Understanding nursing practice in stroke units: a Q-methodological study

Abstract

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.

• Implications for Rehabilitation

• Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.

• Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.

• Nurses can routinely incorporate rehabilitation principles in their care.

• Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

     

Exploring the role of the district nurse in rehabilitation

This article reviews the available literature to examine the district nurse's contribution to rehabilitation of the older patient in the community. It is argued that policy and demographic changes indicate that there is a demand for nursing care in the home that enables individuals and their carers to live with chronic health problems and develop strategies that maintain and improve their health. The ways in which district nurses incorporate an understanding of patient rehabilitation within their work is discusses. It is suggested that although there is an expectation that district nurses can and should be involved in planning and supporting rehabilitation for their patients, the process is often poorly defined, hampered by contextual problems and dependent on the cooperation and support of others. Furthermore, in specific areas of care such as cardiac rehabilitation and services for those recovering from stroke, there would appear to be an increase in specialist nurses who either undertake or coordinate the rehabilitation process for patients. This raises questions regarding how district nurses should develop their skills in rehabilitation and what strategies could be adopted to develop patterns of work that ensure collaboration and development rather than overlap and duplication.     

The role of the nurse within the multi-professional rehabilitation team

AIM OF THE STUDY/PAPER: To identify the contribution of the nurse within the multi-professional rehabilitation team. BACKGROUND: The requirement for nurses to work effectively within the multi-professional rehabilitation team is increasingly important with the higher incidence of chronic disease, growing numbers of older people and enhanced survival from major trauma. METHODS: A 2-year qualitative investigation was undertaken centred on three contrasting condition case studies (fractured neck of femur, rheumatoid arthritis and stroke). Clients were theoretically sampled, with their 'rehabilitation pathway' through different services providing the window through which the nurse's contribution was explored. Multiple methods and points of data collection were used, including observation, face to face interviews (clients, carers and staff) and record review. To enhance generalisability, a series of national expert workshops were undertaken with four groups: users, carers and carers' organizations; nurses; members of the multi-professional team; and educationalists. FINDINGS: Six interlinked roles for the nurse were identified: assessment, co-ordination and communication, technical and physical care, therapy integration and therapy carry-on, emotional support, and involving the family. Of particular significance is the creation of a supportive environment for rehabilitation to occur. Some nurses undertook aspects of all of these roles at any one time while others were only involved in one or two areas. While nurses expressed a desire to integrate therapy into their care delivery, the actual achievement of this goal was variable. CONCLUSIONS: Key elements of the nurse's contribution within rehabilitation should aim to maximize client choice to enhance independent living in the client's future environment. At a nursing educational policy level the nurse needs to have a full understanding of the principles and models of rehabilitation. At a practice level, the nurse's role must be valued and recognized, by nurses themselves and other team members.     

Nurses Create a Rehabilitative Milieu

Despite the recognition of milieu therapy as a nursing intervention, nursing's contribution to the creation of inpatient environments that facilitate patient rehabilitation has been underresearched. A large study conducted in five inpatient rehabilitation units in Australia that sought to develop a grounded theory of nursing's contribution to inpatient rehabilitation has begun to address this gap in the literature. Analysis of data collected from 53 nurses during interviews and observations of their everyday practice revealed that nurses act purposefully to create a milieu conducive to rehabilitation. In doing so, they target all patients using a range of strategies that include allowing time, keeping patients' spirits up, protecting patients from embarrassment, and making hospitals more homelike than is typically experienced in acute‐care environments. As a consequence, rehabilitative milieu therapy is proposed as a subset of milieu therapy.     

Perceptions of the nursing role in spinal cord injury rehabilitation

In the UK, over the last 50 years there have been many developments in the rehabilitation of spinal cord-injured people leading to improvements in outcomes. In spinal cord injury rehabilitation nurses work as members of a multiprofessional team but their role is not clearly defined and, unlike other professionals, they have a 24-hour relationship with patients. This article presents some findings from a larger ongoing ethnographic research study. The aim of this section of the study was to identify how nurses and patients perceive the nursing role in spinal cord injury rehabilitation. Semistructured interviews were carried out with 14 spinal cord-injured patients and 14 registered nurses. The findings suggest that patients value the nursing contribution as a means of emotional and physical support but that they do not necessarily see nursing input as rehabilitation. Nurses see their role as multifaceted but identify difficulties in crossing over from an acute care philosophy to a rehabilitation philosophy. The 24-hours close relationship with patients may be a source of imbalanced power relationships between nurses and patients and this causes distress to some patients. It is suggested that nurses need to develop their bedrock role in a way that empowers patients in spinal cord rehabilitation.     

