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

Oral health status of inpatients with varying physical activity limitations in rehabilitation wards: A cross-sectional study

Poor oral hygiene can be potentially life-threatening in inpatients. However, no basic protocol on oral hygiene customized for inpatients exists, and lack of oral care related knowledge, attitude, and skills among caregivers could be detrimental to the general health of patients. This study sought to identify the oral care practices and oral health status of inpatients with varying physical activity limitations in a rehabilitation ward.Sixty-one inpatients in a rehabilitation ward were evaluated for their medical and physical conditions and oral health status. These were assessed using the bedside oral exam, decayed, missing, filled teeth index, plaque index, gingival index, and caries activity test.In total, 40 men and 21 women (mean age, 56.6 years) were included in this study. Among them, 50.8% of the patients could brush their teeth unassisted, whereas 49.2% required assistance from an assistant for oral care. The proportion of patients receiving nasogastric tube feeding was higher in the group that could not provide oral self-care; 36.7% and 33.3% of these patients showed moderate and severe dysfunction, respectively, based on bedside oral exam. Scores for the swallowing, tongue, and total domains of bedside oral exam were poorer for patients who could not provide oral self-care (P < .01). The caries activity test indicated a moderate risk for both groups.Our findings suggest that an oral care protocol that considers the physical activity limitations in inpatients in rehabilitation wards is necessary to minimize negative influences on the systemic health of these patients.

A Unique Approach to Quality Improvement Within the Stroke System of Care Utilizing Developmental Evaluation

Stroke is a significant cause of death that requires multiple systems of care to work together to prevent incidence and improve patient outcomes. The Wisconsin Coverdell Stroke Program partnered with a Model Hospital to understand and improve the stroke system of care in one community. Developmental evaluation (DE) is an approach in which evaluators collaborate closely with project stakeholders to examine complex processes and systems within changeable contexts to develop interventions to improve outcomes. DE was used to assess this community's stroke systems across the care continuum through process mapping with Model Hospital staff and through key stakeholder interviews with Model Hospital and emergency medical services staff, patients, and caregivers. Process mapping identified how patients and health care data flow through the system of care and highlighted areas where streamlining could improve the movement of patients and data across the care continuum. Interviews with stakeholders unveiled challenges and successes about how patient data are accessed and shared across the care continuum, and ideas for improving systems to be more efficient and supportive of stroke prevention and patient outcomes. Overall, DE was valuable in gaining an in-depth understanding of this complex environment to develop strategies to enhance stroke systems of care.

Understanding the therapeutic alliance in stroke rehabilitation

PURPOSE

The quality of the therapeutic alliance between a client and their clinician is thought to play an important role in healthcare but there is limited research about this concept in stroke rehabilitation. This study explored the core components of a therapeutic alliance and the factors perceived to impact on its development in a stroke rehabilitation unit.

METHODS

Interpretive description methodology was used to gather and synthesise participants' experiences of their therapeutic relationships. Ten individual client interviews and one clinician focus group were conducted. Data was were analysed using conventional content analysis.

RESULTS

A therapeutic alliance appeared to consist of three overlapping core components: a personal connection, a professional collaboration, and family collaboration. Clients valued these components to different degrees and priorities could change over time. Alliance breakdowns were perceived to stem from a clinician's incorrect assumptions about their client's relationship preferences or lack of responsiveness to their needs. Recovery of the alliance seemed to depend on the strength of the pre-existing relationship and steps taken to repair it.

CONCLUSIONS

Establishing and maintaining a therapeutic alliance appears to be an individualised and complex process. A clinician's ability to use their personal attributes therapeutically, and professional skills flexibly, appeared integral to relationship quality.IMPLICATIONS FOR REHABILITATIONDeveloping therapeutic relationships requires a person-centred and sometimes family/whānau-centred approach.The judicious use of self-disclosure may achieve emotional proximity and yet maintain professional boundaries.Maintaining relationship health requires a proactive approach to detect and manage relationship disruptions.

