. Over the past few years, researchers have explored the use of mHealth technologies to support healthcare-related activities due to their ability to provide real-time care at any given place or time. The purpose of this content review is to investigate mHealth apps in supporting stroke caregiving engagement based on three aspects: motivation, value, and satisfaction. We searched app stores and repositories for apps related to stroke caregiving published up to September 2020. Extracted apps were reviewed and filtered using inclusion criteria, and then downloaded onto compatible devices to determine eligibility. Results were compared with evidence-based frameworks to identify the ability of these apps in engaging and supporting the caregiver. Forty-seven apps were included in this review that enabled caregivers to support their needs, such as adjustment to new roles and relationships, involvement in care and caring for oneself using several different functionalities. These functionalities include information resources, risk assessment, remote monitoring, data sharing, reminders and so on. However, no single app was identified that focuses on all aspects of stroke caregiving. We also identified several challenges faced by users through their reviews and the factors associated with value and satisfaction. Our findings can add to the knowledge of existing mHealth technologies and their functionalities to support stroke caregiving needs, and the importance of considering user engagement in the design. They can be used by developers and researchers looking to design better mHealth apps for stroke caregiving.

Benefits finding among Chinese family caregivers of stroke survivors: a qualitative descriptive study

OBJECTIVES

The caregiving experience includes both caregiver burdens and benefits finding. However, the benefits obtained by family caregivers of stroke survivors in Chinese community dwellings are unknown. The objective of this study was to explore the benefits experienced by family caregivers of stroke survivors in Chinese community dwellings.

DESIGN

A qualitative descriptive design was used, fulfilling the consolidated criteria for the Standards for Reporting Qualitative Research reporting guidelines. Semi-structured interviews were conducted with 20 family caregivers of stroke survivors. The interviews were audiotaped, transcribed and analysed. Thematic analysis was performed to analyse the interview transcripts.

SETTING AND PARTICIPANTS

Home interviews were conducted with family caregivers of stroke survivors in two communities in Zhengzhou, China.

RESULTS

The family caregivers of stroke survivors experienced various benefits from caregiving. There were both internal benefits (increases in knowledge and skills, the development of positive attitudes, and the development of a sense of worthiness and achievement) and external benefits (family growth and gains in social support), which interact to create a healthy lifestyle.

CONCLUSION

Our findings provide a comprehensive perspective in understanding the benefits perceived by family caregivers of stroke survivors. This study provides insights into interventions focused on identifying benefits finding in six domains that may help reduce negative emotions and promote the mental health of caregivers.

"Caregiving is a full-time job" impacting stroke caregivers' health and well-being: A qualitative meta-synthesis

Family caregivers contribute to the sustainability of healthcare systems. Stroke is a leading cause of adult disability and many people with stroke rely on caregiver support to return home and remain in the community. Research has demonstrated the importance of caregivers, but suggests that caregiving can have adverse consequences. Despite the body of qualitative stroke literature, there is little clarity about how to incorporate these findings into clinical practice. This review aimed to characterise stroke caregivers' experiences and the impact of these experiences on their health and well-being. We conducted a qualitative meta-synthesis. Four electronic databases were searched to identify original qualitative research examining stroke caregivers' experiences. In total, 4,481 citations were found, with 39 studies remaining after removing duplicates and applying inclusion and exclusions criteria. Articles were appraised for quality using the Critical Appraisal Skills Programme (CASP), coded using NVivo software, and analysed through thematic synthesis. One overarching theme, 'caregiving is a full-time job' was identified, encompassing four sub-themes: (a) restructured life, (b) altered relationships, (c) physical challenges, and (d) psychosocial challenges. Community and institution-based clinicians should be aware of the physical and psychosocial consequences of caregiving and provide appropriate supports, such as education and respite, to optimise caregiver health and well-being. Future research may build upon this study to identify caregivers in most need of support and the types of support needed across a broad range of health conditions.

