Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring

Purpose. To examine the support required by family carers for stroke survivors.

Methods. Forty-two family carers were recruited for surveys of needs, knowledge, satisfaction, and competence in caring before and 4 - 6 weeks after discharge from an Acute Stroke Unit (ASU).

Results. Information deficits about dealing with psychological, emotional, and behavioural problems and local service information were priorities before and after discharge. Younger female carers (under 56 years) were least satisfied with communication with ASU staff. Face to face contact was valued. After discharge younger female carers, particularly of non-White ethnic groups, reported lower levels of competence in caring and higher burden. Knowledge of stroke risk factors was low in all groups. High satisfaction with treatment and therapy in the ASU, was not transferred to the community. Carers reported feeling alone and described uncoordinated services.

Conclusions. Carers are able to anticipate and prioritise their needs, value communication with staff and involvement with discharge-planning, but particular difficulties were experienced by younger female carers and those from non-White ethnic groups. This requires particular attention when developing targeted interventions for family carers from a mixed ethnic community. In-depth and longitudinal studies are needed to detail psychosocial needs and guide practice particularly amongst non-White family carers.     

Chinese elderly patients' perceptions of their rehabilitation needs following a stroke

Stroke is the third leading cause of death and disability among Chinese elderly patients in Hong Kong and yet the rehabilitation needs of these patients are rarely explored. The aim of this study was to identify the rehabilitation needs of Chinese elderly patients following a stroke. The study adopted an ethnographic approach, information being gathered by the researcher through interviews with 15 key informants selected by purposive sampling. The perceptions of patients as to their own needs were sought at three stages of recovery - in the acute and rehabilitation settings and at 1 month following discharge. Ethical approval was gained from the Chinese University Faculty of Medicine ethical committee and access agreed by the hospital authorities. Verbal approval was gained from the patients before each interview, following confirmation of the voluntary nature of participation and assurance of confidentiality and anonymity. The researcher's role was also clearly stated. Analysis of the interview data produced five categories of patient need at the three stages of recovery, namely informational, physical, psychological, social and spiritual. The most frequently stated, but largely unmet, need in all settings was the need for information, particularly information about the reasons for stroke and about the activities that promote recovery. In the acute and rehabilitation settings patients' responses indicated a need to be respected as individuals, to be addressed by name and to be provided with privacy. Although the Barthel Index administered during interviews charted recovery at different rates, nurses did not always make links between the level of functional ability and the help needed with physical tasks. They also failed to recognize the relationship between physical and psychological needs and the equal importance of both in recovery from stroke. As Chinese elderly patients tend to take a passive role in seeking help and information, nurses play a significant role in the identification of individual rehabilitation needs. Implications for nursing practice are discussed.     

Exploration of patients' needs for information on arrival at a geriatric and rehabilitation unit

Aim. The aim of this study was to gather information about patients’ needs prior to transferring from an acute care facility to a rehabilitation setting that could assist patients to engage actively in rehabilitation activities upon entering the unit. Background. The provision of information is an important aspect of health care as it assists patients to become informed and actively participate in this care. Improved recovery has been associated with patients’ adherence to care regimes. Method. Semi‐structured interviews were undertaken with a convenient sample of nine patients shortly after admission/transfer to a rehabilitation unit and with four of these patients after discharge. The intent was to learn what information patients receive prior to admission to the rehabilitation unit, whether this information is useful and whether different information would be more useful to facilitate patients’ engagement in the activities central to rehabilitation treatment. Results. Interviews revealed that, generally, patients received very little information about what to expect on admission to the rehabilitation unit and patients’ engagement was more dependent on perceptions about rehabilitation. Thematic analysis identified that, in general, rehabilitation was perceived as ‘a ticket out’ and ‘a good thing’. In relation to provision of information of participants identified that ‘doesn't matter that I don't know’; ‘information is not always meaningful’ and ‘I will adjust in my own time’. Relevance to clinical practice. Health professionals need to recognize that patients are often compliant with decisions made while they are inpatients of the current health care system. Even though patients may ‘actively participate’ in rehabilitation processes it is often still as a passive recipient of health care.     