Spiritual care: practical guidelines for rehabilitation nurses.

Spiritual care has long been recognized as an essential component in providing holistic care to patients. However, many nurses have acknowledged that their education lacked practical guidelines on how to provide culturally competent spiritual care. Although all nurses are required to provide spiritual care, rehabilitation nurses are particularly challenged to be competent in this area, due to the lengthy recovery time and special needs often presented by rehabilitation patients. This article provides practical guidelines for rehabilitation nurses, to assist patients in meeting their spiritual needs.     

Implementation of nurse-delivered vestibular rehabilitation in primary care: a qualitative study of nurses' views on involvement in an innovative service

Aim: To explore practice nurses’ perceptions of vestibular rehabilitation and its place in relation to their general role development. Background: Vestibular rehabilitation has been known for a long time to be effective for chronically dizzy patients in secondary care, but its use in primary care has been limited. A recent pragmatic trial of vestibular rehabilitation delivered by practice nurses in primary care has confirmed its utility in a community setting. This type of role is increasingly common for practice nurses, but few studies explore the nurses’ perspective. Methods: A qualitative study was undertaken; 19 nurses took part in focus group sessions. Participants discussed their views on vestibular rehabilitation and its potential for integration with their existing role. A thematic analysis of the data was undertaken. Findings: Four main themes were identified: creating a unique nursing role; the therapeutic role; responsibility and role boundaries; and time. Nurses were positive about developing extended roles, but sought ways to achieve this without eroding fundamental nursing skills. Vestibular rehabilitation was seen as fulfilling both the need for a distinct nursing identity and professional development. Concerns over responsibility for patient assessment and time management constraints are potential obstacles to overcome in the wider development of this therapy in primary care. Conclusions: Understanding the perspective of nurses will be vital in future development of chronic disease management within primary care. Whilst nurses may be positive about such role expansion, the implementation of services of this type will require clarity about nurses’ responsibilities and flexibility in managing workload. Relevance to clinical practice: Vestibular rehabilitation is simple, low‐tech and appropriate for widespread development in primary care. Nurses wishing to provide vestibular rehabilitation or similar chronic disease management activities will need to work with medical colleagues to define role boundaries.     

Experiences of nurses working in a stroke rehabilitation unit

Title. Experiences of nurses working in a stroke rehabilitation unit. Aim. This paper is a report of a study to explore the perceptions, beliefs and feelings of a group of nurses who provided care to individuals admitted to a stroke rehabilitation unit. Background. Following a stroke, survivors should ideally be referred to multidisciplinary inpatient rehabilitation programmes, which attain better outcomes compared to the care provided on general medical wards. However, to achieve these outcomes, team members must work closely together. Communication problems have been reported in these teams, and other members may consider that nurses do not practise functional activities with patients. Methods. An interpretive phenomenological approach was adopted. Eight nurses in one Canadian stroke rehabilitation unit were interviewed during 2004–2005 about their experiences of providing care to stroke survivors. Findings. The nurses enjoyed giving this type of care, feeling that their role was pivotal to the rehabilitation process. At times, they found it difficult to let patients struggle to complete their activities of daily living. The nurses felt that lack of resources, including time, contributed to stroke survivors being short-changed in their rehabilitation nursing care. Despite holding strong views that others devalued their role within the stroke team, the nurses retained positive attitudes. Conclusion. Stroke teams need to recognize the constraints nurses experience in fulfilling their stroke rehabilitation role in order to foster the collegial support that could contribute to a more interactive and respectful work environment. They also need to consider ways to increase the job satisfaction of nurses working in stroke rehabilitation settings.     

