On parallel tracks: newly home from hospital—people with stroke describe their expectations

A person-centred care transition support for people with stroke/TIA: A study protocol for effect and process evaluation using a non-randomised controlled design

INTRODUCTION

Care transitions following a stroke call for integrated care approaches to reduce death and disability. The proposed research described in this study protocol aims to evaluate the effectiveness of a person-centred multicomponent care transition support and the process in terms of contextual moderators, implementation aspects and mechanisms of impact.

METHODS

A non-randomized controlled trial design will be used. The intervention includes person-centred dialogue intended to permeate all patient-provider communication, various pedagogical modes of information, a person-centred care and rehabilitation plan, and a bridging e-meeting to prepare patients for homecoming. Patients with stroke or TIA who are to be discharged from the participating hospitals to home and referred to a neurorehabilitation team for continued rehabilitation will be included. Follow-ups will be conducted at one week, 3 months and 12 months. Data will be collected on the primary outcome of perceived quality of the care transition, and on the secondary outcomes of health literacy, medication adherence, and perceived person-centeredness. Data for process evaluation will be collected through semi-structured interviews, focus groups, participatory observations, and the Normalisation Measure Development Questionnaire.

DISCUSSION

The study will provide insights on implementation, mechanisms of impact, contextual moderators, and effectiveness of a care transition support, targeting a poorly functioning part of the care trajectory for people with stroke and TIA.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05646589.

In search of self after stroke: a longitudinal qualitative study in the context of client-centred rehabilitation

PURPOSE

The aim was to illuminate the experiences of stroke survivors returning to everyday life in the year following stroke, in the context of client-centred rehabilitation.

METHODS

Four men who participated in a client-centred rehabilitation program were followed during the first year after stroke. Semi-structured interviews were conducted, allbut the first in the participants' home. The data were analysed using a grounded theory approach.

RESULTS

The results revealed a process with the overarching core category; The "new" self becomes reality through challenging everyday experiences, and five main categories driving the process: 1) Striving for structure in a "new" chaotic world, 2) Homecoming an ambiguous experience, 3) Reaching the "new" self through reflections of self-understanding, 4) Socialising in new circumstances, and 5) Realising a new reality.

CONCLUSIONS

While in hospital, stroke survivors can have unrealistic expectations. When at home they can begin to realise their actual capacity . To find a "new" self after a stroke can involve time-consuming and taxing processes of reflections of self-understanding. Engagement in self-selected meaningful and valued activities can support stroke survivors' reconstruction of the "new" self but not all stroke survivors may succeed in finding their "new" self during the first year after stroke.

Integrative-interpersonal dynamic therapy for poststroke depression (INID): study protocol of a randomised controlled pilot trial

INTRODUCTION

Depression is the most frequent psychiatric disorder following stroke, affecting about one-third of stroke survivors. Patients experience poorer recovery, lower quality of life and higher mortality compared with stroke survivors without depression. Despite these well-known malign consequences, poststroke depression (PSD) is regarded underdiagnosed and undertreated. Evidence of beneficial effects of psychotherapy to treat PSD remains scarce and inconclusive and is limited by heterogeneity in design, content and timing of the intervention. This pilot study aims to assess the feasibility of a newly developed integrative-interpersonal dynamic PSD intervention in an outpatient setting and provide a first estimation of the potential effect size as basis for the sample size estimation for a subsequent definite trial.

METHOD AND ANALYSIS

Patients will be recruited from two German stroke units. After discharge from inpatient rehabilitation, depressed stroke survivors will be randomised to short-term psychotherapy (12 weeks, ≤16 sessions) or enhanced treatment as usual. The manualised psychotherapy integrates key features of the Unified Psychodynamic and Cognitive-Behavioural Unified Protocol for emotional disorders and was adapted for PSD. Primary endpoints are recruitment feasibility and treatment acceptability, defined as a recruitment rate of ≥20% for eligible patients consenting to randomisation and ≥70% completion-rate of patients participating in the treatment condition. A preliminary estimation of the treatment effect based on the mean difference in Patient Health Questionnaire-9 (PHQ-9) scores between intervention and control group six months poststroke is calculated. Secondary endpoints include changes in depression (PHQ-9/Hamilton Depression Scale) and anxiety (Generalised Anxiety Disorder 7) of all participants across all follow-ups during the first year poststroke.

ETHICS AND DISSEMINATION

The INID pilot study received full ethical approval (S-321/2019; 2022-2286_1). Trial results will be published in a peer-reviewed journal in the first half of 2025. One-year follow-ups are planned to be carried out until summer 2025.

TRIAL REGISTRATION NUMBER

DRKS00030378.

"My head feels like it has gone through a mixer" - a qualitative interview study on recovery 1 year after aneurysmal subarachnoid hemorrhage

PURPOSE

To describe patients' perceived and expected recovery 1 year after aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

Semi-structured interviews were conducted with 16 persons 1 year after aSAH. Inductive manifest qualitative content analysis was used.