脑卒中后失语症患者口语功能障碍的家庭康复治疗

目的 :观察口语功能障碍家庭康复治疗的疗效 ,探讨以家庭口语功能康复治疗为主的模式是否有效。方法 :按照配对因素共选择脑血管意外后失语症患者 18对 ,并根据随机化的原则分配至康复组和对照组。用前瞻性研究方法对两组进行比较分析。对照组患者让其口语功能自然变化。康复组的患者在医师的定期指导下 ,由患者家属对其进行口语功能康复训练。在发病后 6个月和 12个月 ,两组患者重新进行口语功能的评估。结果 :对照组患者口语功能有一定程度的自然改善。康复组患者口语功能有显著的改善。无论是在发病后 6个月还是 12个月时 ,康复组患者口语功能的改善程度明显比对照组高。结论 :作为成本低、患者负担得起的治疗方法 ,家庭口语康复治疗是一种患者依从性高、效益好的有效模式     

Towards rehabilitative handling in caring for patients following stroke: a participatory action research project

Aim of the study. This study aimed to facilitate nurses to take ownership of their moving and handling practice. Objectives. To (i) facilitate nurses in sharing their insights in moving and handling patients following stroke, (ii) enable nurses to identify facilitators of safer moving and handling practice, and (iii) empower nurses in collaboration with physiotherapists to direct changes in their practice. Background. Traditional top down moving and handling training has had variable impact on nursing practice. A moving and handling incident in a stroke unit demonstrated that there were professional development needs for staff in the stroke unit in relation to their moving and handling practice in the care of patients following stroke. Methods. An insider participatory action research approach was utilized. Data were analysed from focus group meetings, brainstorming sessions, observational studies, and from written reflective accounts. Findings. Peer pressure, communication, rehabilitative handling awareness, teamwork between nurses and physiotherapists, equipment and environmental issues were affecting moving and handling practice. Nurses identified that equipment, environment, communication and teamwork strategies would facilitate them in using rehabilitative moving and handling practice. Nurses in collaboration with physiotherapists directed changes in their practice. Participant staff members felt involved and valued, and reported changes in understanding, in their handling practice, and enhanced teamwork. Conclusion. Participatory action research creates a supportive environment, where those directly involved in moving and handling patients can investigate and direct changes in their practice. Thus it is a significant vehicle for delivering professional development in moving and handling practice. Relevance to clinical practice. Professional development initiatives in moving and handling practice must incorporate processes that enhance inter‐disciplinary teamwork and value and utilize the views and experiences of the staff who move and handle patients.     

二级综合医院脑卒中患者早期康复治疗现状及影响因素分析

目的：了解脑卒中患者接受早期康复治疗的现状,并分析探索人口社会学、经济、医疗保障、认知因素对患者接受早期康复服务治疗的影响。方法：自行设计调查问卷,选取国内2家提供康复治疗服务的综合医疗机构,对正在接受康复治疗服务的229例脑卒中患者进行问卷调查。结果：89．1％正在接受康复治疗的脑卒中患者在急性期住院时接受过早期康复治疗;不同居住地、医疗保险类型、费用支付方式、收入来源的患者,以及对制定康复治疗方案的方式有不同认识的患者,在脑卒中发作急性住院期是否接受早期康复治疗有明显差异。结论：综合医疗服务机构给予脑卒中患者早期康复治疗的模式有待改善;经济收入、医疗保障和认知态度因素是影响脑卒中患者接受早期康复治疗的重要因素。     

