Stroke: a family dilemma

Post-stroke family resilience is correlated with family functioning among stroke survivors: The mediating role of patient's coping and self-efficacy

AIM

Family resilience and healthy family functioning are crucial for stroke survivors' rehabilitation. This study aimed to determine the mediating effects of self-efficacy and confrontation coping on the relationship between family resilience and functioning among patients with first-episode stroke.

DESIGN

A cross-sectional design was applied.

METHODS

288 patients with first-episode stroke were recruited from 7 hospitals in Shangqiu and Shanghai, China, from July 2020 to October 2020. A shortened Chinese version of the Family Resilience Assessment Scale, family adaptation, partnership, growth, affection and resolve questionnaire, Medical Coping Modes Questionnaire, and Self-efficacy for Chronic Disease 6-item Scale were used to collect the self-reported data. The relationships among the studied variables were studied using spearman correlation and structural equation model.

RESULTS

The average level of family functioning among stroke patients was 7.87 (SD = 2.32). About 26.8% (n = 76) of patients reported family dysfunction. The structural equation model showed that family resilience directly affected patients' satisfaction with family functioning (r = 0.406, p < 0.001) and indirectly affected the mediating role of patients' self-efficacy and confrontation coping style (r = 0.119, p < 0.001). The model was with good fit (χ2/df = 2.128, RMSEA = 0.065, GFI = 0.956, AGFI = 0.919, NFI = 0.949, and TLI = 0.956).

CONCLUSION

Family resilience and functioning among patients with first-episode stroke are positively associated with the mediating effects of the patients' confrontation coping style and self-efficacy between family resilience and functioning. The findings indicate that the professionals should pay special attention to families exhibiting poor family resilience or with patients who rarely use confrontation coping styles or with poor self-efficacy since they are more likely to suffer from low functioning.

Expanding Occupational Therapy Perspectives with Family Caregivers

Background. Family caregivers are ever-present and crucial collaborators in the work of occupational therapists but are rarely the focus of their efforts. Purpose. This lecture will discuss the greater inclusion of family caregivers in occupational therapy and the exciting possibilities that emerge from this change. Key issues. Family caregivers are a unique client population. This position statement is supported by recent research on occupational therapists’ values and shifts towards an occupational participation approach in the profession. Working with this client population requires a nuanced understanding of their experience. Caregiving can be burdensome, but it can also create positive effects many of which can be identified and understood through a relational lens. Implications. Through a three-fold approach, occupational therapists can work with caregivers to locate and mitigate negative caregiving effects, discover, and build on positive effects, and further develop positive outcomes by encouraging and balancing caregiving and non-caregiving occupations.

Dyadic profiles of family resilience among patients with first-episode stroke: A longitudinal study of the first 6 months after stroke

BACKGROUND

The importance of family resilience in the recovery of stroke patients has been demonstrated in numerous studies. However, little is known about post-stroke family resilience.

AIMS

To investigate the family resilience of stroke patients from a patient-caregiver dyadic perspective during the first 6 months after stroke.

METHODS

A total of 288 dyads of patients diagnosed with a first-episode stroke and their principal caregivers were recruited from neurology departments of 7 tertiary hospitals in Shanghai and Shangqiu, China. Family resilience and family function were assessed during hospitalisation and at 1, 3 and 6 months after stroke. K-means cluster analysis was used to identify different clusters of family resilience based on family resilience of patients and caregivers during hospitalisation. The STROBE guidelines for observational studies were followed.

RESULTS

Three clusters of family resilience were identified with distinct trajectories: cluster of high resilience (HR), cluster of low resilience (LR) and cluster of discrepant resilience (DR). The level of family function was consistently highest in cluster HR and lowest in cluster with LR at four time points. Most (69.8%) families fell into the cluster with low resilience and low family function. Characteristics such as the Rankin scores and education level of patients, education level of caregivers, family monthly income and living district were different among the three clusters.

CONCLUSIONS

We concluded that family resilience was linked to the family functioning of patients with a first-episode stroke, however, the levels of resilience in most families were low. Factors, including the education level, family income and stroke severity of patients were revealed to influence the family resilience and its development.

RELEVANCE TO CLINICAL PRACTICE

A resilience-focused approach to family-related treatment is beneficial for families. Therefore, understanding family resilience among stroke survivors is needed to inform the development of interventions for enhancing the recovery of stroke families.

Selection process for botulinum toxin injections in patients with chronic-stage hemiplegic stroke: a qualitative study

Background

Botulinum toxin (BT) injection is a new treatment for spasticity with hemiplegia after stroke. How a patient decides to receive BT injections after becoming aware of the treatment remains unclear. In this exploratory qualitative study, we aimed to investigate patients’ decision-making about treatment strategies in collaboration with family and health professionals and to identify conflicts in patients’ feelings about BT treatment.

