Transition Experiences of Stroke Survivors Following Discharge Home

BACKGROUND

Little is known about the transition experiences of stroke survivors after discharge home.

PURPOSE

The purpose of this article is to describe three domains of psychosocial experiences of stroke survivors during the first month following discharge for acute stroke.

METHOD

Data were collected from 125 stroke survivors interviewed at 1 month following discharge home.

RESULTS

Findings indicate that changes in sense of self, connectedness with others, and community integration presented the major challenges.

Social isolation poststroke: relationship between race/ethnicity, depression, and functional independence

Research suggests that individuals recovering from a stroke often experience social isolation, which is linked to increased depressive symptomatology and decreased ability to manage activities of daily living. Research also indicates that different racial and ethnic groups are more adversely affected than whites. This article uses poststroke narratives to explore the relationship between social isolation, depressive symptomatology, and the ability to manage activities of daily living poststroke for white, African American, and Puerto Rican veterans. Findings suggest those who were socially isolated during the first year of poststroke recovery reported higher levels of depressive symptoms and a decreased ability to manage daily activities. Implications for stroke rehabilitation practice are discussed.

Patterns of informal care among Puerto Rican, African American, and white stroke survivors

BACKGROUND

There has been an increase in the number of non-institutionalized stroke survivors over the past few decades leading to larger numbers of family caregivers. Less is known about the patterns of informal caregiving within racially and ethnically diverse families even though there is greater post-stroke morbidity and mortality for these groups.

RESEARCH AIMS

The purpose of our research is to examine the informal caregiving networks of white, African American, and Puerto Rican caregivers.

METHODOLOGY

We examine data collected from 118 stroke survivors and caregivers to explore the dynamics of caregiving. Data are drawn from a diverse group of whites, African Americans, and Puerto Ricans living on the US Mainland and Puerto Rico at three different time points over the course of 12 months.

ANALYSIS

We examine the size, stability, change, and family dynamics of informal caregiving networks.

FINDINGS AND IMPLICATIONS

We find that whites, African Americans, and Puerto Ricans each have differing caregiving structures highlighted by expansion and contraction across time, size of network, and relationship to the stroke survivor. Greater cultural awareness among health professionals can lead to improved coordination of information or formal care services. These findings may also be used as a baseline for understanding the caregiving patterns of other Spanish-speaking Caribbean nations.

Association between health education needs and stroke caregiver injury

OBJECTIVE

Many stroke caregivers are inadequately informed about stroke and its sequelae and have little preparation for the physical demands of moving, lifting, and handling often required. Our objectives are to examine the association between health education needs and physical injury sustained as a result of activities related to the caregiving role.

METHOD

A total of 276 caregivers of veterans who suffered an acute stroke event were surveyed about their information needs and injury status.We used multivariate logistic regression analysis to calculate adjusted and unadjusted odds ratios for injury status.

RESULTS

Results indicate that in the adjusted model, caregivers who had increased educational needs were almost twice as likely (OR: 1.80; 95% CI: 1.74-1.94) to have incurred an injury related to caregiving activities.

CONCLUSIONS

Health education interventions that provide stroke caregivers with educational materials may help reduce caregiver injuries.

Consequences of poststroke falls: activity limitation, increased dependence, and the development of fear of falling

OBJECTIVES

We used qualitative data to explore the perceived consequences of poststroke falls during the first 6 months after discharge from the hospital.

METHOD

We interviewed 132 male stroke survivors 1 and 6 months after discharge to describe stroke recovery trajectories. Interviews of participants who discussed falling after stroke as one of their major concerns were analyzed to explore the consequences of poststroke falls.

RESULTS

During the first 6 months after stroke, 42 (32%) participants discussed poststroke falls. The results of the qualitative analysis indicate three important emergent themes related to the consequences of poststroke falls: (1) limiting activity and participation, (2) increasing dependence, and (3) developing a fear of falling.

CONCLUSION

Falls after discharge home were common in this group of stroke survivors. Future research is needed to better understand the impact of fall-related consequences and to explore strategies for fall prevention.