急性脑卒中偏瘫患者早期康复介入与并发症关系的临床研究

目的探讨急性脑卒中偏瘫患者早期康复介入与并发症的关系。方法选取2008年4月至2011年12月急性脑卒中患者患者220例,分为研究组和对照组,并分别评定治疗第1天、第14天及第28天的肢体运动功能(Fugl-Meyer)以及Barthel指数(BI)分数。两组患者均进行常规治疗,研究组同时给予康复训练。分析早期康复介入与临床运动功能评分、日常生活活动能力、并发症的关系。结果研究组Fugl-Meyer以及BI分数在第14天和第28天与对照组比较明显提高,差异有统计学意义(P<0.05)。研究组在第1天,第14天,第28天运动功能Fugl-Meyer评分与同时期ADL的BI评分有相关性(r值分别为0.59、0.63和0.58,P<0.01)。研究组与对照组比较并发症(呼吸道感染、泌尿系感染)较少,差异有统计学意义(P<0.05)。结论早期的康复介入能够促进偏瘫患者肢体功能的恢复,提高日常生活活动能力。接受早期的康复介入能够明显减少并发症的发生。未接受康复治疗的患者运动功能恢复慢,而且易患并发症。     

Perceptions related to time in a qualitative study of informal carers of terminally ill cancer patients

? Caring for a terminally ill relative is a complex, time-consuming experience. ? Demands on carers' time stem from a variety of sources, notably the practical and emotional work they must perform. ? Carers should be helped to plan their time effectively. ? Carers need to come to terms with their perceptions about past, present and future. ? Achieving some sense of equilibrium in the caring role is important. ? Professionals working with families experiencing terminal illness have a duty to assess each family individually in order to provide appropriate help and support.     

Need for appropriate written information for patients,with particular reference to head and neck cancer

Patients need and want written information. There is evidence that giving comprehensible information increases overall satisfaction with the care given by healthcare professionals. This paper provides a review of the literature on patients' need for appropriate information, with particular reference to head and neck cancer, based on searches of electronic databases. Head and neck cancers are among the least common cancers in the UK but these patients have very specific and great needs. Written information is a cost-effective intervention that complements verbal advice given by healthcare professionals. Evidence suggests that patient information leaflets are poor and are in language that is difficult for the public to understand. Considerable time, effort and user involvement are required to produce acceptable and appropriate information leaflets for patients.     

Dose–response relationship between physiotherapy resource provision with function and balance improvements in patients following stroke: a multi‐centre observational study

Rationale, aims and objectives Inpatient rehabilitation of patients following stroke can be resource intensive, with optimal models of service delivery unclear. This study investigates the dose–response curves between physiotherapy service delivery variables and balance and function clinical outcomes. Method This was a multi‐centre (15 sites), prospective, cohort study involving patients (n = 288) admitted for rehabilitation following stroke conducted across two states in Australia. Physiotherapy department resource provision variables were collected and examined for association with change in patient function and balance outcomes (Functional Independence Measure, step test, functional reach test) measured at admission and discharge from inpatient care. Results A greater amount of log‐transformed physiotherapy department resource provision was associated with greater improvement in the functional independence measure [Regression coefficient (95% CI): 4.05 (1.15, 6.95)] and functional reach test [46.43 (17.03, 75.84)], while physiotherapist time provided to patients was associated with greater improvement for the step test [0.15 (0.03, 0.28)], and functional reach [0.35 (0.19, 0.52)]. Conclusion Receiving a higher rate of physiotherapist input is an important factor in attaining a greater amount of recovery in function and balance outcomes; however, the improvement by patients who received the greatest amount of input was highly variable.     

Evaluating a community‐based stroke nursing education and rehabilitation programme for patients with mild stroke

This study evaluated whether mild stroke patients who received a community‐based stroke nursing intervention had better stroke knowledge, behaviour and self‐efficacy than those who were exposed to traditional education programmes. The intervention group consisted of sixty five stroke patients randomly selected from seven communities who received three 2‐hour stroke interventions per week for 8 weeks. The normal care group consisted of sixty two stroke patients randomly selected from a medical centre who received a general stroke education programme. The stroke patients in two groups were assessed at baseline, after intervention and at the 6‐month follow‐up. At the 6‐month follow‐up, the intervention group demonstrated an improvement in the knowledge of stroke risk factors compared with the normal care group. Three months after education, the intervention group exhibited changes in the knowledge of stroke, social participation and self‐efficacy compared with those at baseline. Also, self‐efficacy was correlated with the knowledge of stroke risk factors after intervention and at the 6‐month follow‐up; self‐efficacy was correlated with social participation after the 6‐month follow‐up. A community‐based stroke nursing intervention might have effects on changes in the knowledge of stroke risk factors, social participation and self‐efficacy.     