RESULTS

The analysis resulted in two categories and seven subcategories. The category "A spectrum of varying experiences of recovery" includes four subcategories describing physical recovery, mental recovery, alterations in social life, and perceived possibilities to return to normality. Some informants felt that life was almost as before, while others described a completely different life, including a new view of self, altered relationships, not being able to return to work, and effects on personal finances. The category "A spectrum of reflections and expectations of recovery" comprises three subcategories depicturing that expectations of recovery were influenced by existential thoughts, describing what they based own expectations of recovery on, and how expectations from others influenced them.

CONCLUSIONS

aSAH was perceived as a life-changing event. The changes impacted on informants' view of self and relationships, and they perceived new barriers in their living conditions. Lack of information on expected recovery was expressed and expectations of recovery were at times unrealistic.IMPLICATIONS FOR REHABILITATIONContracting an aneurysmal subarachnoid hemorrhage (aSAH) is a life-changing event with possible impact on a variety of areas in daily life.There is a need for improved information to aSAH survivors and their significant others on the course of the recovery and possible long-term consequences.aSAH survivors may need assistance to balance unrealistic expectations on recovery.

How is the environment integrated into post-stroke rehabilitation? A qualitative study among community-dwelling persons with stroke who receive home rehabilitation in Sweden

Studies have shown a need to consider environmental factors to best support the rehabilitation and recovery process after a stroke. In addition, despite intentions to increase individuals' participation in care and rehabilitation, patients and family members report weak participation. The aim of this study was to explore how the environment was integrated into rehabilitation at home from the perspective of patients after a stroke. We conducted as a qualitative study with 17 patients rehabilitated at home. Data on the participants' experiences of the rehabilitation process and their perceptions of how the environment was considered in the process were collected via interviews and analysed using qualitative content analysis. The main category that was constructed from the data was "Partial integration of person- environment dynamics in the rehabilitation", which was informed by three subcategories: (a) I recover in my home: Challenges and opportunities in the environment, (b) Following a generic approach to therapy: Limited integration of the environment, and (c) Informed more than involved. Our study showed that the environment was integrated in a limited manner. The participants were more informed about than involved in their planning of the rehabilitation. The results are important for informing the ongoing development of rehabilitation at home and person-centred care strategies.

A qualitative study exploring how stroke survivors' expectations and understanding of stroke Early Supported Discharge shaped their experience and engagement with the service

PURPOSE

To explore how stroke survivors' expectations and understanding of Early Supported Discharge (ESD) helped them make sense of their experiences, and shaped their engagement with the service.

METHODS

Data were collected as part of a study of large-scale implementation of stroke ESD: the WISE realist mixed-methods study. Semi-structured interviews were conducted with five purposefully selected stroke survivors from six sites in England implementing stroke ESD (n = 30). Participants were aged 32-88 years (20 males). Interviews were audio recorded, transcribed verbatim and transcripts were analysed using reflexive thematic analysis.

RESULTS

Three overarching themes were identified: (1) ESD as a post-stroke recovery tool, (2) desire to recover quickly, (3) psychosocial impact and support. Stroke survivors were uncertain about what to expect when they first entered the service, however, their experience of ESD exceeded their expectations and increased their engagement with the service. Stroke survivors especially valued the goal-oriented approach the team adopted. Rehabilitation at home was perceived as positive and practical, encouraging independence within real-life contexts. Psycho-social support played an important role in the stroke survivors' rehabilitation.

CONCLUSIONS

Ensuring stroke survivors are fully informed about ESD and what to expect, optimises engagement with the services, improves experience and could enhance outcomes.IMPLICATIONS FOR REHABILITATIONInforming stroke survivors about what to expect from ESD services could optimise engagement and improve their experience.The provision of personalised and target focussed therapy at home improves stroke survivors' experience and could potentially accelerate recovery.Preparing stroke survivors early for discharge from ESD can reduce anxiety and enhance engagement with the service.

Psychological experience and social reintegration needs of young stroke patients: a systematic review and meta-aggregation of qualitative studies

BACKGROUND

The visible physical dysfunction and invisible psychological effects after stroke prevent young patients from returning to their pre-stroke roles and social activities.

PURPOSE/AIM

To comprehensively analyze the psychological experience and social reintegration needs of young stroke patients, which may be beneficial for improving quality of life and social reintegration after stroke.

METHODS

We conducted a comprehensive literature search of 10 databases. The screening and quality assessment of the included articles were performed by the Qualitative Assessment and Review Instrument (QARI). Meta-aggregation was conducted to synthesize the findings of the included studies. We summarized the certainty of confidence using the Confidence in Evidence from Reviews of Qualitative Research (CERQual) approach.

RESULTS

A total of 5506 studies were screened, of which 12 were included. Data synthesis suggested two new themes: (a) the self-growth process from denial of stroke to accepting stroke (high CERQual confidence), and (b) desire to regain pre-stroke normality, but having difficulty in the social reintegration process (high CERQual confidence).

CONCLUSION

Stroke, as a traumatic event, disrupts the life structure of young patients, and their needs of reintegration are not adequately considered. Interventions based on the principle of individuation should focus on this issue to restore continuity in life after stroke.