Client-Therapist Relationships: Experiences of Occupational Therapy Clients in Rehabilitation

The relationship between a therapist and his or her client has been recognised to be an important determinant of the success or failure of occupational therapy. The purpose of this qualitative study was to explore clients' perceptions of the relationship that they formed with their occupational therapist in the context of rehabilitation. Twenty clients with varied health problems were interviewed.

The analysis of data revealed three main categories, therapist role, power and connection, as pertaining to the characteristics of the client-therapist relationship. From these categories, seven different relationship dimensions were identified and arranged hierarchically. The dimensions were described as concern, direction, fellowship, guidance, coalition, detachment and rejection. Relationships were generally experienced as positive; however, there were also examples of negative and detrimental experiences.

The findings are discussed in relation to the definition of the therapeutic relationship and to client-centred practice. Occupational therapists are encouraged to consider their own attitudes, needs and boundaries when it comes to establishing close connections and to share power with their clients. Furthermore, therapists must explore which form of relationship and participation each client prefers in order to establish an effective collaborative relationship.

Therapeutic Alliances in Stroke Rehabilitation: A Meta-Ethnography

OBJECTIVE

To synthesize qualitative studies exploring patients' and professionals' perspectives and experiences of developing and maintaining therapeutic alliances in stroke rehabilitation.

DATA SOURCES

A systematic literature search was conducted using the following electronic databases: PsycINFO, CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database, Applied Social Sciences Index and Abstracts, and ComDisDome from inception to May 2014. This was supplemented by hand searching, reference tracking, generic web searching, and e-mail contact with experts.

STUDY SELECTION

Qualitative peer reviewed articles reporting experiences or perceptions of the patient or professional in relation to therapeutic alliance construction and maintenance in stroke rehabilitation were selected for inclusion. After a process of exclusion, 17 publications were included in the synthesis.

DATA EXTRACTION

All text identified in the results and discussion sections of the selected studies were extracted verbatim for analysis in a qualitative software program. Studies were critically appraised independently by 2 reviewers.

DATA SYNTHESIS

Articles were synthesized using a technique of meta-ethnography. Four overarching themes emerged from the process of reciprocal translation: (1) the professional-patient relationship: degree of connectedness; (2) asymmetrical contributions; (3) the process of collaboration: finding the middle ground; and (4) system drivers.

CONCLUSIONS

The findings from the meta-ethnography suggest that the balance of power between the patient and professional is asymmetrically distributed in the construction of the alliance. However, given that none of the studies included in the review addressed therapeutic alliance as a primary research area, further research is required to develop a conceptual framework relevant to stroke rehabilitation, in order to determine how this construct contributes to treatment efficacy.

Nursing practice in stroke rehabilitation: systematic review and meta-ethnography

AIMS AND OBJECTIVES

To identify and synthesise the available research evidence in order to generate an explanatory framework for nursing practice in stroke rehabilitation.

BACKGROUND

Although nurses are the largest professional group working with stroke survivors, there is limited understanding of nursing practice in stroke units. In particular, there is currently very little evidence in respect of nurses' involvement in poststroke rehabilitation.

DESIGN

Meta-ethnography.

METHOD

A systematic review was undertaken. The review question was: 'What is the nature of nursing practice in the care and rehabilitation of inpatient stroke survivors?' Searches of 12 electronic databases identified 14,655 publications, and after screening, 778 remained; 137 papers were obtained and 54 retained for mapping. Sixteen qualitative studies were included in the meta-ethnography.

RESULTS

Nurses' involvement in poststroke rehabilitation was limited. Contextual factors impacted on nurses' perceptions and practice. Nurses' integration of rehabilitation skills was perceived to be contingent on adequate nurse staffing levels and management of demands on nurses' time. Team working practices and use of the built environment indicated separation of nursing and therapy work. Physical care and monitoring were prioritised. Stroke-specific education and training was evident, but not consistent in content or approach. Stroke survivors and families needed help to understand nurses' role in rehabilitation.