Methods

The study included six patients with stroke sequelae. Data were collected using comprehensive interviews and were analyzed using the grounded theory approach and trajectory equifinality modeling.

Results

After patients learned about BT treatment, they clearly exhibited the following two concurrent perceptions: “the restriction of one’s life due to disabilities” and “the ability to do certain things despite one’s disabilities.” Some patients reported a “fear of not being able to maintain the status quo owing to the side effects of BT.” To alleviate this fear, timely support from family members was offered, and patients overcame anxiety through creative thinking. However, there were also expressions that revealed patients’ difficulties dealing with negative events. These factors influenced the patients’ development of “expectations of BT” or “hesitations about BT.”

Conclusions

To establish treatment strategies in collaboration with patients, healthcare professionals should show supportive attitudes and have discussions with patients and their family members to help patients resolve their conflicts and should establish treatment strategies that maintain the positive aspects of patients’ lives.

Instruments for assessing the burden of informal caregiving for stroke patients in clinical practice: a comparison of CSI, CRA, SCQ and self-rated burden

Objective: To compare the feasibility, convergent and clinical validity of three commonly used burden scales: Caregiver Strain Index (CSI), Caregiver Reaction Assessment (CRA) and Sense of Competence Questionnaire (SCQ), with a self-developed single question on self-rated burden (SRB).

Subjects: Stroke patients receiving support from an informal caregiver ( n=148) and their caregivers were followed up to six months after stroke.

Intervention: Feasibility was assessed with several measures of missing values. Convergent validity was assessed on the basis of the correlation patterns between the burden scales, and clinical validity through evaluation of expected associations between levels of burden and explanatory patients' and caregivers' characteristics.

Results: Missing values were less often observed on CSI and SRB than SCQ and CRA. Significant correlation coefficients ( p<0.05) could be demonstrated between all burden scales, except for one subscale of CRA. Evidence for clinical validity was strongest for CSI and SRB, based on associations between higher burden scores and patients' disability, and patients' and caregivers' poor level of health-related quality of life (all p<0.05).

Conclusions: A concise and simple measure would facilitate early detection of caregivers at risk in clinical practice and research. CSI and SRB are more feasible and at least as valid instruments for assessment of caregiver burden in stroke than the longer and more complex SCQ and CRA. SRB could be used for quick screening of caregivers at risk. CSI is indicated for further diagnosis of the burden of informal caregivers.

Measures used to assess burden among caregivers of stroke patients: a review

Objective: To describe measures used to evaluate the burden of caregiving experienced by caregivers of stroke patients and their clinimetric properties.

Design: A review of the literature was conducted to examine burden scales with regard to concept, feasibility, internal consistency, validity, reliability and responsiveness.

Results: The literature search resulted in 45 measures of caregiver outcomes, including 16 different measures of caregiver burden. About half of the scales were used only once and were not further described. Nearly all instruments measure the various dimensions of burden (competency, negative feelings, social relations, participation problems, physical and mental health and economic aspects), but not in the same proportions. Most measures showed good internal consistency, and validity was demonstrated for all measures except one. However, not much is known about the reliability and responsiveness of these measures.

Conclusions: No measure has proven superiority above others. Future research should focus on comparisons between existing instruments and on their reliability and responsiveness.

Clinical Implications of Family-Centered Care in Stroke Rehabilitation

PURPOSE

Most stroke survivors will be cared for at home by family caregivers with limited training. Families actively involved in rehabilitation feel more prepared for the new responsibilities of caring for the stroke survivor. The focus of this article is to highlight the relevant concepts of a family-centered model of care and provide general guidance on how integrating a family-centered mindset may be clinically applicable.

DESIGN

Concept Analysis.

METHODS

Synthesis of literature on family-centered care and its application in for rehabilitation nurses.

FINDINGS

Family-centered care is a model of collaborative healthcare that encourages collaboration and partnership among patients, families, and providers with respect to the planning, delivery, and evaluation of health care. Care provided within such a model can expand providers' knowledge of the impact of illness and any issues that may affect eventual transition back home.

CONCLUSION

Rehabilitation nurses should view stroke patients and family caregivers as a unit. Using family-centered strategies can help nurses provide appropriate, individualized care during rehabilitation.

Family Adaptation to Stroke: A Metasynthesis of Qualitative Research based on Double ABCX Model

PURPOSE

There is growing interest in synthesizing qualitative research. Stroke is a very common cause of disability often leaving stroke survivors dependent on their family. This study reports an interpretive review of research into subjective experience of families with stroke survivors based on the components of the Double ABCX Model including stressors, resources, perception, coping strategies, and adaptation of these families.