Living with the aftermaths of a stroke in the era of the COVID-19 pandemic; the significance of home and close surroundings

Stay-at-home recommendations to reduce the spread of the COVID-19 virus have had a major impact on people's everyday lives. However, while the evidence indicates that such recommendations have caused distress, anxiety, and fear among the public, little is known about how persons living with complex health conditions, e.g., disability after stroke, have experienced and handled the situation. We interviewed fourteen participants (7 women, 7 men) aged 61–91 years living in ordinary housing during summer 2020 to explore how people who recovered after a stroke experienced their everyday lives in their homes and close surroundings during the COVID-19 pandemic recommendations. Three intertwined themes were constructed from the narrative data and the iterative thematic analysis: (1) Places within and out of reach, (2) Upholding activities–strategies and structures, and (3) Adapting to new circumstances. The findings suggest that places within reach were important to maintain activities and provide structure in daily life. The participants seemed to make use of their previous experiences of adjusting to new circumstances after stroke when adapting to living under the stay-at-home recommendations. In addition, feeling that they now shared the restrictions with all other people in society seemed to ease their situations. Access to nature and spaces in the close surroundings was essential for staying socially connected and receiving support in daily life. The significance of the home and the neighbourhood for health experiences among people who recently have had a stroke should inform rehabilitation interventions both during and after pandemics and environmental planning.

Referral-based transition to subsequent rehabilitation at home after stroke: one-year outcomes and use of healthcare services

Background

There is a lack of knowledge about patients’ journeys across the stroke care continuum, especially regarding the transition from inpatient to outpatient care and rehabilitation. Therefore, the aim of the present study was to explore and describe patterns of healthcare use over a one-year period, health outcomes at 3 and 12 months for patients following a referral-based transition to subsequent rehabilitation in the home, and the caregiver burden on their significant others. A further aim was to explore factors associated with the use of rehabilitation and healthcare after the referral-based transition to continued rehabilitation in the home for people recovering from a stroke.

Methods

Data regarding healthcare use during the first 12 months post-stroke was collected from the Region Stockholm computerized register. Data on patient characteristics, disease-related data, and functioning were retrieved drawn from medical records and questionnaires. Descriptive statistics were used to present healthcare use, participants’ characteristics, disease-related data, and patient functioning. Multivariable regression models were created to explore associations between the total number of outpatient contacts, total visits with the neurorehabilitation team, and the independent variables.

Results

The mean age for the 190 participants was 73 years for men and 78 years for women. Twenty-one participants (11%) had an acute rehospitalization within 30 days after discharge, and 41 participants (21%) were re-hospitalized within 90 days. Twenty-two (12%) of the participants had no visits with the neurorehabilitation team, 73 (39%) participants had 1–3 visits, 57 (30%) had 4–16 visits, and 38 (20%) had ≥17 visits. Female sex and length of hospital stay were associated with a higher number of visits with the neurorehabilitation team. Living alone, higher self-rated recovery, and being able to walk independently were associated with a lower number of visits with the neurorehabilitation team. Female sex, having home help services before the stroke, longer length of hospital stay, and more comorbidities were associated with a higher number of outpatient contacts.

Conclusions

The findings indicate that there is no generic pattern of healthcare use during the first-year post-stroke in patients receiving referral-based transition to continued rehabilitation in the home. The different patterns of healthcare use seemed to mirror the participants’ level of functioning. However, there is a need to further investigate how follow-up and rehabilitation correspond to the needs of patients and their significant others in the short- and long-term perspective.

Trial registration

ClinicalTrials.gov, registration number: NCT02925871. Date of registration: October 6, 2016.

Person-centred care transitions for people with stroke: study protocol for a feasibility evaluation of codesigned care transition support

BACKGROUND

Care transitions following stroke should be bridged with collaboration between hospital staff and home rehabilitation teams since well-coordinated transitions can reduce death and disability following a stroke. However, health services are delivered within organisational structures, rather than being based on patients' needs. The aim of this study protocol is to assess the feasibility, operationalised here as fidelity and acceptability, of a codesigned care transition support for people with stroke.

METHODS

This study protocol describes the evaluation of a feasibility study using a non-randomised controlled design. The codesigned care transition support includes patient information using videos, leaflets and teach back; what-matters-to me dialogue; a coordinated rehabilitation plan; bridged e-meeting; and a message system for cross-organisational collaboration. Patients with stroke, first time or recurrent, who are to be discharged home from hospital and referred to a rehabilitation team in primary healthcare for continued rehabilitation in the home will be included. One week after stroke, data will be collected on the primary outcome, namely satisfaction with the care transition support, and on the secondary outcome, namely health literacy and medication adherence. Data on use of healthcare will be obtained from a register of healthcare contacts. The outcomes of patients and significant others will be compared with matched controls from other geriatric stroke and acute stroke units, and with matched historic controls from a previous dataset at the intervention and control units. Data on acceptability and fidelity will be assessed through interviews and observations at the intervention units.

ETHICS AND DISSEMINATION

Ethical approvals have been obtained from the Swedish Ethical Review Authority. The results will be published open-access in peer-reviewed journals. Dissemination also includes presentation at national and international conferences.