Racial/ethnic variation in recovery of motor function in stroke survivors: role of informal caregivers

Research documents that African American and Latinos who have experienced an acute stroke recover more slowly than Caucasians in the United States. This descriptive study examines (1) the variation in Caucasian, Puerto Rican, and African American motor function after stroke; (2) the association between caregiver attributes and motor recovery after stroke; and (3) the degree to which caregiver attributes explain the variation in motor recovery between different racial/ethnic groups. One hundred and thirty-five veterans who had been hospitalized after an acute stroke, released home, and identified an informal caregiver were enrolled in the study. Veterans and caregivers were surveyed at five time points over the course of 24 months. Results indicate that Puerto Ricans show greater impairment and African Americans show less impairment at discharge from the hospital compared with Caucasians. Caregiver characteristics mediate the racial/ethnic differences in impairment at discharge and motor recovery across time.

Informal caregivers and racial/ethnic variation in health service use of stroke survivors

We investigated the racial and ethnic variation in health service use among stroke survivors with informal caregivers in a number of Department of Veterans Affairs Medical Centers in one Veterans Integrated Service Network in the southeastern United States. We focused on the role of caregivers as an enabling factor in the use of health services. One hundred twenty-five veterans who had been hospitalized after an acute stroke, been released home, and identified an informal caregiver were enrolled in the study. Veterans and caregivers were surveyed at four time points over 12 months. Poisson multivariate regression analyses were used to model the relative risk (RR) of health service use. African Americans and Puerto Ricans were half as likely as Caucasians to use inpatient therapy services (RR = 0.522 and 0.494, respectively; p < 0.01), Puerto Ricans were less likely to be admitted to the hospital (RR = 0.689, p < 0.05), and Puerto Ricans were more likely to use outpatient services than Caucasians (RR = 1.230, p < 0.01). Stroke survivors that received more hours of informal care were associated with a higher likelihood of outpatient service use (RR = 1.01, p < 0.01). Stroke survivors living with their caregiver had a lower likelihood of inpatient therapy use (RR = 0.791, p < 0.01) and a higher likelihood of outpatient service use (RR = 1.17, p < 0.01). Greater likelihood of inpatient therapy (RR = 1.340, p < 0.01) and outpatient services (RR = 1.160, p < 0.05) was related to caregivers who received outside help. This study provides insight into the role of informal care in health service use for stroke survivors.

Communicating information to families of polytrauma patients: a narrative literature review

Family caregivers of U.S. servicemembers with polytraumatic injuries (injuries to multiple body systems) need support and information to care for their family members. Providing information to patients'families may reduce stress and increase coping abilities. Because the field of polytrauma research is new and evidence is lacking, providers rely on traumatic brain injury (TBI) research to guide their practice. This article presents a narrative literature review on the information needs of families of patients with TBI. It summarizes the types of needed information, the most appropriate time to provide information, and the best approaches for providing information. Future research on information needs is critical if polytrauma rehabilitation providers are to effectively support families in their caregiving roles. Such research likely will benefit caregivers of patients with polytrauma who acquire their injuries as civilians, as well. Research gaps are identified with regard to the information needs of families of patients with TBI; these gaps also are applicable to polytrauma caregivers. Additional research areas are highlighted in light of the new polytrauma population.

Fear of falling: an emerging issue after stroke

PURPOSE

Qualitative data regarding stroke survivors' recovery experiences were used to describe factors important in the development of fear of falling (FoF) during the first 6 months after stroke.

METHOD

Stroke survivors were interviewed 1 and 6 months after stroke to obtain data on their experiences related to stroke recovery trajectory. Analyses identified FoF as a naturally occurring part of stroke survivors' descriptions of their everyday lives. Interviews were reexamined to identify and describe personal experiences related to FoF in this population.

RESULTS

Forty-two (32%) veterans who participated in the larger study discussed FoF during the first 6 months after stroke. Analyses indicate three important factors may be associated with the development of poststroke FoF: (a) the initial fall coinciding with stroke onset, (b) perception of poststroke body changes, and (c) a pervasive everyday fear of future falls.

CONCLUSION

These factors related to FoF need to be further studied in the poststroke population. It is possible that individualized interventions may be necessary to assist stroke survivors to manage FoF, decrease fear, and reduce falls after discharge home poststroke.