CONCLUSION

The review provides compelling evidence that there is an need to re-examine the role of nurses in contributing to poststroke rehabilitation, including clarifying when this process can safely begin and specifying the techniques that can be integrated in nurses' practice.

RELEVANCE TO CLINICAL PRACTICE

Integrating stroke-specific rehabilitation skills in nurses' practice could contribute substantially to improving outcomes for stroke survivors. The explanatory framework developed from the review findings identifies issues which will need to be addressed in order to maximise nurses' contribution to the rehabilitation of stroke survivors.

A systematic review of nursing rehabilitation of stroke patients with aphasia

AIM AND OBJECTIVES

To explore the evidence on rehabilitation of stroke patients with aphasia in relation to nursing care, focusing on the following themes: (1) the identification of aphasia, (2) the effectiveness of speech-language interventions.

BACKGROUND

Patients with poststroke aphasia have higher mortality rates and worse functional outcome than patients without aphasia. Nurses are well aware of aphasia and the associated problems for patients with stroke because they have daily contact with them. The challenge is to provide evidence-based care directed at the aphasia. Although rehabilitation stroke guidelines are available, they do not address the caregiving of nurses to patients with aphasia.

DESIGN

Systematic review.

METHOD

Published studies were reviewed, focusing on identification and treatment of aphasic patients after stroke in terms of the consequences for nursing care. Also, data concerning effective speech-language interventions were extrapolated into nursing practice with respect to the classification of nursing interventions.

RESULTS

Intensive speech-language therapy, which was initiated in the acute stage post stroke, showed the best rehabilitation outcomes. Trained persons other than speech-language therapists provided effective speech-language interventions. Speech-language therapy included several types of intervention that met nursing intervention classifications.

CONCLUSION

The contribution of nursing to the rehabilitation of patients with aphasia is relevant. The use of screening instruments by nurses can increase early detection of aphasia, a precondition for initiating timely speech-language therapy. Collaboration between speech-language therapists and nurses is of the utmost importance for increasing the intensity and functionality of speech-language exercises, which may enhance the quality of treatment.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can be used to develop nursing rehabilitation guidelines for stroke patients with aphasia. Further research is necessary to explore the feasibility of using such guidelines in clinical nursing practice and to examine the experiences of patients with nursing interventions directed at aphasia.

"You feel like family..." professional boundaries and social model aphasia groups

In this theoretical paper, we argue that the adoption of the social model to aphasia rehabilitation within group settings changes the metaphorical location of the boundaries between clinicians and clients. Despite a growing literature on group work for aphasia and social model applications for people with chronic aphasia, there has been almost no attention paid to how professional boundaries are negotiated. This paper reviews how this issue is dealt with within professional codes of ethics and what is written more broadly on professional boundaries, and then uses a number of real case examples to encourage further discussion and awareness of this important issue in aphasia rehabilitation within group settings.

Patients, doctors, and therapists perceptions of professional roles in spinal cord injury rehabilitation: Do they agree?

Spinal cord injury is a devastating condition, requiring extensive rehabilitation from a range of health care professionals. However, it is unclear if patients view the professionals' input into their rehabilitation in the same way as those professionals. This paper presents findings from a qualitative study into patient participation in spinal cord injury rehabilitation. The aim of the part of the study reported here was to identify whether there is agreement between health care professionals and patients perceptions of professional roles in spinal cord injury rehabilitation. Results are presented from semi-structured interviews conducted with five doctors, five physiotherapists, three occupational therapists and 20 patients in a spinal cord injury unit in England. Findings suggest considerable agreement between professionals and patients about the role those professionals play in their rehabilitation. Physiotherapists are perceived to be key to rehabilitation, occupational therapists focus on hand function but physiotherapists and occupational therapists complement each other. Doctors coordinate the team yet reduce their input as patients move out of the acute phase into rehabilitation. There are some tensions but the early input of these professionals into patients' rehabilitation may help to develop understanding of roles. Congruence between patients and professionals may mean that patients have realistic expectations and encourage a more equal relationship between them.