DISCUSSION

The care transition support addresses a poorly functioning part of care trajectories in current healthcare. The development of this codesigned care transition support has involved people with stroke, significant other, and healthcare professionals. Such involvement has the potential to better identify and reconceptualise problems, and incorporate user experiences.

TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov id: NCT02925871. Date of registration 6 October 2016.

PROTOCOL VERSION

1.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background

In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.

Objectives

To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.

Design

A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.

Setting and interventions

Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.

Participants

Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.

Data and main outcome

Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.

Results

A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.

Limitations

Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.

Conclusions

The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.

Trial registration

Current Controlled Trials ISRCTN15568163.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

Transitions in Technology-Mediated Cardiac Rehabilitation and Self-management: Qualitative Study Using the Theoretical Domains Framework

Background

An acute cardiac incident is a life-changing event that often necessitates surgery. Although surgery has high success rates, rehabilitation, behavioral changes, and self-care are critical to long-term health. Recent systematic reviews have highlighted the potential of technology in this area; however, significant shortcomings have also been identified, particularly with regard to patient experience.

Objective

This study aims to improve future systems and to explore the experiences of cardiac patients during key phases after hospitalization: recuperation, initial rehabilitation, and long-term self-management. The key objective is to provide a holistic understanding of behavioral factors that impact people across these phases, understand how experiences evolve over time, and provide user-centered recommendations to improve the design of cardiac rehabilitation and self-management technologies.

Methods

Semistructured interviews were conducted with people who attended rehabilitation programs following hospitalization for acute cardiac events. Interviews were developed and data were analyzed via the Theoretical Domains Framework, a pragmatic framework that synthesizes prior theories of behavioral change.

Results

Three phases that arise posthospitalization were examined, namely, recuperation, rehabilitation, and long-term self-management. Through these phases, we describe the impact of key factors and important changes that occur in patients’ experiences over time, including the desire for and redefinition of normal life, the need for different types of formal and informal knowledge, the benefits of safe zoning and connectedness, and the need to recognize capability. The use of the Theoretical Domains Framework allows us to show how factors that influence behavior evolve over time and to identify potential sources of tension.

Conclusions

This study provides empirically grounded recommendations for the design of technology-mediated cardiac rehabilitation and self-management systems. Key recommendations include the use of technology to support a normal life, leveraging social influences to extend participants’ sense of normality, the use of technology to provide a safe zone, the need to support both emotional and physical well-being, and a focus on recognizing capability and providing recommendations that are positive and reinforce this capability.

The perspectives of stroke survivors and health professionals on the use of augmented reality for inpatient stroke rehabilitation: an anticipatory exploration

Background:

Augmented reality is a novel technology with potential to overlay aspects or objects from the home environment into hospital-based training, which may increase relevance and motivation for hospital-based rehabilitation. Consultation with people with lived experience and clinician stakeholders is an important step when exploring possibilities for use of new technology in the hospital environment.

Aims:

This study sought to understand the need and acceptability of augmented reality from the perspectives of health professionals and stroke survivors during inpatient stroke rehabilitation.

Methods:

This qualitative descriptive study included stroke survivors (n = 4) and health professionals (n = 10) from a large metropolitan hospital. Data collection was undertaken via focus groups which were transcribed verbatim and analysed using qualitative content analysis.

Results:

Inductive content analysis revealed three themes: everything is computerised these days; the possibilities are endless…but what about?; and bringing the outside into the hospital. Participants were open to the use of augmented reality for stroke rehabilitation; however there was uncertainty with pragmatic concerns and stroke survivors describing possible applications in building confidence and self-efficacy, and sharing experiences to enhance caregivers understanding.

Conclusion:

This research identified that there is potential acceptability for augmented reality in stroke rehabilitation. The needs identified by the participants may inform development of current and future technology.

Enablers and barriers in hospital-to-home transitional care for stroke survivors and caregivers: A systematic review

AIMS AND OBJECTIVES

To synthesise qualitative research evidence on the experience of stroke survivors and informal caregivers in hospital-to-home transitional care.

BACKGROUND

Due to a shortened hospital stay, stroke survivors/caregivers must take over complex care on discharge from hospital to home. Gaps in the literature warrant a meta-synthesis of qualitative studies on perceived enablers and barriers during this crucial period.

DESIGN

A systematic review and meta-synthesis.

METHODS

A review was guided by Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist where six databases were searched from April to June 2020 including CINAHL Plus, MEDLINE, PsycINFO, Scopus, Web of Science and ProQuest and ProQuest Dissertations and Theses. There was no date limit to the search. Selected studies were critically appraised. A thematic synthesis approach was applied.

RESULTS

The synthesis of 29 studies identified three major findings. First, partnerships with stroke survivors/caregivers empower discharge preparation, foster competence to navigate health and social care systems and activate self-management capabilities. Second, gaps in discharge planning and the lack of timely postdischarge support contribute to unmet care needs for stroke survivors/caregivers and affect their ability to cope with poststroke changes. Third, stroke survivors/caregivers expect integrated transitional care that promotes shared decision-making and enables long-term self-management at home.

CONCLUSIONS

Hospital-to-home transition is a challenging period in the trajectory of poststroke rehabilitation and recovery. Further research is required to deepen understandings of all stakeholders' views and address unmet needs during transitional care.