Why ethnic designation matters for stroke rehabilitation: comparing VA administrative data and clinical records

Using existing administrative data to look at issues of ethnic disparities in rehabilitation-related outcomes may lead to misleading results. Problems can emerge from apparently small issues of reliability that are magnified by reclassification of ethnic designation and missing data in complete-subject analyses. We compared the reliability of ethnic assignment in Department of Veterans Affairs (VA) medical rehabilitation records for stroke patients with administrative records; reclassified the racial identifier from the administrative data in two ways; and examined the different sources of ethnic information in relation to severity, length-of-stay, disability assessment, and discharge disposition. Our results show how small changes increase the potential for Type II error when describing ethnic differences in outcomes or using ethnicity as a predictor with dichotomous response variables. We discuss our results with reference to the literature on ethnic classification and underline the importance of initiatives for improved data collection on ethnicity in VA data sources and in rehabilitation research.

Metaphor shifts in stroke recovery

An illness event like stroke is generally believed to produce a biographical disruption in the individual, resulting in a reconstruction of one's self identity. One method of narrative reconstruction is the use of personal metaphor. Although previous research has illustrated a variety of illness metaphors, including that of war, there has been little research conducted on how these metaphors shift throughout a person's recovery period. The authors present data that indicate an intricate connection exists among changes in individuals' physical functioning, self-reported depression level, self-identity, and the metaphors they use to describe the stroke and stroke recovery experience. As the metaphor one uses to describe one's stroke experience shifts, so does one's sense of self. As one's self-identity changes, one's level of self-reported depression may also increase.

Constructing the stroke: sudden-onset narratives of stroke survivors

In this article, the authors explore the narrative production of stroke from the perspectives of survivors, that is, the stroke itself, not its implications for the individual poststroke. In the vast amount of literature on both sudden onset and chronic illness, the narrative construction of the onset of the illness, for the most part, has been ignored by social scientists, most notably in qualitative research. This is certainly true of stroke. Drawing on existing literature in both chronic illness and the body, the authors extend this to explore the phenomenological construction of stroke onset. Using data gathered from in-depth interviews with 111 stroke survivors postdischarge, they suggest three narrative mechanisms are used in the construct of the sudden-onset event itself: the use of typifications to construct the body during stroke, stroke as an internal communicative act, and stroke as a physical sensation and the mechanisms used to minimize bodily concerns.

The social organization in constraint-induced movement therapy

Ethnographic data were collected at two rehabilitation facilities conducting ongoing research to evaluate functional and neurological outcomes of constraint-induced movement therapy (CIMT). Our findings indicate that several patterns of behavior occur during participant/therapist interaction in therapy sessions: coaching, cheerleading, reminding, changing, and contemplating. These interaction patterns indicate that learned nonuse of an affected limb does not exist in social isolation and that people who participate in CIMT routinely consider the balance of any improvement against the costs of using an affected limb that is still not fully functional. These patterns of social interaction that occur during therapy--which often influence a participant's hope for future physical progress--are an important part of CIMT that may not be fully acknowledged in the clinical training of therapists.

The sense of coherence, burden, and depressive symptoms in informal caregivers during the first month after stroke

BACKGROUND

Individuals with a strong sense of coherence (SOC), which considers one's ability to respond to stressors by the appropriate use of adaptive coping resources, can avoid breakdown when confronted with stress. This study examined the associations between SOC, perceived burden (caregiver's perception of the effect of caregiving-related stress) and depressive symptoms of informal caregivers (family members and involved friends) of stroke survivors one-month after the stroke.

METHODS

One-hundred and four ethnically diverse veterans who were hospitalized after experiencing an acute stroke and their informal caregivers were enrolled in the study prior to discharge. One-month after being discharged from one of five Veterans Affairs Medical Centers in Florida and Puerto Rico, comprehensive data was collected and analyzed.

RESULTS

Multiple regression analyses showed that greater SOC was associated with both lower burden (p < 0.0001) and fewer depressive symptoms (p < 0.0001). Higher caregiver burden, in turn, was significantly associated with more depressive symptoms (p = 0.003). However, when depressive symptoms was regressed on both SOC and burden jointly, the previously significant association between burden and depressive symptoms was no longer significant (p = 0.80) and SOC was still strongly associated with fewer depressive symptoms (p < 0.0001).