Patient participation in nursing care from a patient perspective: a Grounded Theory study

the study's rationale: Patients' active participation in their own care is expected to contribute to increased motivation to improve their own condition, better treatment results and greater satisfaction with received care. Knowledge of patients' understanding of participation is of great importance for nurses in their efforts to meet patient expectations and for quality of nursing care.

AIM

The aim was to explore the meaning of patient participation in nursing care from a patient point of view.

METHODOLOGICAL DESIGN AND JUSTIFICATION

Six tape-recorded focus group interviews with 26 Swedish informants described opinions on and experiences of patient participation. The informants consisted of patients in somatic inpatient care as well as discharged patients from such a setting. The Grounded Theory method was used and the data were analysed using constant comparative analysis.

ETHICAL ISSUES AND APPROVAL

The ethics of scientific work was followed. Each study participant gave informed consent after verbal and written information. The Ethics Committee of Göteborg University approved the study.

FINDINGS

The patients emphasised the importance of collaboration to improve participation. The core category, Insight through consideration, was generated from four inter-related categories: (i) Obliging atmosphere; (ii) Emotional response; (iii) Concordance; and (iv) Rights and their 15 subcategories.

CONCLUSIONS

The meaning structures of patient participation in nursing care revealed from a patient point of view, seemed to mainly consist of not only external factors presented by the institutions -- by the professionals -- but also internal patient factors. The patients' view of participation should be considered to a greater degree in nursing practice and education, as should also further development of nursing care policy programmes, evaluation and quality assurance criteria. For further development, studies are needed in similar and other settings.

Patient, carer and staff experience of a hospital-based stroke service

OBJECTIVE

Here, the aim is to study the experiences of patients, carers and staff throughout a hospital stroke care pathway.

DESIGN

Focus groups of patients, carers and staff followed a semi-structured format to elucidate experiences. The groups were recorded, transcribed and subjected to thematic analysis. Analyses were verified by researchers and participants.

RESULTS

Patients and carers produced four overlapping themes: 'information', 'staff attitudes', 'availability of care/treatment' and 'considering the whole person in context'. The carers' group produced two additional themes: 'accommodation of patients' individual needs' and 'burden of care'. Their experiences were complex and multi-faceted; positive views of the whole service co-existed with negative views of some aspects. The staff groups produced six themes: 'specialist service', 'split service', 'availability of care', 'consistency of care', 'staff morale' and 'wish for change'. Positive views of the specialist service were tempered by problems with physical and professional separation, staff shortages and 'hierarchical practice' that reduced collective decision-making.

CONCLUSION

Some of the patients' and carers' perspectives have not been previously reported in the stroke literature, including a desire for individualized treatment, the consideration of wider, non-physical needs and the carers' sense of burden. In addition, the study revealed how staff, carers and patients viewed each other and the service and demonstrated the concordance of their perceptions. However, staff showed little insight into the users' need for information and negative experiences of care. In contrast with previous research, lack of emotional care, poor continuity of care and lack of staff knowledge and skills were not identified as problems.

Patients' and nurses' perceptions of nursing problems in an acute care setting

AIM

This paper reports a study to determine the degree of agreement or disagreement between nurses and patients in their perceptions of the presence, severity, and importance of nursing problems.

BACKGROUND

Patient experiences, values and preferences are increasingly acknowledged as important factors underpinning healthcare decision-making. The ability to identify patient problems accurately is an important prerequisite for planning and implementing individualized high quality care.

METHODS

A convenience sample of patients (n = 80) and Registered Nurses (n = 30) in an acute care setting responded to a 43-item questionnaire. Findings. Nurses identified patients' problems with a sensitivity of 0.53 and a positive predictive value of 0.50. Patients identified several severe problems that were not identified by nurses, particularly problems with nutrition, sleep, pain, and emotions/spirituality. Nurses underestimated the severity in 47% of mutually-identified problems. An overall level of agreement of 44% was found on the importance of patient problems. Low levels of agreement on severity and importance were related more to individual differences than to systematic differences.