RELEVANCE TO CLINICAL PRACTICE

Protocols and clinical guidelines relating to discharge planning and transitional care need to be reviewed to ensure partnership approach with survivors/caregivers in the design and delivery of individualised transitional care. Stroke nurses are in a unique position to lead timely support for survivors/caregivers and to bridge service gaps in hospital-to-home transitional care.

The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies

The unmet needs perceived by community-dwelling stroke survivors may truly reflect the needs of patients, which is crucial for pleasant emotional experiences and a better quality of life for community-dwelling survivors not living in institutionalized organizations. The purpose of the study is to identify the scope of unmet needs from the perspectives of stroke patients in the community. A qualitative meta-synthesis was performed according to the Joanna Briggs Institute method. Six electronic databases were searched from inception to February 2020. A total of 24 articles were involved, providing data on 378 stroke survivors. Eight categories were derived from 63 findings, and then summarized into four synthesized findings based on the framework of ICF: (1) unmet needs regarding with the disease-related information; (2) unmet physical recovery and activity/participation needs; (3) unmet needs for social environmental resources; (4) unmet psycho-emotional support needs. We found the framework of ICF mostly complete, but unmet information needs still remain. The needs that are mainly unsatisfied include physical, psychosocial and informational, as well as the practical support from professional or environment resources. The ever-present unmet needs perceived by community-dwelling stroke survivors who do not live in institutions are discoverable and mitigable. Future studies should focus on quantifying unmet needs comprehensively derived from experiential domains, assessing the rationality of the unmet needs expressed by patients' perspectives and developing flexible strategies for long-term and changing needs.

An integrative review: Challenges and opportunities for stroke survivors and caregivers in hospital to home transition care

AIM

To identify challenges and opportunities for stroke survivors and caregivers in hospital to home transition care.

BACKGROUND

Due to shortened hospital stays, stroke survivors and caregivers must take responsibility for complex care on discharge from hospital to home. Gaps exist in the literature that synthesizes studies on hospital to home transition care.

DESIGN

A systematic integrated review.

DATA SOURCES

Six databases were searched systematically between 18 June 2018 - 31 October 2018 including Medline, CINAHL, Web of Science, ProQuest, Scopus and Science Direct. The search did not have a date limit.

REVIEW METHODS

Studies that met the selection criteria were critically reviewed. Data were extracted from the studies for analyses. A convergent qualitative synthesis approach using inductive thematic synthesis was applied to the review.

RESULTS

The analysis of 23 studies identified three major findings. First, health and social care systems influence transition care by either enabling stroke survivors and caregivers to manage transition care via well-coordinated services or preventing them from accessing services. Second, health professionals' partnership with stroke survivors and caregivers largely decides tailored support for them. Successful partnerships and engagements with stroke survivors and caregivers depend on organizational resources. Third, survivors and caregivers are at different levels of readiness to cope with challenges. Individualized support for them to develop resilience is highly regarded.

CONCLUSION

Stroke survivors and caregivers encounter enormous challenges in self-management of hospital to home transition care. Further research is required to address their expectations of support during transition care.

IMPACT

There is a lack of synthesis of studies on factors affecting hospital to home transition care for stroke survivors. Health and social care system designs, health professionals' commitment to individualized care and the self-management capability of stroke survivors and their caregivers have a profound influence on the transition care experiences.

Reduced striatal activation in response to rewarding motor performance feedback after stroke

INTRODUCTION

Motor skill learning can help stroke survivors to cope with motor function deficits but requires many repetitions. One factor that keeps patients motivated is obtaining reward upon successfully completing a motor task. It has been suggested that stroke survivors have deficits in reward processing which may negatively impact skill learning.

OBJECTIVE

To test the hypothesis that stroke survivors have deficient reward processing during motor skill learning evident in reduced activation in the striatum and its subdivisions in functional magnetic resonance imaging as compared with healthy, age-matched control subjects.

METHODS

Striatal activity in response to performance dependent feedback and monetary reward was measured in 28 subacute stroke patients and 18 age-matched healthy control subjects during the training of visuomotor tracking an arc-shaped trajectory using the wrist (unimpaired side in patients, dominant side in controls) in an fMRI scanner.

RESULTS

Despite comparable monetary rewards, stroke patients showed reduced activation in the ventral part (p < 0.01), but not in the dorsal part of the striatum (p = 0.11). 14 patients had their lesion extending into the striatum. The nucleus accumbens as part of the ventral striatum was unlesioned in all participants and still showed a marked hypoactivation in stroke patients as compared with controls (p < 0.001), a finding that could not be explained by motivational differences between the groups.

CONCLUSION

Striatal hypoactivation in stroke survivors may cause impaired consolidation of motor skills. Stronger rewarding stimuli or drug-mediated enhancement may be needed to normalize reward processing after stroke with positive effects on recovery.