METHODS

Metasynthesis was applied to review qualitative research looking at stroke family members' experiences and responses to having a stroke survivor as a family member. Electronic database from 1990 to 2013 were searched and 18 separate studies were identified. Each study was evaluated using methodological criteria to provide a context for interpretation of substantive findings. Principal findings were extracted and synthesized under the Double ABCX Model elements.

RESULTS

Loss of independence and uncertainty (as stressors), struggling with new phase of life (as perception), refocusing time and energy on elements of recovery process (as coping strategy), combined resources including personal, internal and external family support (as resources), and striking a balance (as adaptation) were identified as main categories. Family members of stroke survivor respond cognitively and practically and attempt to keep a balance between survivor's and their own everyday lives.

CONCLUSIONS

The results of the study are in conformity with the tenets of the Double ABCX Model. Family adaptation is a dynamic process and the present study findings provide rich information on proper assessment and intervention to the practitioners working with families of stroke survivors.

Care Coordination/Home-Telehealth for Veterans with Stroke and Their Caregivers: Addressing an Unmet Need

BACKGROUND

Stroke is a life-disrupting, costly event for many stroke patients and their families. An estimated 4.8 million stroke survivors are living in the community with some level of disability, and the incidence of stroke is expected to rise with correspondingly higher costs, both in dollars and other forms of burden for families of patients with stroke. Approximately 80,000 veterans have experienced a stroke, leaving approximately 40% with moderate residual impairments and 15%-30% with severe residual disability.

PURPOSE

The purpose of this study was to identify postdischarge needs of veterans with stroke and their caregivers and to identify how to design a care coordination/home-telehealth (CC/HT) program to address these needs.

METHOD

Veterans and their caregivers (N = 22) were interviewed about their experiences with stroke, their postdischarge stroke recovery needs, and their experiences with the Veterans Administration's existing Care Coordination/Home-Telehealth (CC/HT) program. Data were analyzed using the process of grounded dimensional analysis.

RESULTS

Core concepts identified were (a) assessing and managing the residual effects of stroke, and (b) shifting roles and responsibilities.

CONCLUSION

The findings suggest that a comprehensive care coordination program that includes home telehealth could aid veterans and their caregivers in managing stroke recovery across the continuum of care at home and within the community. The results of the study can provide elements to be included in the CC/HT program.

Enhancing patient-provider communication for long-term post-stroke spasticity management

Stroke is a major public health concern, with estimated 16 million people worldwide experiencing first-time strokes each year, a number that is expected to rise. Two-thirds of those experiencing a stroke are younger than 70 years of age. Stroke is a leading cause of disability in adults as a result of major sequelae that include spasticity, cognitive impairment, paresis, and depression. Disabling spasticity, defined as spasticity severe enough to require intervention, occurs in 4% of stroke survivors within 1 year of first-time stroke. The aim of this report is to focus instead on a discussion of patient-provider communication, and its role in post-stroke spasticity (PSS) rehabilitation within the context of patient-centered health care. A discussion based on a review of the literature, mainly since 2000. Problems within communication are identified and suggestion to enhance communication are proposed thus improving patient-centered goal setting/goal achievement for the effective management of spasticity rehabilitation. These are as follows: (i) involving family members, (ii) educating patients and family members on stroke and rehabilitation, and (iii) establishing a common definition for long-term goals. Increased communication among physicians, patients, and payers may bridge some of the gaps and increase the effectiveness of PSS rehabilitation and management.

Experiences of adult stroke survivors and their parent carers: a qualitative study

OBJECTIVE

To explore the experiences of adult stroke survivors and their parent carers.

DESIGN

Qualitative methodology: interpretative phenomenological analysis.

SETTING

Six residential areas across England and south Wales.

PARTICIPANTS

Six adult stroke survivors (aged 27-46), six mothers (aged 59-76) and five fathers (aged 55-76).

METHOD

Semi-structured interviews to explore the relationship and interactions between parent and survivor prior to and after a stroke, with opportunities to explore both positive and negative changes. All interviews were transcribed and analysed by a six step interpretative phenomenological analysis process. Survivors, mothers and fathers were analysed as three separate groups and the results were synthesised.

RESULTS

Identical and interconnected themes emerged from the three groups, permitting synthesis into a single organising framework with four superordinate themes capturing the key issues for all three groups. The four superordinate themes were: 'emotional turmoil'; 'significance of parents'; 'negotiating independence versus dependence' and 'changed relationships'.

CONCLUSIONS

Parents reported adjusting to caring with relative ease. Survivors did not adjust to being cared for with such ease and felt positioned in a child role. Balancing independence and dependence was a challenge for survivors and parents and is considered within a systemic theory framework. Implications for service developments and guidelines are considered.