Cultural assessment in rehabilitation nursing practice

Relationships between disability and culture may affect the outcomes of care, clients' interactions with rehabilitation nurses, and clients' responses to rehabilitation services. Rehabilitation nurses have leadership roles that include coordinating and managing care, advocating for clients in the health system, educating family, clients, and community, and conducting research that can be applied to practice. Professional rehabilitation nurses are encouraged to examine the content and process of their clients' beliefs and behaviors in order to improve the outcomes of care for clients and to add to the body of knowledge of rehabilitation nursing.     

Improving stroke care through action research

• ? Stroke accounts for ～20% of beds occupied on general medical wards yet nurses felt inadequately prepared to participate fully in the interdisciplinary approach to stroke rehabilitation.
• ? An action research project was established to improve stroke care and rehabilitation in a general medical ward.
• ? Results indicate a correlation between knowledge and attitudes: the greater the nurse's understanding the more positive the nurse is towards nursing involvement in rehabilitation.
• ? It was concluded that nurses have a vital part to play in the rehabilitation of stroke patients and that their contribution can be enhanced through greater understanding.
• ? Further research is needed to determine the effects of greater nursing involvement in terms of quality of patient recovery and length of patient stay.

     

The Caring-Disability Creation Process model: a new way of combining ‘Care’ in nursing and ‘Rehabilitation’ for better quality of services and patient safety

In an effort to continuously improve the quality of the services provided to persons in rehabilitation and patient safety, this article presents a model for the development of a Caring-Disability Creation Process that combines two elements that, in the past, have often been separated: care in nursing and rehabilitation. This new model and its underlying concepts introduce to a comprehensive approach in the recognition of the added value of caring by the contribution of rehabilitation nurses making an optimal development of the individual's potential and achieving successful social participation.     

The Caring-Disability Creation Process model: a new way of combining 'Care' in nursing and 'Rehabilitation' for better quality of services and patient safety

In an effort to continuously improve the quality of the services provided to persons in rehabilitation and patient safety, this article presents a model for the development of a Caring-Disability Creation Process that combines two elements that, in the past, have often been separated: care in nursing and rehabilitation. This new model and its underlying concepts introduce to a comprehensive approach in the recognition of the added value of caring by the contribution of rehabilitation nurses making an optimal development of the individual's potential and achieving successful social participation.     

A study of clinical nursing research priorities in aged care: a Hong Kong perspective

The aim of this study was to identify clinical research priorities in aged care from the perspectives of rehabilitation aged care nurses in Hong Kong. The Delphi method was used whereby 33 registered nurses working in an aged care rehabilitation ward identified 28 research questions pertaining to areas in which nurses could take a leadership role: clinical research that is of highest value to patients and nurse specialists; clinical research which would provide improved community care; facilitate health promotion and disease prevention and be of value to the professional needs of clinical nurses. Study findings have implications and provide direction for clinical nursing research in aged care.     

Staff perspectives on the role of the nurse in rehabilitation wards for elderly people

• ? The increasing demand for cost-effective and efficient health care may create a demand for more demonstrably effective hospital-based rehabilitation services, with the explicit goal of enabling patients to return home after short admissions; thus rehabilitation is centre stage.
• ? This paper reports the findings from a study of the rehabilitation of elderly people in hospital; in particular it focuses on an aspect of the process of care: namely staff perceptions of rehabilitation work, with particular emphasis on the role of the nurse.
• ? A conversational style of interviewing was used with 56 staff respondents from two rehabilitation wards for elderly people.
• ? Findings suggest that therapists are often seen as experts, and nursing is viewed as separate from rehabilitation, and hence nurses are an under-utilized resource in this field.
• ? It is suggested that there is a need to examine further the reality of multidisciplinary teamwork in rehabilitation, particularly with respect to maximizing the potential contribution of nurses, with the end goal of improving patient outcomes.

     

The Rehabilitation Nursing Team in the Home Healthcare Setting

This article discusses the initiation and development of a home care rehabilitation nursing team at a large home care agency in northern Virginia. The team had its origins in the concept of the therapy nurse, which evolved into the current rehabilitation nursing role. A team of rehabilitation nurses at the agency provides in-service programs and consultation and case management services for clients with a variety of medical diagnoses. The idea of the rehabilitation nursing team in the home care setting is a fairly new one and warrants the attention of all rehabilitation nurses who are concerned with patients' posthospital care as well as those nurses who are ready to consider moving into the home care field.     