Predictors of Remission of Early-Onset Poststroke Depression and the Interaction Between Depression and Cognition During Follow-Up

Objectives: This study aimed to examine the rate of remission in individuals experiencing early-onset poststroke depression (PSD) in China and to identify predictors of remission during a 3-month follow-up. This study also explored the interaction between cognitive impairment and depression. Methods: A total of 820 patients with PSD from a massive multicenter prospective cohort project in China (PRIOD) were included in the present study. Depressive symptoms were measured with the Hamilton Depression Rating Scale (17 Items, HDRS-17) at 2 weeks and the endpoint of the 3-month follow-up. The cut-off score of HDRS-17 (< 8) was used to define remission of depression at the endpoint. The Mini-Mental State Exam (MMSE) was used to evaluate the cognitive impairment of the patients (at the 2-week follow-up and 3-month endpoint). The National Institutes of Health Stroke Scale (NIHSS) was used to measure the severity of stroke. Results: (1) Six hundred and forty-two patients completed the 3-month follow-up, and 332 (51.7%) patients remitted by the end of the study. Univariate analyses indicated that there was a higher proportion of patients who had hypertension, frontal lobe lesion, basal ganglia lesion, poor outcome at 2 weeks, high scores on the NIHSS at 2 weeks, major life events within 3 months, and major medical diseases within 3 months in the nonremission group. In stepwise multiple logistic regression analyses, remission was significantly predicted by lower NIHSS scores at 2 weeks (p = 0.001, OR = 1.086, 95% CI 1.035-1.139), fewer major life events (p = 0.036, OR = 5.195, 95% CI 1.111-27.283), fewer major medical comorbidities (p = 0.015, OR = 2.434, 95% CI 1.190-4.979), and fewer frontal lobe lesions (p = 0.042, OR = 1.717, 95% CI 1.019-2.891). (2) After controlling for confounding variables, repeated measures analysis of variance revealed a significant interaction between time (2 weeks vs. 3 months) and group (remitters vs. nonremitters) on MMSE scores [F (1, 532) = 20.2, p < 0.001]. Conclusions: Early-onset PSD patients with milder neurological impairment, fewer major life events, fewer major medical comorbidities and no frontal lobe lesion at baseline were more likely to achieve remission 3 months after stroke. Only remitters of PSD improved significantly in cognitive impairment after stroke. The PRIOD trial is registered at http://www.isrctn.com/, number ISRCTN62169508.

General self-efficacy as a driving factor of post-stroke depression: A longitudinal study

Post-stroke depression (PSD) is the most common psychiatric condition after stroke, affecting one third of survivors. Despite identification of meaningful predictors, knowledge about the interplay between these factors remains fragmentary. General self-efficacy (GSE) is closely linked to PSD, yet direction and magnitude of this relationship remains unclear. The authors assessed the relationship between GSE and depression during the first two years post-stroke while controlling for stable inter-individual differences using continuous time (CT) structural equation modelling (SEM). Patients of two German rehabilitation centres (N = 294, mean age = 63.78 years, SD = 10.83) were assessed six weeks after ischemic stroke and at four follow-ups covering two years. GSE Scale and Geriatric Depression Scale (GDS) were used to assess GSE and depression. CT-analysis revealed significantly higher within-person cross-effects of GSE on GDS (a₂₁ = -.29) than vice versa (a₁₂= -.17). Maximal cross-lagged effects emerged six months post-stroke. Our results show that decreasing GSE led to increasing depressiveness, and only to a smaller extent vice versa. This suggests that fostering GSE by strengthening perceived control after stroke can counter PSD emersion and exacerbation. Six months post-stroke, when patients face social re-integration, programmes focusing on GSE could potentially help to prevent later PSD.

The influence of early depressive symptoms, social support and decreasing self-efficacy on depression 6 months post-stroke

BACKGROUND

Post-stroke depression (PSD) is the most frequent mental disorder after stroke, affecting about 30% of stroke survivors. Despite extensive research, little is known about the influence of general self-efficacy (GSE) on PSD. We investigated the effect of GSE on depression six months post-stroke while controlling for established risk factors.

METHODS

Eighty-eight patients from two rehabilitation centers with first-ever ischemic stroke were assessed around 8 weeks and 6 months after stroke. Baseline assessment included demographic variables, GSE scale, physical disability (Barthel-Index), stroke severity (modified NIH Scale), pre-stroke mental illness, cognitive status (Mini-Mental-State-Test), social support (F-SozU Questionnaire) and depressiveness (Geriatric Depression Scale, GDS). Follow-up assessment included DSM-IV depression, GDS and GSE. The influence of each risk factor on PSD was analyzed by binary hierarchical regression.

RESULTS

Baseline depressiveness (OR=1.41, p<.01) and social support (OR=.95, p=.03) predicted PSD. Decreasing GSE was associated with high baseline GSE (r=.51, p<.01) and influenced later PSD (OR=1.39, p<.01).

LIMITATIONS

Patients' range of impairment may have been limited as sufficient speech comprehension and capacity for interview participation were required. Causal relationship between decreasing GSE and increasing GDS cannot be assumed based on correlations.

DISCUSSION

Decreasing GSE was linked to PSD, especially in patients with high baseline GSE. This effect may be due to dissatisfaction with recovery following high expectations. Early depressive symptoms and low social support predicted PSD. Early screening for depressive symptoms and focusing on self-efficacy might help to prevent later depression.