People's experiences of the impact of transient ischaemic attack and its consequences: qualitative study

AIM

This paper is a report of a study of how people's experiences of transient ischaemic attack affect their perception of their health and their uptake of health maintenance measures.

BACKGROUND

Transient ischaemic attack is a well-recognized warning sign of subsequent stroke, but early diagnosis and management of risk factors can substantially reduce this risk. Even though the physical effects of a transient ischaemic attack are transient, it is known to negatively affect quality of life. However, no qualitative studies have explored the impact of transient ischaemic attack on people's everyday lives.

METHODS

Sixteen participants were recruited from a vascular surgery clinic in a district general hospital in North West England. All had a recent transient ischaemic attack. A qualitative grounded theory study using detailed interviews (n = 21) was conducted.

FINDINGS

Participants experienced conflict between acknowledgement of the transient ischaemic attack as a significant illness episode with implications for their long-term health, and denial of its seriousness. Although they often ignored the initial signs, participants also experienced fear due to increased awareness of their risk of stroke. Often, they believed that they were having a permanent stroke. Many participants were prompted to seek medical advice by a family member or acquaintance. Having a transient ischaemic attack negatively changed their perception of their health and their quality of life, but some also viewed it as a positive event that had warned of their stroke risk and enabled them to take up health maintenance measures.

CONCLUSIONS

Having a transient ischaemic attack permanently changes people's quality of life and their perception of their health, despite the transience of the symptoms. The ability of people to make positive health changes after a transient ischaemic attack to some extent ameliorates the negative effects of being aware of their heightened stroke risk. Their appreciation of their quality of life may also be enhanced. The transience of the symptoms and lack of knowledge of transient ischaemic attacks lead to delays in seeking medical advice.

An exploration of the support person's perceptions and experiences of complex regional pain syndrome and the rehabilitation process

We explored the perceptions and experiences of those who support a relative or friend with complex regional pain syndrome (CRPS), a chronic pain condition of unknown aetiology usually affecting a single limb. Semi-structured interviews were analysed using interpretative phenomenological analysis, and four superordinate themes are presented here. These themes describe the efforts of carers to make sense of CRPS and the rehabilitation process, to be sensitive to the discomfort of the person with CRPS and to respond in an attuned and helpful way. CRPS had become integrated into the carers' lives as they sought to monitor, protect and motivate the person they supported. The themes are discussed in relation to each other and to extant literature, including work on social support and adjustment to chronic illness, and the clinical implications are explored.

Informal stroke caregivers' self-appraised problem-solving abilities as a predictor of well-being and perceived social support

AIM

To describe the relationship between self-appraised problem-solving abilities and psychological distress, burden and perceived social support in informal, family stroke caregivers.

BACKGROUND

Previous research suggests that self-appraised problem-solving abilities play a significant role in the well-being of family caregivers of patients with chronic illness. However, little is known about its role in caregivers of stroke survivors.

DESIGN

Prospective correlational study.

METHODS

One week before discharge, 103 family caregivers of survivors of a first stroke were assessed for their perceived problem-solving abilities, social support, anxiety, depression and physical well-being. At three months postdischarge, 85 of these caregivers (83% retention) were reassessed on the same measures. In addition, their levels of burden and perceived difficulties were also measured.

RESULTS

Using multiple regression, overall self-appraised problem-solving abilities and its subscale 'confidence in problem-solving' at one week before discharge were significant predictors of caregiver perceived social support (R(2) = 29%) and perceived physical well-being (R(2) = 42%) at three months postdischarge. Other relationships were non-significant.

CONCLUSIONS

Caregivers' perceived social support and physical well-being were significantly predicted by confidence in problem-solving.

RELEVANCE TO CLINICAL PRACTICE

This study is timely given the challenges facing health systems in Hong Kong to effectively manage chronic illness through family-centred care. The significant relationships between caregiver self-appraised problem-solving, perceived social support and well-being suggest that interventions maximising caregiver confidence in problem-solving might be valuable in supporting family caregivers of stroke survivors. Nurses working with families caring for stroke survivors both close to discharge and in the early transition stages back at home may be in an ideal position to offer this support.

The caregiving relationship and quality of life among partners of stroke survivors: a cross-sectional study

Background

Since the majority of stroke survivors return home following their stroke, families play a pivotal role in their care. Few studies have addressed both positive and negative aspects of this role or the broader construct of health-related quality of life (HRQL). Furthermore, little consideration has been given to the context of care in terms of relationship quality, and reciprocity. The present study examined the relationships between caregiver quality of life (HRQL), caregiver role, relationship satisfaction, balance and reciprocity in caregivers of partners who had experienced a stroke. Specific hypotheses were made based on equity theory in social relations.

Methods

Fifty-six partner caregivers completed a postal survey that included measures of HRQL (SF-36), caregiver role (negative and positive aspects), relationship satisfaction, reciprocity and balance. Data were also collected on the care recipients' quality of life (Stroke Specific Quality of Life scale).