The unmet needs of carers of stroke survivors: An evaluation of Google search results

Google is the most used search engine in the world, and likely to be used by caregivers of stroke survivors to find online forums and online communities to connect with other caregivers. This study aims to identify the types of websites accessed by caregivers of stroke survivors to connect with other caregivers, and analyse the online content produced by caregivers to identify their unmet needs. The first 20 websites from eight search strings entered into Google were systematically reviewed. Unmet needs on included websites were identified using a pre-determined coding schedule. Six websites were analysed. Most were discussion boards (n = 5, 83%) developed by organisations in the United States (n = 4, 66.6%). Overall, 2124 unmet needs appeared in 896 posts from caregivers. 'Emotional and psychological' were the most reported needs across posts (n = 765, 36%). Content produced on websites may address social isolation and provide insight into delivering and developing services to meet the needs of caregivers of stroke survivors.

The use of carer perspectives and expert consensus to define key components of a biopsychosocial support intervention for stroke carers

Objective: To identify the key components of a biopsychosocial support intervention to improve mental wellbeing for informal stroke carers within the first year post-stroke based on the combined perspectives of experts in the field of psychological care after stroke and informal stroke carers themselves. Methods: After reviewing the existing literature a cross-sectional mixed-methods design was adopted comprising 1) focus groups with informal stroke carers about their psychological support needs, and 2) nominal group technique with academic and clinical stroke care experts to reach consensus on intervention priorities. Transcripts were thematically analyzed and combined with the ranked priorities from the nominal group to identify key components for intervention content. Results: Key themes for informal stroke carers were associated with: 1) changes in relationships, roles, and dynamics; 2) emotional impact and acceptance; 3) drawing on inner resources; 4) looking for information, solutions, and explanations; 5) support from others. The expert nominal group placed priority on eight ranked areas: 1) acknowledging "normal" emotions; 2) education about the effects of a stroke; 3) reactions to loss and adjustment; 4) recognizing signs and symptoms of not coping; 5) knowing how and when to access practical and emotional support; 6) strategies for taking care of own health; 7) dealing with difficult emotions; and 8) problem solving skills. Conclusions: Themes from the informal carer focus groups, and ranked priority areas will inform the development of a biopsychosocial support intervention for stroke carers to be tested in a feasibility randomized controlled trial.

Receiving Bad News: A Thematic Analysis of Stroke Survivor Experiences

Background

Breaking bad news to patients may be required in service provision to stroke survivors. While challenging, it may be critical to the retention of optimism and participation in rehabilitation.

Objectives

To explore the experience of stroke survivors when receiving bad news (RBN) from medical practitioners.

Methods

Data were obtained via 1:1 interviews conducted at stroke support groups with survivors at least 12 months into recovery and subsequently transcribed for thematic analysis and coded using NVivo.

Results

Eight of 10 participants experienced RBN, and 2 participants did not. The themes of being "lucky to be alive" and waiting for "delayed information" were expressed by all participants early in the interviews. Three sub-themes emerged and were labelled alliance, dissent, and dissatisfaction, each with a further 3 contextual themes. The perception of RBN was marked amongst the dissent and dissatisfaction groups, with the latter reporting negative implications for their rehabilitation as well as negative emotions, such as anger and anxiety. The perception of a poor-quality relationship with medical practitioners was said to impede rehabilitation and recovery processes. The dissent group was characterized by initial disbelief after RBN and consequently poorer long-term outcomes, whilst the Alliance group experienced very good quality of care due to existing personal knowledge and therefore did not perceive RBN during their early medical meetings.

Conclusions

In the period soon after their stroke, survivors required their medical practitioners to not only communicate knowledge and information, but also needed validation of their hopes and fears for the future from an empathically attuned clinician.

How is sexuality after stroke experienced by stroke survivors and partners of stroke survivors? A systematic review of qualitative studies

Objective:

To synthesise how post-stroke sexuality is experienced by stroke survivors and partners of stroke survivors.