脑卒中急性期血压的变化规律及肢体运动前后血压变化

目的：监测脑卒中急性期患者血压变化规律, 观察急性脑梗死患者肢体运动前后血压变化的幅度。方法：随机选择脑卒中急性期患者148例, 分为两组,其中，脑梗死组102例，脑出血组46例。观察急性期两组患者的血压变化，测量102例急性脑梗死患者右侧肱动脉血压，床边肢体松动运动前测量1次,运动后即5、10、15min各测量1次。结果：脑卒中急性期血压增高者占86.5%，以后在无特殊降压措施并且不用对血压有影响的药物条件下，血压随时间逐渐下降。第7天与第1天比较,收缩压(SBP)及舒张压(DBP)均有明显下降[SBP(145.6±16.3)vs(157.1±22.5) mmHg (P<0.01);DBP(84.7±15.2)vs(89.8±21.2)mmHg(P<0.01) ];脑出血组动态血压均高于脑梗死组。[SBP(159.7±19.8)vs(154.7±23.4)mmHg；DBP(96.2±13.1)vs(91.3±17.5)mmHg (P<0.01)]。 86%的脑卒中患者血压的昼夜节律消失。脑梗死组床边肢体松动运动前后血压比较，差异无显著性(P>0.05)。结论：脑梗死急性期患者血压增高, 血压有自发下降的趋势；脑出血患者血压水平比脑梗死者高；绝大多数脑卒中患者血压的昼夜节律消失；脑梗死患者床边肢体松动运动前后的血压比较差异无显著性。     

Meeting the psychological needs of community-living stroke patients and carers: a study of third sector provision

Purpose: To elucidate how community stroke staff in a major third sector organisation experienced their role and understood and responded to clients’ psychological needs. Method: In stage 1, three focus groups of 28 staff in total were recorded, transcribed and analysed using inductive thematic analysis. Themes were authenticated by new staff groups. In stage 2, these themes informed the construction of a questionnaire delivered through the organisation’s intranet by “Survey Monkey”. Results: Five themes emerged from the focus groups: background and context; perceptions of clients’ psychological issues; approaches to meeting psychological needs; the experience of working with psychological needs and sources of support; aspirations for future development. Four themes were used in constructing the questionnaire. Responses from 144 staff with diverse qualifications and experience were received; over half encountered 16 (of 35) psychological issues at least once per week. Stroke survivors’ needs predominated over carers’ needs. Skills used to address psychological problems were identified, also training and support needs and future aspirations. Support needs included information, training and access to specialist consultants. Conclusions: Psychological issues were central in the work of third sector community stroke staff; psychological skills were routinely used. Attention to means of supporting and developing these skills is required.

• Implications for Rehabilitation

• Service leaders and commissioners should be aware that third sector community stroke staff frequently deal with a diverse range of psychological issues and perceive psychological care as central.

• Service leaders should consider providing training in assessment and management of mood and cognition, risk assessment and management and basic counselling.

• Staff should be provided with access to specialist consultation and better information about psychological aspects of referrals.

• There is uncertainty about key methods for supporting the delivery of psychological care (supervision, mentoring and peer support) which requires consideration.

     

Combined somatosensory and motor training to improve upper limb function following stroke: a systematic scoping review

Purpose: The purpose of this systematic scoping review was to (1) identify combined somatosensory and motor training interventions for the upper limb and their training components, and (2) review the efficacy of the combined interventions.

Methods: Participants were adults post-stroke with somatosensory and/or movement deficits in the upper limb. All studies with interventions combining somatosensory and motor training and targeting the affected upper limb were included. Outcome measures were assessments of somatosensory and/or motor impairment and upper limb function.