A day in the life of older people in a rehabilitation setting: an observational study

Abstract

Purpose: Nurses' contribution during inpatient rehabilitation is well documented. However, despite being the largest professional group in this setting, the specialty of rehabilitation nursing is poorly recognised. This article reports on the first of a four-phase study that aimed to clarify and develop the nursing contribution to inpatient rehabilitation for older persons. The aim of this study was to identify activity patterns and time use during daytime and evenings of older adult patients undergoing inpatient rehabilitation. Methods: Direct observation using behavioural modelling was undertaken of a convenience sample of 37 older people undergoing inpatient rehabilitation in a specialist unit of a large tertiary hospital in New Zealand. The primary outcome was the observation of meaningful activity. Binomial logistic regression was used to study the association between relevant variables. Findings: Meaningful activity was most likely to involve walking without assistance and to occur 08:00 to 14:00?h and 16:00 to 21:00?h during weekdays. Patients were more likely to receive treatment during the weekend. Irrespective of time, registered nurses were the health professionals most often present with patients. Conclusions: There is likely to be unrealised opportunities for registered nurses to support improved rehabilitation outcomes. Registered nurses' involvement in rehabilitation needs to be actively optimised.

• Implications for Rehabilitation

• Nurses' engagement with older adults in rehabilitation settings is likely to be substantial, placing them as key members of the rehabilitation team.

• Nurses make a pivotal contribution to inpatient rehabilitation based on specialised knowledge and skills but this contribution is not well understood.

• Opportunities are likely, at times when allied health professionals are less often present, e.g. evenings and weekends, for registered nurses to more intentionally overlap rehabilitation activities with other care requirements.

     

教育干预对护士康复护理行为的影响

目的探讨教育干预对护士实施康复护理的感知控制、态度和行为意向的影响。方法选择某综合医院骨科护士70名,随机分为对照组和试验组,每组各35名。对试验组护士实施教育干预,而对照组护士不实施教育干预,比较实施教育干预前后两组护士在感知控制、态度和行为意向得分的差异。结果实施教育干预后,试验组护士在感知控制、态度和行为意向上的得分高于对照组(均P<0.001)。结论 教育干预能有效改变护士对康复护理的态度,增强自我效能感和感知控制力,并改变康复护理的行为意向,从而有利于促进康复护理的实施。     

Living the healthy heart path. Rehabilitation after a cardiac event

Although cardiac rehabilitation has traditionally been linked to specific programs in which patients participate after having a cardiac event, the concept of cardiac rehabilitation has expanded to many domains of nursing. Not only are critical care nurses the initiators of cardiac rehabilitation through thorough and accurate teaching of the cardiac event but all nurses should be attuned to the modifiable risk factors to direct patients at high risk for possible prevention of a cardiac event. It is a critical care nurse who is knowledgeable about the focus and goals of cardiac rehabilitation, who incorporates the patient's family in the early rehabilitation stages, and who considers cultural variations who can provide optimal care to the patient, helping him or her lead a healthy and productive life.     

A framework for the role of Registered Nurses in the specialty practice of rehabilitation nursing in Australia

AIM OF THE STUDY: This study sought to explore systematically the role of Registered Nurses working in rehabilitation in Australia. BACKGROUND: Rehabilitation has been identified as an important aspect of health care. However, evidence of a comprehensive investigation of the nurses' role in rehabilitation cannot be found. From Australia, in particular, no research has been published in this area. METHODS: This study used a qualitative approach by engaging 13 nurses in one-to-one interviews and a further 21 in focus group discussions. Thematic analysis was conducted on the interview and focus group data. FINDINGS: Seven domains of practice were identified and are suggested as a framework for the specialty practice of rehabilitation nursing. They capture the 'how' and 'what' of rehabilitation nursing practice. Central to this practice is a rehabilitative approach to patient care, teaching and coaching, and continual assessment. The nurses explained in detail how these aspects of rehabilitation nursing differentiate their practice from that of their acute care colleagues. CONCLUSION: The rehabilitative approach is one of a variety of approaches to nursing care, but should not be seen as the exclusive domain of rehabilitation nurses. Rehabilitation belongs in every nurse's toolkit.