Results

Compared to a normative sample, caregivers' HRQL was lower for all SF-36 domains. Care recipient and caregiver age, care recipient quality of life and caregiver role (negative) significantly predicted physical component summary scores on the SF-36, while care recipient quality of life and caregiver role (negative) significantly correlated with mental component summary scores. Relationship satisfaction and intrinsic rewards of caregiving were found to be important predictors of positive aspects of the caregiver role. Caregivers who viewed their relationship as less balanced in terms of give and take had significantly greater caregiver burden than those who viewed their relationship as more equitable.

Conclusions

The study highlights the importance of taking a broader approach to examining partner caregiving in the context of stroke, in terms of the caregiving relationship and their influence on the health and well-being of caregivers.

Interdependence of stroke survivors' recovery and their relatives' attitudes and health: A contribution to investigating the causal effects

PURPOSE

One goal of the study was to test specific hypotheses concerning the interdependence of the stroke survivors' recovery and their caregiving partners' attitudes and health. The other aim was to find an applicable method for investigating causal effects on the rehabilitation of chronically sick persons in longitudinal studies with medium-sized samples.

METHOD

The recovery of 81 stroke survivors regarding the physical and mental functioning in everyday life and their caregiving partners' health and attitudes were assessed twice, once after the patients left the hospital and again one year later. We applied the structure equation modeling and the cross-lagged partial correlation analysis (CLPC) for testing causal effects.

RESULTS

Particularly stroke victims' cognitive and emotional recovery seems to be influenced by psychosocial factors such as the caregiving partners' acceptance of a post-stroke life-situation. In contrast to this, the research suggests that the patients' recovery regarding physical functioning is not substantially affected by the partners, rather the patients' difficulties with motor functioning influence their partners' health.

CONCLUSIONS

Caregivers merit attention as part of rehabilitation interventions. We recommend the CLPC for investigating causal effects in the complex interdependence of chronically sick persons' convalescence and their family members' health and state of mind in medium-sized samples.

Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors

OBJECTIVE

To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke.

DESIGN

Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families.

SETTING

Neurology inpatient service of a large urban hospital.

PARTICIPANTS

Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index).

RESULTS

Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning.

CONCLUSIONS

Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.

Predictors of life satisfaction among stroke survivors and spousal caregivers: a narrative review

Stroke is a major cause of disability and death worldwide. It affects 15 million people globally and 60% either die or are permanently disabled as a result of stroke. In a rapidly aging population, stroke is expected to continue to be a major concern for survivors, their families and health and social care providers. Most stroke survivors live in the community and are assisted by family caregivers, especially spouses. However, stroke-related impairments and poststroke depression interfere with recovery and result in impaired relationships and reduced life satisfaction for the survivors and their spouses. New interventions are needed to assist stroke survivors and their spouses to cope with the many physical, emotional and environmental changes that result after stroke and enable survivors to become reintegrated into the community.

Informal carers of stroke survivors--factors influencing carers: a systematic review of quantitative studies

PURPOSE

Despite increasing evidence of adverse effects on informal carers of caring for stroke survivors, little is known about the characteristics of carers and survivors that influence carer outcomes. The purpose of this review is to summarize factors influencing outcomes in carers of stroke survivors.

METHODS

A systematic review of studies identified from English language medicine, nursing and psychology databases from 1996-2006 was carried out.

RESULTS

Thirty-nine studies were identified. Studies from Europe and the USA investigating negative carer outcomes dominated. Carer psychological characteristics and survivor disability were shown to influence carer outcomes. However, the diversity of carers and outcomes investigated and differences in study timing post-stroke make generalizations difficult.

CONCLUSIONS

Despite improvements in study design over the last two decades, atheoretical studies employing overlapping concepts and poorly defined participants still dominate. Future studies should have theoretical underpinning and should acknowledge the diversity of carers, survivors and their situations. In addition, future emphasis on positive carer outcomes may improve understanding of protective carer factors.

A Longitudinal Study of Health-Related Quality of Life of First Stroke Survivors’ Close Relatives

BACKGROUND AND PURPOSE

Mental and social burdens of stroke patients' relatives have been investigated repeatedly, but there is little information about their quality of life (QoL). The purpose of the study was to describe the health-related QoL of stroke patients' relatives at 3 points in time after the stroke.

METHOD

Sixty-four closest relatives of patients suffering from a disabling stroke were questioned at admission to inpatient rehabilitation as well as 6 months and 1 year after discharge with the SF36 (short form 36-item questionnaire) and about probable covariates.