CONCLUSIONS

Determining factors that may lessen burden and depressive symptoms for caregivers of stroke survivors during the transition period after discharge to their residence are imperative for developing successful interventions. SOC appears to be an important response in alleviating the levels of perceived burden and especially in depressive symptoms.

Sudden illness and biographical flow in narratives of stroke recovery

The conceptual framework of biographical disruption has dominated studies into the everyday experience of chronic illness. Biographical disruption assumes that the illness presents the person with an intense crisis, regardless of other mitigating factors. However, our data suggests that the lives of people who have a particular illness that is notably marked by sudden onset are not inevitably disrupted. Extensive qualitative interviews were conducted with a sample of veteran non-Hispanic white, African-American, and Puerto Rican Hispanic stroke survivors, at one month, six months and twelve months after being discharged home from hospital. Narrative excerpts are presented to describe specific discursive resources these people use that offset the disrupting connotations of stroke. Our findings suggest a biographical flow more than a biographical disruption to specific chronic illnesses once certain social indicators such as age, other health concerns and previous knowledge of the illness experience, are taken into account. This difference in biographical construction of the lived self has been largely ignored in the literature. Treating all survivor experiences as universal glosses over some important aspects of the survival experience, resulting in poorly designed interventions, and in turn, low outcomes for particular people.

The experience of time in the transition from hospital to home following stroke

This paper reports findings related to the transition from hospital to home during the first month after discharge following acute stroke. Qualitative data were obtained from in-depth, semistructured interviews with 51 male stroke survivors and their caregivers. Data were analyzed with the N6 software application, designed to assist with qualitative data analysis. Stroke survivors described experiences related to changes in the temporal order of life, disruptions in sense of self, and strategies used to manage time. Findings indicate that changes in the temporal order of life are related to functional impairments and disruption in the taken-for-granted body. At 1 month post-discharge, survivors are struggling with establishing routines in their day and coping with an increased amount of idle time. In conclusion, strategies for managing increased idle time are "passing time," "waiting on time," and "killing time."

Outcomes from stroke rehabilitation in Veterans Affairs rehabilitation units: detecting and correcting for selection bias

This paper addresses the issue of statistical selection bias in multivariate models of functional gain estimated from observational data. Stroke patients from 20 high-volume Veterans Affairs Medical Centers (VAMCs) with acute and subacute inpatient rehabilitation treatment units were observed. Their gains in overall, motor, and cognitive functional status were measured with the use of the Functional Independence Measure (FIM). In estimating multivariate models of FIM gain during rehabilitation using these observational data, we found statistically significant evidence of selection bias, along with considerable differences in inferences between standard multivariate analyses and our selectivity-corrected models. Our results demonstrate the importance of detecting and correcting for statistical selection bias when one uses nonexperimental data to study gains in functional status.

The hazards of stroke case selection using administrative data

BACKGROUND

Administrative data and ICD-9-CM diagnostic codes are frequently used in research efforts to evaluate risk adjusted patient outcomes, particularly mortality. Varying ICD-9-CM sampling algorithms have been used to identify stroke patients.

OBJECTIVES

This study evaluates the effects of different sampling strategies (one high sensitivity and one high specificity) on modeling stroke mortality as a performance indicator.

RESEARCH DESIGN

Risk adjustment models were developed for two stroke cohorts identified using differing ICD-9-CM algorithms. Standard mortality ratios were calculated in a validation sample as network performance measures and compared across the two stroke samples.

SUBJECTS

VHA inpatients with stroke during years 1997 (model development) and 1998 (model validation) were selected from the Patient Treatment File based on cerebrovascular diagnostic codes.

MEASURES

Patient mortality within 30 days of admission.

RESULTS

The model development and validation for each stroke sampling method produced consistent results: c-statistics 0.74 to 0.75, R2 0.07 to 0.09, concordance 73% to 74%. However, ranking differences in network performance varied by 5 or more positions for 7 of the 22 patient networks.

CONCLUSIONS

These findings highlight a potential problem when using administrative data to assess stroke mortality. In the absence of an agreed upon definition of stroke patients, results of provider profiling will vary depending on the ICD-9 algorithm used.