Methods:

MEDLINE, PubMed, SCOPUS, CINAHL and PsycINFO were searched from inception to May 2018 using a combination of relevant Medical Subject Headings and Free Text Terms. Only papers published in English reporting original qualitative research were included. Methodological quality was assessed using the Critical Appraisal Skills Programme Qualitative Research Checklist. All text presented as ‘results’ or ‘findings’ in the included studies was extracted and subjected to a thematic analysis and synthesis which was discussed and agreed by the research team.

Results:

The initial search yielded 136 unique papers with a further 8 papers identified through reference checking. Following full-text review, 43 papers were included in the final synthesis. Two analytical themes were identified: sexuality is silenced and sexuality is muted and sometimes changed, but not forgotten. These themes were made up of six descriptive themes: struggle to communicate within relationships, health professionals don’t talk about sexuality, sexuality and disability is a taboo topic, changes to pre-stroke relationships, changed relationship with the stroke survivor’s own body and resuming sexual intimacy – adaptation and loss.

Conclusion:

Stroke has a profound impact on how sexuality is experienced by both stroke survivors and partners of stroke survivors. Despite this, post-stroke sexuality is rarely discussed openly. Stroke survivors and partners value sexuality and may benefit from strategies to support adjustment to post-stroke sexuality.

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography

Objective

To describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services.

Design

Systematic review and meta-ethnography.

Data sources

Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015).

Eligibility criteria

Primary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services.

Data synthesis

A set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria.

Results

51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke.

Limitations

Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems.

Conclusions

Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services.

Systematic review registration number

PROSPERO 2015:CRD42015026602

Return to work predictors of stroke survivors and their spousal caregivers

BACKGROUND

Return to work is an issue of concern for stroke survivors and their spouses. Ramifications may include loss of income and self-efficacy.

OBJECTIVE

This study describes the return to work patterns of stroke survivors and their spousal caregivers post stroke.

METHODS

One hundred fifty-nine dyads were examined for their return to work patterns at baseline (post hospital discharge) and then at 3 month intervals for one year. Relationships were determined between work and gender, age, ethnicity, education, type of insurance, type of stroke, location of stroke, motor and cognitive functional status, depression, mutuality, and life satisfaction.

RESULTS

Low levels of return to work by stroke survivors (7.5%) and a small decrease in the amount of working caregivers (from 45.3% to 40.35%) were found one year post baseline. Variables that predicted return to work changed over the five data points except for younger age for the caregiver, which was consistently significant across all data points. Three case scenarios representative of working patterns are offered.

CONCLUSIONS

Further research is needed regarding the return to work needs of stroke survivors and their spousal caregivers, particularly what role the occupational therapist may play in facilitating that process.

Validity and reliability of Chinese version of Adult Carer Quality of Life questionnaire (AC-QoL) in family caregivers of stroke survivors

The Adult Carer Quality of Life questionnaire (AC-QoL) is a reliable and valid instrument used to assess the quality of life (QoL) of adult family caregivers. We explored the psychometric properties and tested the reliability and validity of a Chinese version of the AC-QoL with reliability and validity testing in 409 Chinese stroke caregivers. We used item-total correlation and extreme group comparison to do item analysis. To evaluate its reliability, we used a test-retest reliability approach, intraclass correlation coefficient (ICC), together with Cronbach’s alpha and model-based internal consistency index; to evaluate its validity, we used scale content validity, confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) via principal component analysis with varimax rotation. We found that the CFA did not in fact confirm the original factor model and our EFA yielded a 31-item measure with a five-factor model. In conclusions, although some items performed differently in our analysis of the original English language version and our Chinese language version, our translated AC-QoL is a reliable and valid tool which can be used to assess the quality of life of stroke caregivers in mainland China. Chinese version AC-QoL is a comprehensive and good measurement to understand caregivers and has the potential to be a screening tool to assess QoL of caregiver.

Needs of Stroke Survivors as Perceived by Their Caregivers: A Scoping Review

OBJECTIVE

Caregivers usually are not involved while planning the stroke survivor's medical and rehabilitation goals and interventions. This review aimed to identify the needs of stroke survivors as perceived by their caregivers.