RESULTS

During inpatient rehabilitation relatives' perception of their physical role as well as of all mental health scales was significantly lower than the normative data. We found improvements in all scales except physical functioning between inpatient rehabilitation and 6 months after discharge. Deteriorations between 6 months and 1 year occurred in physical functioning, role physical, social functioning, role emotional and mental health.

CONCLUSIONS

Changes in perceived health-related QoL indicate that relatives go through different stages while coping with the chronic illness of their family member during rehabilitation and in the first year after discharge. These findings may aid support and counseling.

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

OBJECTIVES

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

SETTING

East Dorset Health Authority.

SUBJECTS

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

DESIGN

Qualitative methods.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The meaning and experience of being a stroke survivor: an interpretative phenomenological analysis

PURPOSE

To investigate the meaning and experience of being a stroke survivor.

METHOD

Qualitative in-depth semi-structured interviews were conducted with 10 stroke survivors (five face-to-face and five e-mail interviews). The interview data were transcribed verbatim (these were pre-transcribed in e-mail exchange) and analysed using Interpretative Phenomenological Analysis.

RESULTS

Four themes emerged from the analysis: Disrupted embodiment and the loss of self; Invisibility of emotional difficulties; Gender, romance and sexuality; and Social interaction. These themes, respectively, revealed that participants often had difficulties with psychological adaptation to the physically disabling aspects of their stroke; they experienced enduring and disabling emotional difficulties; they had a particular concern for the viability and maintenance of romantic and sexual relationships; and they often became socially withdrawn, resulting in an increased pressure on familial caregivers.

CONCLUSION

The findings of the present work suggest the need for post-stroke counselling regarding romantic and sexual relationships, as well as promoting acceptance of some of the physical disabilities that come with having a stroke and encouraging positive self-regard. There would also appear to be a need to address the issue of social withdrawal and familial relationships, perhaps when health professionals convey information regarding the person's stroke, and in counselling targeted specifically at family caregivers.

A national study of the quantity and cost of informal caregiving for the elderly with stroke

BACKGROUND

As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients.

OBJECTIVE

To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke.

METHODS

The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated.

RESULTS

Of 7,443 respondents, 656 (8.8%) reported a history of stroke. Of those, 375 (57%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke +/- SRHP (p < 0.01). Using the median 1999 home health aide wage (8.20 dollars/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from 3,500 dollars to 8,200 dollars. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to 6.1 billion dollars for stroke-related informal caregiving in the United States.

CONCLUSIONS

Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

Perceptions of stroke in the general public and patients with stroke: a qualitative study

OBJECTIVES

To gain insight into people's thoughts on stroke and to inform the development of educational strategies in the community.

DESIGN

Focus group discussions: two groups of people who had a stroke and their carers, and two groups of members of the general public.

SETTING

New South Wales, Australia.

PARTICIPANTS

35 people participated: 11 from the general public, 14 people who had had a stroke, and 10 carers or partners.

MAIN OUTCOME MEASURES

Views on risk factors, symptoms, treatment, information resources, and prevention.

RESULTS

All groups reported similar knowledge of risk factors. People generally mentioned stress, diet, high blood pressure, age, and smoking as causes of stroke. Participants in the community group gave little attention to symptoms. Some participants who had had a stroke did not initially identify their experience as stroke because the symptoms were not the same as those they had read about. There were mixed feelings about the extent of involvement in management decisions during hospital admission. Some felt sufficiently involved, some wanted to be more involved, and others felt incapable of being actively involved.

CONCLUSIONS

Symptoms of stroke are not easy to recognise because they vary so much. Presentation of information about stroke by hospital and community health services should be improved. Simple and understandable educational materials should be developed and their effectiveness monitored.

'Seeking': a key activity for new family carers of stroke survivors

Stroke is one of the major causes of disability in the United Kingdom and considerable numbers of stroke survivors need help and support from family carers. The sudden and unexpected nature of stroke means that there is very little time for family members to prepare for a caring role. This paper draws on data from 37 interviews with 14 new carers of stroke survivors and highlights the uncertainty and lack of confidence that family members experience in adopting a caring role. During the initial period following the stroke carers engage in a number of different 'seeking' activities in order to try and ensure that they feel competent, confident and safe to provide care and that they understand the likely future demands they may face. Rather than being facilitated by staff, carers' efforts often go unnoticed or are overlooked, resulting in carers feeling that they are 'going it alone'. Staff need to be more aware of carers' 'seeking' behaviour and actively encourage the formation of partnerships with family members.

Developing the nurse's role in patient education: rehabilitation as a case example

Over the past decade considerable emphasis has been placed on the nurse's role in patient education. Despite this numerous studies have suggested that this aspect of nursing practice is under-developed. Using rehabilitation as a case example this paper explores the nursing contribution to patient education in five conditions: multiple sclerosis; arthritis; myocardial infarction; spinal injury and stroke. Although the literature identifies considerable potential for nurses to take a lead role in patient education this is rarely achieved in practice. Analyses of printed curricula from a range of courses indicate that nurses are not adequately prepared for patient education and that a reorientation of nurse education is required.