Understanding the dimensions of home for people returning home post stroke rehabilitation

Introduction

Home is a meaningful and important place and the transition to home from hospital is considered a significant point in recovery for people after stroke. Six dimensions of the home environment have previously been described as important for well-being and contributing to one's experience of home: the physical, social, personal, temporal, occupational and societal dimensions. The aim of this study was to understand the experience of home for people with stroke after discharge to home from hospital rehabilitation.

Method

A secondary template analysis applied the dimensions of home to semi-structured interviews that explored the transition to home experience for seven participants with stroke at 4–6 weeks post discharge.

Results

All six dimensions were present in the descriptions of returning to home from stroke rehabilitation. The social, personal and occupational dimensions appeared to be the most prominent and often centred on loss or change.

Conclusion

People returning home after a stroke enter a different home environment than the one they experienced prior to stroke, with changes experienced in all dimensions of home. Closer attention to the dimensions during discharge preparation may enhance the transition experience.

Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study

BACKGROUND

An Early Supported Discharge (ESD) and rehabilitation from a coordinated team in the home environment is recommended in several high-income countries for patients with mild to moderate symptoms after stroke. Returning home from the hospital takes place very early in Sweden today (12 days post stroke), thus the term Very Early Supported Discharge (VESD) is used in the current study. The aim of this study was to describe patients' expectations of coming home very early after stroke with support and rehabilitations at home.

METHOD

This is an interview study nested within a randomized controlled trial; Gothenburg Very Early Supported Discharge (GOTVED), comparing VESD containing a home rehabilitation intervention from a coordinated team to conventional care after stroke. Ten participants (median age 69) with mild to moderate stroke symptoms (NHISS 0 to 8 points) were recruited from the intervention group in GOTVED. Interviews were conducted 0-5 days before discharge and the material was analyzed with qualitative content analysis.

RESULTS

Four main categories containing 11 subcategories were found. The VESD team was expected to provide "Support towards independency", by helping the participants to manage and feel safe at home as well as to regain earlier abilities. The very early discharge gave rise to expectations of coming home to "A new and unknown situation", causing worries not to manage at home and to leave the safe environment at the ward. A fear to suffer a recurrent stroke when being out of reach of immediate professional help was also pronounced. In contrast to these feelings of insecurity and fear, "Returning to one's own setting" described the participants longing home, where they would become autonomous and capable people again. They expected this to facilitate recovery and rehabilitation. "A new everyday life" waited for the participants at home and this was expected to be challenging. Different strategies to deal with these challenges were described.

CONCLUSIONS

The participants described mixed expectations such as insecurity and fear, and on the other hand, longing to come home. Moreover, they had a high degree of confidence in the expected support of the VESD team. The health professionals at the hospital may build on this trust to reduce the patients' insecurity for coming home. In addition, it may be beneficial to explore the patients' expectations thoroughly in front of discharge, as certain feelings and thoughts could complicate or support the home coming process. Thus, a greater attention on such expectations may facilitate the patient's transition from hospital to home after stroke.

Three different points of view in stroke rehabilitation: patient, caregiver, and physiotherapist

BACKGROUND

The similarities or differences of the three some (physiotherapists, patients, and caregivers) thought about the process of stroke rehabilitation can play a key role in the success of rehabilitation.

OBJECTIVE

The aim of this qualitative study was to investigate the perspectives of the three some, with regard to the two themes of the study: (1) What are the problems faced by the patients after stroke?; and (2) What does recovery after stroke mean to you?

METHODS

The qualitative questions and possible answers were prepared by four physiotherapists. The answers were matched to International Classification of Functioning (ICF) components. Seventy patients who were having treatment as in-patient rehabilitation centers, their caregivers, and physiotherapists were invited to the study. After the questions were asked and the possible response choices were presented, subjects were asked to prioritize these response choices.

RESULTS

One hundred and fifty-nine subjects, including 53 patients, 53 caregivers, and 53 physiotherapists, were included to the study. When the theme 1 were examined, we found that the patients' first priority was functional abilities (ICF: body function and structure) such as using the hands and feet while the caregivers and physiotherapists prioritized self-care problems (ICF: activity and participation). The most common response to the theme 2 was "being in same health condition before the disease" (ICF: activity and participation) among the patients and caregivers and "being able to move arm and leg on the affected side" (body function and structure) among the physiotherapists.

CONCLUSION

As a conclusion, problems faced by the patients, caregivers, and physiotherapists were perceived under the same ICF domain and that caregivers' and physiotherapists' priorities were the same.

Striving for a life worth living: stroke survivors' experiences of home rehabilitation

BACKGROUND

For mild-to-moderate stroke survivors, early supported discharge from hospital, followed by home rehabilitation is preferred over conventional care. How this mode of service contributes to recovery from stroke survivors' perspective needs further investigation.

AIM

The aim of this study was to explore mild-to-moderate stroke survivors' experiences with home rehabilitation after early supported discharge from hospital.

METHODS

A qualitative interpretive interview design was used in the context of a randomised controlled trial. A purposive sample of eight participants (45-80 years) was followed by an ambulant team, and a specific healthcare team provided home rehabilitation. Data were analysed using interpretive description, systematic text condensation and coping theory.