Results: Ten studies (n?=?219) were included, comprising three randomized controlled trials, two pre-post studies with non-randomized comparison groups, three single-case experimental studies, and two case reports. There was heterogeneity across studies with regards to intervention contents and dosage, participant characteristics, and outcome measures. The interventions included combinations of tactile stimulation/discrimination, proprioceptive stimulation/discrimination, haptic object discrimination/recognition, movement training, and functional training. Only one group study, a non-randomized controlled study with multiple active components and the largest dose of treatment, found significant improvements in fine motor and somatosensory measures. Some improvements were found in case studies.

Conclusion: There was little consistency across ‘combined somatosensory and motor training’ interventions and few have been rigorously tested for efficacy across somatosensory, motor and functional outcomes.     

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as ‘the sick role’ and the labelling of patients as ‘good’ or ‘bad’. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources - especially suitably qualified and trained nursing staff- are a negative influence on building the relationships which are vital to successful rehabilitation.     

Rehabilitation nurses practices in relation to urinary incontinence following stroke: a cross‐cultural comparison

Aim. To explore nurses’ practices and influences in relation to urinary incontinence following stroke, in the UK, Sweden and China. Background. Urinary incontinence following stroke is common, under‐recognised and poorly researched. Before appropriate rehabilitation interventions can be developed, an understanding of nurses’ current management approaches and cultural influences is required. Design. Qualitative. Methods. Semi‐structured interviews were undertaken with ten registered nurses from at least four different stroke units in three countries (n = 30). Interviews were carried out in the participants’ first language, using an agreed interview guide. Following translation, thematic analysis focusing on manifest meaning was undertaken, using an iterative approach involving electronic and face‐to‐face discussions. Results. The consequence of only superficial assessment was no systematic identification of types or causes of urinary incontinence and no individualised plans developed. A process model of practice, common to all three countries, was identified for stroke survivors with urinary incontinence. Routine core activities were followed by the palliative pathway (most frequently), where urinary incontinence was contained to protect the stroke survivors’ safety and ensure social continence; or the rehabilitative route (more rarely), where simple continence promoting activities were implemented with the purpose of facilitating recovery of bladder function. Conclusions. Nurses’ reactively manage urinary incontinence following stroke, adopting a routinised approach based on local custom and practice. Promotion of urinary continence is not a priority area of stroke rehabilitation for nurses in western or eastern countries. Relevance to clinical practice. The dearth of evidence‐based interventions available to rehabilitate bladder function following stroke means that stroke nursing practice is an experience‐based endeavour. This study explains the nurses’ focus on containment and social continence and highlights the need to systematically assess stroke survivors’ bladder rehabilitation needs, identify types of urinary incontinence and adopt appropriate urinary continence promoting practices.     

Efficient screening of cognitive dysfunction in stroke patients: Comparison between the CAMCOG and the R-CAMCOG,Mini Mental State Examination and Functional Independence Measure-cognition score

Background. The CAMCOG is a valid screening instrument for cognitive dysfunction in stroke patients but too time-consuming to be used by physicians in acute or post-acute care settings. The aim of this study was to identify a shorter cognitive screening test or combination of tests that yields the same results as the CAMCOG.

Methods. A total of 169 stroke patients completed the CAMCOG and the abbreviated Rotterdam-CAMCOG (R-CAMCOG), Mini Mental State Examination (MMSE) and the cognitive part of the Functional Independence Measure (FIM cognition) after admission to clinical rehabilitation and 1 year after stroke. The CAMCOG score was used as criterion standard for validity.

Results. Spearman correlations with the CAMCOG were very strong for the R-CAMCOG (both 0.92), strong for the MMSE (0.66 and 0.69) and moderate to weak for the FIM cognition (0.35 and 0.27). Stepwise linear regression analyses showed that, at admission, the R-CAMCOG explained 83% of the variance in the CAMCOG. The MMSE and R-CAMCOG together explained 87%. At 1 year after stroke the correlations and explained variances were similar.

Conclusion. The recently constructed R-CAMCOG appears an efficient alternative for the CAMCOG as a screening tool for cognitive dysfunction of stroke patients.