DESIGN

A literature search from 2003 to 2014 was conducted using Medline, CINAHL, PsychINFO, and Google Scholar. Sixty-six studies were included. Most studies excluded did not encompass caregivers' perspectives. Four reviewers screened the titles, abstracts, and full texts of the articles for inclusion. The data extracted from these studies were synthetized into metathemes.

RESULTS

Fifty-two qualitative, ten quantitative survey, and four mixed-methods studies were included in the final synthesis. The studies came from 11 countries. The data synthesis produced following three metathemes: (a) body functional needs, including psychological function, physical function, cognitive function, and uncertainty related to function; (b) activity and participatory needs, including healthy lifestyle, physical activities, speech, independence, cognitive activities, and uncertainty related to activities and participation; and (c) environmental needs, encompassing support, services, safety, accommodation and accessibility, and uncertainty related to environmental factors.

CONCLUSIONS

This scoping review identified a range of needs of stroke survivors as perceived by their caregivers. Incorporating the caregiver's preferences and values into clinical decisions may improve outcomes among stroke survivors.

The role of the family in supporting the self-management of chronic conditions: A qualitative systematic review

AIMS AND OBJECTIVES

To explore the contribution of family members in promoting and supporting the self-management of chronic conditions amongst adult family members.

BACKGROUND

The prevalence of chronic disease continues to grow globally. The role of the family in chronic condition management and support for self-management has received little attention.

DESIGN

A systematic review of qualitative literature using the Joanna Briggs Institute approach for qualitative systematic reviews.

METHODS

Ovid (MEDLINE, CINAHL and PsycINFO) were searched for the period of database inception-2016. The QARI (Qualitative Assessment and Review Instrument) critical appraisal instrument was used to assess the quality of each study. Using the Joanna Briggs Institute-QARI data extraction tool, findings related to the family role in the self-management of chronic conditions were extracted and each finding rated according to Joanna Briggs Institute-QARI levels of credibility. Findings were categorised and synthesised to produce a final set of aggregated findings.

RESULTS

Families were key in constructing an environment that was conducive to family engagement and support. Adaptation within the family included maintaining cohesion between family members, normalisation and contextualisation of the chronic condition.

CONCLUSIONS

Whilst evidence on the value of the family in promoting positive health outcomes is clear, research on how families can specifically support the self-management of chronic conditions is emerging.

RELEVANCE TO CLINICAL PRACTICE

Family adaptability has been found to be the most powerful predictor of carer depression. Families may need support to change their home and family organisation to adapt to the challenges they face overtime. Change in roles and subsequent adaptation can be stressful, even for those family members at a distance. Nurses working in hospital and community settings can play an important role in assessing how families are adapting to living with chronic illness and to explore strategies to cope with challenges in the home setting.

Resilience as a concept for understanding family caregiving of adults with Chronic Obstructive Pulmonary Disease (COPD): an integrative review

AIMS

This paper was a report of the synthesis of evidence on examining the origins and definitions of the concept of resilience, investigating its application in chronic illness management and exploring its utility as a means of understanding family caregiving of adults with Chronic Obstructive Pulmonary Disease.

BACKGROUND

Resilience is a concept that is becoming relevant to understanding how individuals and families live with illness, especially long-term conditions. Caregivers of adults with Chronic Obstructive Pulmonary Disease must be able to respond to exacerbations of the condition and may themselves experience cognitive imbalances. Yet, resilience as a way of understanding family caregiving of adults with COPD is little explored.

DESIGN

Literature review - integrative review.

DATA SOURCES

CINAHL, PubMed, Google Scholar and EBSCO were searched between 1989-2015.

REVIEW METHODS

The principles of rapid evidence assessment were followed.

RESULTS

We identified 376 relevant papers: 20 papers reported the presence of the concept of resilience in family caregivers of chronic diseases patients but only 12 papers reported the presence of the concept of resilience in caregivers of Chronic Obstructive Pulmonary Disease patients and have been included in the synthesis. The term resilience in Chronic Obstructive Pulmonary Disease caregiving is most often understood using a deficit model of health.