Domains and determinants of quality of life after stroke caused by brain infarction

OBJECTIVE

To evaluate the domain-specific quality of life (QOL), including physical, social and role functioning, mental health, vitality, bodily pain, and general health domains, and to assess QOL's clinical and sociodemographic correlates in patients who were disabled by ischemic stroke.

DESIGN

One-year prospective study of an inception cohort of patients with first-ever brain infarction.

SETTING

Stroke unit of a neurologic department of a university hospital.

PATIENTS

Eighty-five consecutive patients (36 women, 49 men; mean age +/- SD, 65+/-12.5 yr) with first-ever stroke of a mild to moderate nature caused by brain infarction.

MAIN OUTCOME MEASURES

Patients were examined at 3 and 12 months poststroke. QOL was measured using the RAND 36-Item Health Survey. The variables studied were lateralization of cerebral lesion, neurologic and functional status, depression, age, gender, marital status, and living conditions. Depression was evaluated according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Neurologic impairment was assessed by Scandinavian Stroke Scale, performance in activities of daily living by the Barthel index, and the intellectual deterioration by the Mini-Mental State Examination.

RESULTS

QOL was poorer for the patients with mild to moderate stroke impairments at 3 months poststroke. The test domains most prone to being affected were physical functioning, physical role limitations, vitality, and general health. Only the domains of physical functioning and physical role limitations improved during the follow-up at 1 year. Depression, although mostly minor, was the most important reason for impaired QOL. Depression, being married, and age emerged as significant independent contributors to the low score value of vitality. Depression and being married were related to the low score value of physical role limitations.

CONCLUSIONS

Stroke affects QOL, impairing its physical and psychosocial domains. The most important determinants of low QOL seem to be depression and being married. These findings provide new challenges for stroke rehabilitation, calling for identification of patients and spouses in need of supportive services.

Stroke patients' needs and experiences regarding autonomy at discharge from nursing home

In this qualitative study stroke patients rehabilitating in nursing homes experienced an increase in their autonomy (particularly in self-determination, independence and self-care) in the last weeks before discharge. The change in autonomy was found to be related to regained abilities and self-confidence, and to patients' strategies (e.g. taking initiative, being assertive). The attitude of health professionals and family, and the nursing home could influence patient autonomy. Overprotection, paternalism, care routines and an inconsistent approach constrain autonomy. Conversely, attentiveness, tailored interventions and a respectful dialogue facilitate autonomy, like moderate instrumental and emotional support by the family. Nursing homes can enhance autonomy by minimizing care routines and by providing room for doing activities independently and privately. Attention to patient autonomy may improve patients' active participation in rehabilitation, quality of life, and autonomous living after discharge. Multidisciplinary guidelines based on the results may increase attention to the stroke patients' autonomy and stimulate a team approach.

Rules of relevance after a stroke

In line with the WHO, rehabilitation after a stroke can be viewed as a process of interaction and negotiation between the patient and the health care system about realistic goals and relevant activities. So a relevant question is "Whose understandings and rules of relevance determine the rehabilitation process?" In order to answer the above question the aim of this study was twofold. One aim was to explore how stroke survivors under 65 understand and deal with the activities of the rehabilitation process and how they experience having had a stroke. The second aim was to explore how the same patients and their rehabilitation processes were described in medical records, and ultimately to compare the two results. Ten patients were studied during the first 3 months after their strokes. Data consists of transcripts from interviews with the patients and notes from medical documents. Discourse analysis was used as a methodological approach, and in the analysis the focus was upon the discourse, rather than upon the message itself. The discourse of stroke survivors and health care personnel overlap each other to a great extent. The discourse is a biomedical one and both focus on the physical disabilities of the stroke survivors. The subordinate position of the patients and the authoritative position of the health care providers are also valid for both groups. However, there are also differences. While the stroke survivors portray themselves as individuals having had a position in the society, which they want to recapture, they are portrayed as fragmented male or female bodies of a certain age with certain impairments and dysfunction in the medical records. There is no answer to the question; What is of most importance for the stroke survivors?

'You do know he's had a stroke, don't you?' Preparation for family care-giving--the neglected dimension

Countries throughout the developed world have introduced a policy of community care for older people to reduce costs to the state and maintain quality of life. In reality community care is largely family care and recognition of the need to support family carers is being promoted through the notion of partnership with professional carers. Such a partnership calls for a more complete understanding of how carers' needs change over time and how professional support can be most effective. Support is particularly important at the start of care-giving in order that carers can exercise free choice and be adequately prepared for their role. This paper provides an overview an ongoing longitudinal study and reports specifically on the findings of data from a preliminary study in which a convenience sample of seven experienced carers of stroke survivors who attended a stroke and carers club were interviewed in their own homes. Based on initial data from a longitudinal study of stroke victims, this paper outlines four themes: 'What's it all about', 'Going it alone', 'Up to the job' and 'What about me?' These themes highlight the difficulties carers experience in the immediate aftermath of stroke.