CONCLUSIONS

Nurses need to be more aware that patients and nurses often hold disparate views of the priorities in nursing care. To plan individualized nursing care effectively, nurses need to elicit and use individual patients' preferences more systematically in care planning.

Oral care and stroke units

OBJECTIVE

To investigate oral care provision reported by senior nurses in stroke care settings in Scotland.

BACKGROUND

Stroke can have adverse effects on oral care and health. Little is known about current oral care practices in stroke care settings.

MATERIALS AND METHODS

We designed a postal survey to be completed by ward managers or senior nurses. After piloting, the survey was distributed to all 71 units in Scotland, identified as providing specialist care for patients in the acute or rehabilitation stages following stroke. Pre-notification and reminder letters were circulated. Responses were anonymous.

RESULTS

All but one survey was completed and returned. Help from dental professionals was available to most units (64/70) mostly on request. Only a third of units received oral care training in the last year (23/ 70). The majority of this training was ward based (20/23). The use of oral care assessment tools and protocols was limited (16/70 and 15/70 units respectively). Not all units had access to toothbrushes, toothpaste or chlorhexidine. For patients unable to perform oral care independently, senior nurses expected the patients' teeth or dentures to be cleaned at least twice a day in 59 of 70 and 49 of 70 units respectively.

CONCLUSION

The response rate was excellent and has provided a national overview of oral care provision for patients in stroke care settings. Access to staff training, assessments, protocols and oral hygiene material varied considerably. This information provides a valuable baseline from which to develop and evaluate the effectiveness of ward-based oral care interventions for stroke patients.

Patient participation on a ward for frail older people

AIMS

The paper reports a study whose aims were to explore the meaning of participation for older people in hospital and their health care workers and ways in which staff can enhance patient participation in their care.

BACKGROUND

Participation in care is a concept that is central to nursing practice. However, little is known about patient and staff views of participation and how it takes place in practice.

METHODS

Action research was used, and data were collected by means of focus groups and in-depth interviews. Three focus groups and 24 interviews were undertaken with staff, and 19 interviews were undertaken with patients. The main action undertaken with staff aimed at raising their awareness of participation. In addition small changes in practice were introduced, such as the use of a patient biographical booklet.

FINDINGS

The findings suggest that participation is a dynamic process that is integral to the work of nurses and carers. The process is enacted through the themes of facilitation, partnership, understanding the person, and emotional work.

CONCLUSION

The study demonstrates how nurses can become increasingly aware of the potential for facilitation and creation of opportunities for participation. It is crucial that practitioners working with older people develop a deeper understanding of participation and are also empowered to act in ways that fit with the needs of this specific client group.

Beyond person-centred care: a new vision for gerontological nursing

Currently considerable emphasis is placed on the promotion of person-centred care, which has become a watchword for good practice. This paper takes a constructively critical look at some of the assumptions underpinning person-centredness, and suggests that a relationship-centred approach to care might be more appropriate. A framework describing the potential dimensions of relationship-centred care is provided, and implications for further development are considered.

Do nurses exercise power in basic care situations?

Power is a matter of authority and control. It can be wielded either consciously or unconsciously, and it can be either overt or latent. Using a structured questionnaire, this study set out to describe nurses' opinions about the exercise of power in basic care situations in both acute and long-term care. The questionnaire was organized into four categories in which items concerned: power in obligatory daily activities; power in activities necessitated by obligatory activities; power in voluntary activities; and power in activities that take into account the patient's characteristics. The samples consisted of 228 nurses from five medical and surgical wards of district hospitals, and 233 nurses from five geriatric units of a community health centre and from one nursing home in Finland. The final response rate was 65% (acute care 76%; long-term care 55%). Data analysis was based on statistical methods. The results showed that, in the nurses' own opinion, negative power is exercised only in certain situations and in the patient's best interest, when for instance there are concerns that something may happen to the patient.