Holding Resilience in Trust: Working Systemically With Families Following an Acquired Brain Injury

The conceptualization of resilience following acquired brain injury needs to remain sensitive to the complex nature and enduring dimensions of trauma, loss, and stress. It is essential that a systemic and dynamic view be maintained with a focus on the key adaptation tasks that families face: grieving, restructuring, identity redefinition, and growing through adversity. These tasks are explored in a case example illustrating how these challenges reemerge across the life cycle. The key theme in this contribution is that resilience is a fluid property, a potential that practitioners and service systems can listen for, support, strengthen, and hold in trust.

Tracking patterns of needs during a telephone follow-up programme for family caregivers of persons with stroke

PURPOSE

Programmes that address stroke family caregiver needs and skill-building are recommended based on the literature and patient care guidelines for stroke rehabilitation. The purpose of this study was to explore patterns of perceived needs and skill-building during a stroke caregiver intervention programme.

METHOD

Descriptive statistics were used to analyse data from 123 stroke caregivers enrolled in the intervention group of a randomised controlled clinical trial. Caregivers received eight weekly telephone sessions, with a booster session a month later. At each session, the Caregiver Needs and Concerns Checklist (CNCC) was used to identify and prioritise current needs that were then addressed through skill-building strategies.

RESULTS

Perceived needs changed over time. Information about stroke was the highest priority need during Session 1. Managing survivor emotions and behaviours was the highest priority for Sessions 2 through 4. Caregivers generally waited until Sessions 5 through 9 to address their own emotional and physical health needs. Physical and instrumental care needs were relatively low but stable across all nine sessions. Skill-building was consistently high, though it peaked during Sessions 2 and 3.

CONCLUSIONS

Tracking patterns of needs and skill-building suggest appropriate timing for targeting different types of family caregiver support during stroke rehabilitation. Implications for Rehabilitation Family caregivers of stroke survivors play an essential role in the rehabilitation process of the stroke survivor. Identifying and addressing the priority needs and concerns of stroke caregivers during the early discharge period enables caregivers to provide sustained support for the stroke survivor. Rehabilitation professionals are in a key position to address evolving caregiver needs and concerns as they transition to home settings with follow-up care.

The relationship between caregiver impacts and the unmet needs of survivors of stroke

BACKGROUND

Caregivers play a crucial role in meeting the needs of survivors of stroke. Yet, little is known about how they are impacted by their caregiving role.

OBJECTIVES

To describe the relationship between survivor long-term unmet needs (>12 months) and caregiver impacts, and identify characteristics that are associated with reported moderate to severe impacts on caregivers.

METHOD

This was a cross-sectional survey using data from the Australian Stroke Survivor and Carer Needs Survey. Community dwelling adults 12+ months poststroke and their caregivers participated. Caregivers and survivors were asked about the extent to which the domains of work, leisure and family, and friend and spousal relationships had been impacted using a Likert scale of responses. The extent to which survivor needs were being met was measured over the domains of health, everyday living, work, leisure, and finances, and the total number of unmet needs was calculated. The association between survivor unmet needs and caregiver impacts was assessed using multivariable logistic regression adjusted for caregiver and survivor characteristics.

RESULTS

Of the 738 completed survivor surveys, 369 contained matched caregiver data (survivors: median age, 71 years; 67% male) (caregivers: median age, 64 years; 26% male). For caregivers, the domains of work, leisure, and friendships were most impacted. The odds of a caregiver experiencing moderate to extreme impacts increased with the number of reported survivor unmet needs. This was greatest for spousal (aOR [adjusted odds ratio]: 1.14; 95% CI [confidence interval]: 1.07, 1.21; P<0.001) and friend relationships (aOR: 1.14; 95% CI: 1.07, 1.21; P<0.001). Caring for a survivor who needed daily living assistance was associated with moderate to extreme caregiver impacts across all domains.

CONCLUSION

Caregivers of survivors of stroke experience large negative impacts, the extent to which is associated with survivors unmet needs. Targeted, long-term solutions are needed to support survivors and caregivers living in the community.