FINDINGS

A crucial determinant for the participants' hopes for a life worth living was the mutual confidence expressed in encounters with healthcare professionals and the participants' ability to make sense of their now-altered body. The professional caretakers' communication qualities and their ability to attend to individual needs were important. Help in processing the emotional reactions caused by a changed body and in socialising was requested by participants. Professional caretakers providing home rehabilitation should strive for a more flexible- and individually tailored service and should seek increased cooperation among stakeholders.

CONCLUSION

The focus on therapeutic communicative qualities, bodily changes, emotional processes, social concerns and long-term follow-up should be increased in order to achieve a more beneficial experience for stroke survivors.

Patients Experience High Levels of Anxiety 2 Years Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

To explore anxiety levels during the first 2 years after rupture of aneurysmal subarachnoid hemorrhage.

METHODS

A consecutive sample of patients with aneurysmal subarachnoid hemorrhage (aSAH) (n = 88, 84.6% of eligible) from a Swedish neurosurgical clinic were followed-up with a prospective cohort design at 3 time points; 6 months, 1 year, and 2 years after the onset. Data were collected by postal questionnaires and telephone interviews: State trait anxiety inventory, Hospital anxiety and depression scales, Barthel index, Telephone interview for cognitive status, and a set of study-specific questions.

RESULTS

Most of the respondents scored above the State trait anxiety inventory Swedish norm value on anxiety levels at all 3 follow-up time points. About 59% (n = 52) of respondents scored above the cutoff value for clinical significant level of anxiety in at least 1 time point during the first 2 years after rupture of aSAH. There were no significant differences in levels of anxiety versus the observational period and the 3 follow-up time points. The most significant explanatory variable to high levels of anxiety at all 3 follow-up time points was low perceived recovery.

CONCLUSIONS

Levels of anxiety remained high and stable throughout the first 2 years after rupture of aSAH. High levels of anxiety may reduce health-related quality of life substantially. Identification of individuals with high levels of anxiety and supportive care could therefore potentially improve long-term outcome.

The patient's experience of the psychosocial process that influences identity following stroke rehabilitation: a metaethnography

BACKGROUND AND PURPOSE

Patient experience is increasingly being recognised as a key health outcome due to its positive correlation with quality of life and treatment compliance. The aim of this study was to create a model of how patient's experiences of rehabilitation after stroke influence their outcome.

METHODS

A metaethnography of qualitative articles published since 2000 was undertaken. A systematic search of four databases using the keywords was competed. Original studies were included if at least 50% of their data from results was focused on stroke survivors experiences and if they reflected an overarching experience of stroke rehabilitation. Relevant papers were appraised for quality using the COREQ tool. Pata analysis as undertaken using traditional processes of extracting, interpreting, translating, and synthesizing the included studies.

RESULTS

Thirteen studies were included. Two themes (1) evolution of identity and (2) psychosocial constructs that influence experience were identified. A model of recovery was generated.

CONCLUSION

The synthesis model conceptualizes how the recovery of stroke survivors' sense of identity changes during rehabilitation illustrating changes and evolution over time. Positive experiences are shaped by key psychosocial concepts such as hope, social support, and rely on good self-efficacy which is influenced by both clinical staff and external support.

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

PURPOSE

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

METHOD

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

FINDINGS

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

CONCLUSIONS

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

Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

BACKGROUND

Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.

METHODS AND FINDINGS

The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.

CONCLUSIONS

Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems.

Health-Related Quality of Life 10 Years After Intracranial Aneurysm Rupture

BACKGROUND:

Experiencing an aneurysmal subarachnoid hemorrhage (SAH) could affect health-related quality of life (HRQoL) several years after the onset. Long-term studies are scarce, and there is a lack of knowledge of whether HRQoL is affected &gt; 5 years after the onset and, if so, in what dimensions. In the general population, HRQoL decreases with age and with the occurrence of a disease and differs between sexes. Factors that may influence HRQoL after aneurysmal SAH include neurological outcome, perceived recovery, aneurysm treatment, and family support.

OBJECTIVE:

To measure HRQoL and to explore factors affecting HRQoL 10 years after aneurysmal SAH.

METHODS:

A consecutive sample of all patients admitted for intracranial aneurysm rupture at a neurosurgical clinic in Stockholm (n = 217, 79.5% of eligible) were followed up from 2007 to 2008, approximately 10 years after aneurysm rupture. HRQoL was measured with EQ-5D, and the results were compared with a general population sample from the Stockholm Public Health Survey 2006 matched by age and sex.

RESULTS:

Compared with the general population, the aneurysm sample reported significantly more problems in 4 of 5 EQ-5D dimensions—mobility, self-care, usual activities, and anxiety/depression—and had significantly lower EQ-5Dindex and EQ visual analog scale values. Within the aneurysm sample, HRQoL was most affected in respondents with worse Glasgow Outcome Scale values at hospital discharge, respondents with comorbidities, and respondents with low perceived recovery.

CONCLUSION:

Aneurysmal SAH affects HRQoL to a large extent, even 10 years after the onset, indicating a need for long-term follow-up and support after the onset.