Geriatric rehabilitation revisited

There is no gold standard for rehabilitation of geriatric patients. Although many studies indicate that a multifaceted team approach, such as seen with specialized stroke units, may enhance outcomes for many patients, how these units achieve this is still unclear. However, the evidence shows that a comprehensive program of both medical and psychosocial support tends to result in patients achieving and maintaining higher levels of function, with less need for readmission, and shorter hospital stays. In addition to interventions aimed at improving function, rehabilitation includes assessment, goal setting, and provision of care to maintain the patient's status. More randomized controlled studies of rehabilitation programs are needed so that we can identify which programs are best for which patients.

The impact of stroke on informal carers: a literature review

Stroke incidence is set to rise in Western societies as population projections predict an increase in the proportion of older people. Most of these stroke survivors are supported by close kin members who play an important role in the rehabilitation and care of this group. The objective of this review was to establish the following: (a) to evaluate the impact of the stroke on the informal carers' quality of life, (b) to identify factors which help carers to cope with their caring role, (c) to evaluate health service provision for stroke carers. A systematic literature search using BIDS-EMBASE, MEDLINE and PSYCHLIT, identified 31 relevant studies. These showed that most studies concentrated on carers' psychological health and the negative impact that the stroke had. Carers ability to cope with the stroke was enhanced both by the use of positive coping strategies and more concrete measures e.g. more stroke information. Furthermore, whilst most carers were generally satisfied with health services, the few interventions directed at improving carer outcomes showed mixed results. The studies reviewed had many limitations; few gave definitions of 'informal' carer and there was a predominant use of cross-sectional studies and non-standardised outcome measures. Future studies should broaden their research question to evaluate quality of life, using standardised measures to do this and employing either a longitudinal or randomised control design to improve the robustness of results. More studies are also needed evaluating the effectiveness of health services on carers' quality of life.

A Dutch 'Poststroke Guide': distribution and use

Stroke patients and caregivers have a substantial need for information. The Dutch 'Poststroke Guide' was written in an attempt to meet this need. The study investigates the distribution of this guide among stroke patients, caregivers, and stroke providers. Stroke patients and caregivers who ordered a copy of the first edition received a questionnaire to evaluate the guide and to provide information about personal characteristics. Nearly one-third of the guides finds its way directly to stroke patients and/or caregivers and more than two-thirds goes to providers. Since providers are calling stroke patients' attention to the guide to an increasing extent, the information for caregivers ought to be improved. Mainly young, slightly disabled male stroke patients with healthy caregivers returned the questionnaire. Both stroke patients and caregivers read the guide thoroughly; it clearly meets their need for information. In the future, distribution will have to be less selective.

The burden of caregiving in partners of long-term stroke survivors

BACKGROUND AND PURPOSE

Few data are available on the specific caregiving-related problems of stroke patients' caregivers and factors that influence the burden of these caregivers. The aim of this study was to describe the level and specific nature of the burden of caregiving as experienced by stroke patients' partners and to estimate the relative contribution of patient and partner characteristics to the presence of partners' burden.

METHODS

As part of a multicenter study on quality of care, burden of caregiving was assessed in 115 partners at 3 years after stroke. Explanatory factors of burden were studied in terms of (1) characteristics of patients (sociodemographic status, severity, type, and localization of stroke, disability, handicap, and unmet care demands) and (2) characteristics of partners (age, sex, disability, quality of life, loneliness, amount of care provided, and unmet care demands).

RESULTS

Partners of stroke patients perceived most caregiving burden in terms of feelings of heavy responsibility, uncertainty about patients' care needs, constant worries, restraints in social life, and feelings that patients rely on only their care. Multiple regression analysis revealed that a higher level of burden could partly be explained by patients' disability (R2 = 14%), but primarily by partners' characteristics in terms of emotional distress (R2 = 16%), loneliness (R2 = 6%), disability (R2 = 3%), amount of informal care provided (R2 = 2%), unmet demands for psychosocial care (R2 = 4%), and unmet demands for assistance in activities of daily living (R2 = 2%).

CONCLUSIONS

Higher levels of burden are primarily related to partners' emotional distress and less to the amount of care they provided, or to patients' characteristics. Sharing responsibilities, helping to clarify the patients' needs, and getting occasional relief of caregiving may be important in the support of caregivers.