Phenomenological study of nurses caring for dying patients

Little is known about how nurses experience caring for dying patients. Yet, entering the patient's world often involves dealing with death and dying and is a major challenge to oncology nurses. The purpose of this article is to describe the shared practices of oncology nurses caring for dying patients. Stories from staff nurses on an oncology unit were analyzed using a hermeneutic method to identify and describe four themes: knowing the patient, preserving hope, easing the struggle, and providing for privacy. The four themes contribute to knowledge development about how nurses enter into and experience caring for dying patients. The growing body of knowledge previously reported has included descriptions of critical behaviors in caring for dying patients, coping strategies nurses used when caring for dying patients and their families, and the meaning of oncology nursing practice. The four themes described in this article expand our understanding of the nurses' experience in caring for dying patients.

Strike-through contamination in saturated sterile dressings: a clinical analysis

This multisite study examined the risk of strike-through contamination of 4" x 4" gauze sponges using a shortcut method of saturating sterile sponges directly on their wrappers. Sterile gauze sponges were saturated directly on their wrappers on hospital over-bed tables of postoperative general surgical patients. Cultures were taken at 0.5, 1, 3, and 5 minutes after saturation to ascertain whether strike-through contamination occurred. Saturated sponges showed significant microorganism growth when compared to expected zero microorganisms at all sampling times following saturation. Although microorganisms identified in strike-through contamination were not microbiologically or pathogenically threatening, the basic principle of asepsis was violated. There was no significant difference in strike-through contamination between sponges saturated on coated wrappers and sponges saturated on uncoated wrappers. Clinicians should be aware that coated wrappers do not provide a moisture-proof barrier against strike-through contamination. The findings suggest the shortcut method should not be used for saturating sponges.

Living with renal failure

In this interpretive study, the experience of patients living with chronic renal failure was studied. Within the framework of Heideggerian phenomenology, a hermeneutic analysis revealed three themes and one constitutive pattern. The three themes were: taking on a new understanding of Being, maintaining hope and dwelling in dialysis. The constitutive pattern was "

CONTROL

The Meaning of Technology." The findings provide an understanding of living with renal failure that argues against the traditional understanding of noncompliant behaviors. The study makes visible the meaning of technology in the lives of renal patients and highlights the need for nurses to sustain meaningful human connections with patients.

Social Organization of Length of Stay of Psychiatric Patients

1. Length of stay (LOS) is the major factor determining the use of resources in hospitals and is the primary component in reducing hospital costs. However, relatively little is known about the anatomy of the hospital stay. 2. The stage model of treatment is used to examine the LOS of psychiatric patients. The model assumes the patient is admitted to the hospital, undergoes testing or observation to verify a diagnosis or establish a new diagnosis, and then proceeds to therapy, recovery, and discharge. 3. In practice, the treatment process does not follow a stage model, but is much more complicated. Various kinds of information are revealed throughout the course of hospitalization and treatment continues as events unfold. Diagnosis, therapy, and recovery occur in a dialectical process constantly being reconstructed as it is informed by interpretations of everyday events.

Investigation of a staphylococcal food poisoning outbreak in a centralized school lunch program

The trend in many communities toward centralized school lunch preparation potentially increases the risk of foodborne illness. Foods often are prepared long before serving and may be distributed to satellite schools by persons with little formal training in safe techniques of food preparation or food service. In May 1990, an outbreak of staphylococcal food poisoning occurred in elementary schools in a Rhode Island community participating in such a program. In the investigation of the outbreak, students in schools that reported cases were interviewed. Food preparation, handling, and distribution were reviewed. At School E, 662 lunches were prepared and distributed to 4 additional schools (schools A-D). Schools A and B accounted for nearly all cases of the food poisoning, with rates of 47 percent and 18 percent. Eating ham increased the risk of illness (62 percent of those consuming ham and 3 percent of those who did not, relative risk = 18.0, 95 percent confidence interval = 4.0, 313.4). Large amounts of Staphylococcus aureus were cultured, and preformed enterotoxin A was identified in leftover ham. A food handler, who tested positive for the implicated enterotoxic strain S. aureus, reported having removed the casings from two of nine warm ham rolls 48 hours prior to service. Because of improper refrigeration, prolonged handling, and inadequate reheating, the ham was held at temperatures estimated at 10-49 degrees Celsius (50-120 degrees Fahrenheit) for a minimum of 15 hours. The potential for larger outbreaks prompted a statewide training program in safe food preparation for school lunch personnel, which may have applications for other communities.