Taciturn patients in health counseling at a hospital: passive recipients or active participators?

This study explored patients' taciturnity as observed on videotape during hospital health counseling situations with a nurse. Health counseling sessions, 38 in number, were videotaped, transcribed verbatim, and analyzed by using an adaptation of conversation analysis. The data analysis included information on 18 selected patients who spoke little and did not introduce new topics, but rather supported the discussion on the theme chosen by the nurse. When we examined nurses' and patients' speech word by word, we discovered four participation frames that produced taciturnity: in the hands of professionals, compliant, guilty, and polite. These could fluctuate during interaction. The findings indicate that there is a need for a more extensive description of taciturn, or silent, patients. What has been interpreted as passivity in the literature can be interpreted more constructively. This insight can be useful for developing health counseling practice in hospitals.

The meaning of skilled care providers' relationships with stroke and aphasia patients

Little is known about the reciprocal influence of communication difficulties on the care relationship. To illuminate care providers' lived experiences of relationships with stroke and aphasia patients, narrative interviews were conducted with providers particularly successful at communicating with patients. A phenomenological hermeneutic analysis of the narratives revealed three themes: Calling forth responsibility through fragility, restoring the patient's dignity, and being in a state of understanding. The analysis disclosed caring with regard to the patient's desire, which has its starting point in intersubjective relationship and interplay, in which nonverbal communication is essential--that is, open participation while meeting the patient as a presence. Thus, care providers prepare for deep fellowship, or communion, by being available. They described an equality with patients, interpreted as fraternity and reciprocity, that is a necessary element in presence as communion. The works of Marcel, Hegel, Stern, and Ricoeur provided the theoretical framework for the interpretation.

Stroke rehabilitation: benefits of educational initiatives

The supportive education of stroke survivors and their carers has been identified as a key area of interest to rehabilitation nurses. The Audit Commission recommends the widespread use of stroke units within the NHS (Audit Commission, 2000). The aim of this review is to determine the authority of available evidence and to discuss how such evidence might influence practice. The literature tended to assume that education had a positive effect on the outcome of rehabilitation. Various education interventions were attempted, including information-giving through the use of written material as well as more supportive and facilitative approaches. Factors that may affect the ability to learn or absorb information were identified and attempts have been made to evaluate the effect of educational interventions.

The nursing care of stroke patients in nursing homes. Nurses' descriptions and experiences relating to cognition and mood

Registered nurses working in nursing homes often care for stroke patients with impaired cognition and mood disorders. Understanding the behaviour of these patients often puts great demands on nurses. This study illuminates registered nurses' descriptions and experiences of stroke patients and the nursing care given in nursing homes, with a focus on cognition and mood. Registered nurses responsible for the care of stroke patients in nursing homes were asked to describe the individual patient's state of health and the nursing care given. Patients' cognition and mood have been selected for this article. A qualitative content analysis was used to group the text into categories. Registered nurses' descriptions showed great complexity and variation in patients' disabilities, as well as uncertainty about understanding these patients and the appropriate nursing care. Registered nurses described the need for further education in stroke care, and adequate resources for patient activity training, as well as meeting patients' psychosocial and communicative needs.

Analysing qualitative data: computerized and other approaches

Analysis of qualitative data can be done 'manually' using a variety of techniques such as 'cut and paste' and use of coloured pens to categorize data and develop theoretical explanations. More recently a number of computer software packages have been developed to mechanize this 'coding' process as well as to search and retrieve data. This article reviews the background to and advantages and disadvantages of computerized approaches, and compares these with manual techniques used in a number of recent nursing PhD studies. It is concluded that beginning researchers conducting small-scale studies would be best recommended to use a manual approach in order to gain insight into the intuitive aspects of analysis which are the essential basis of any method of analysis, including computerized forms.