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Hawkins RJ, Jowett A, Godfrey M, Mellish K, Young J, Farrin A, Holloway I, Hewison J, Forster A. Poststroke Trajectories: The Process of Recovery Over the Longer Term Following Stroke. Glob Qual Nurs Res 2017; 4:2333393617730209. [PMID: 28932766 PMCID: PMC5600296 DOI: 10.1177/2333393617730209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/18/2017] [Accepted: 07/02/2017] [Indexed: 11/17/2022] Open
Abstract
We adopted a grounded theory approach to explore the process of recovery experienced by stroke survivors over the longer term who were living in the community in the United Kingdom, and the interacting factors that are understood to have shaped their recovery trajectories. We used a combination of qualitative methods. From the accounts of 22 purposively sampled stroke survivors, four different recovery trajectories were evident: (a) meaningful recovery, (b) cycles of recovery and decline, (c) ongoing disruption, (d) gradual, ongoing decline. Building on the concept of the illness trajectory, our findings demonstrate how multiple, interacting factors shape the process and meaning of recovery over time. Such factors included conception of recovery and meanings given to the changing self, the meanings and consequences of health and illness experiences across the life course, loss, sense of agency, and enacting relationships. Awareness of the process of recovery will help professionals better support stroke survivors.
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Affiliation(s)
| | - Adam Jowett
- Coventry University, Coventry, United Kingdom
| | | | | | - John Young
- University of Leeds, Leeds, United Kingdom.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | | | | | | | - Anne Forster
- University of Leeds, Leeds, United Kingdom.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
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Balakrishnan R, Kaplan B, Negron R, Fei K, Goldfinger JZ, Horowitz CR. Life after Stroke in an Urban Minority Population: A Photovoice Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14030293. [PMID: 28287467 PMCID: PMC5369129 DOI: 10.3390/ijerph14030293] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/23/2017] [Accepted: 02/27/2017] [Indexed: 12/15/2022]
Abstract
Stroke is a leading cause of disability in the United States and disproportionately affects minority populations. We sought to explore the quality of life in urban, minority stroke survivors through their own photos and narratives. Using the Photovoice method, seventeen stroke survivors were instructed to take pictures reflecting their experience living with and recovering from stroke. Key photographs were discussed in detail; participants brainstormed ways to improve their lives and presented their work in clinical and community sites. Group discussions were recorded, transcribed, and coded transcripts were reviewed with written narratives to identify themes. Participants conveyed recovery from stroke in three stages: learning to navigate the initial physical and emotional impact of the stroke; coping with newfound physical and emotional barriers; and long-term adaptation to physical impairment and/or chronic disease. Participants navigated this stage-based model to varying degrees of success and identified barriers and facilitators to this process. Barriers included limited access for disabled and limited healthy food choices unique to the urban setting; facilitators included presence of social support and community engagement. Using Photovoice, diverse stroke survivors were able to identify common challenges in adapting to life after stroke and important factors for recovery of quality of life.
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Affiliation(s)
- Revathi Balakrishnan
- Division of Cardiology, New York University School of Medicine, 462 1st Avenue NBV 17S5, New York, NY 10016, USA.
| | - Benjamin Kaplan
- University of North Carolina School of Medicine, 321 S Columbia St, Chapel Hill, NC 27516, USA.
| | - Rennie Negron
- Yale Institute for Network Science, Department of Sociology, Yale University, 17 Hillhouse Avenue, New Haven, CT 06520, USA.
| | - Kezhen Fei
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY 10029, USA.
| | - Judith Z Goldfinger
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
| | - Carol R Horowitz
- Center of Health Equity and Community Engaged Research at Mount Sinai, Department of Population Health Science and Policy, Icahn School at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
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Affiliation(s)
- Sandra Lever
- Graythwaite Rehabilitation Centre Sydney, Eastwood, Australia
- Royal Rehab, Ryde, Australia
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Musser B, Wilkinson J, Gilbert T, Bokhour BG. Changes in identity after aphasic stroke: implications for primary care. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2015; 2015:970345. [PMID: 25685553 PMCID: PMC4320786 DOI: 10.1155/2015/970345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/15/2014] [Indexed: 06/04/2023]
Abstract
Background. Stroke survivors with aphasia experience difficulty associated with their communication disorder. While much has been written about aphasia's impacts on partners/family, we lack data regarding the psychosocial adjustment of aphasic stroke survivors, with a paucity of data from the patients themselves. Methods. Qualitative study of lived experiences of individuals with poststroke aphasia. Each of the stroke survivors with aphasia completed 3-4 semistructured interviews. In most cases, patients' partners jointly participated in interviews, which were transcribed and analyzed using techniques derived from grounded theory. Results. 12 patients were interviewed, with the total of 45 interviews over 18 months. Themes included poststroke changes in patients' relationships and identities, which were altered across several domains including occupational identity, relationship and family roles, and social identity. While all these domains were impacted by aphasia, the impact varied over time. Conclusion. Despite the challenges of interviewing individuals with aphasia, we explored aphasia's impacts on how individuals experience their identity and develop new identities months and years after stroke. This data has important implications for primary care of patients with aphasia, including the importance of the long-term primary care relationship in supporting psychosocial adjustment to life after aphasic stroke.
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Affiliation(s)
- Benjamin Musser
- Department of Emergency Medicine, Los Angeles County-USC, Los Angeles, CA 90033, USA
| | - Joanne Wilkinson
- Department of Family Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA
| | - Thomas Gilbert
- Department of Family Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Barbara G. Bokhour
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Hospital, Bedford, MA 01730, USA
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Babbitt EM, Cherney LR. Communication Confidence in Persons with Aphasia. Top Stroke Rehabil 2015; 17:214-23. [DOI: 10.1310/tsr1703-214] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bronken BA, Kirkevold M, Martinsen R, Kvigne K. The aphasic storyteller: coconstructing stories to promote psychosocial well-being after stroke. QUALITATIVE HEALTH RESEARCH 2012; 22:1303-16. [PMID: 22785627 DOI: 10.1177/1049732312450366] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Telling stories is essential to the continuous process of creating meaning and to self-understanding. Persons with aphasia are vulnerable to psychosocial problems by their limited ability to talk and interact with others. This single-case study illustrates how a young woman with aphasia and a trained nurse interacted to coconstruct stories within the context of a longitudinal clinical intervention aimed at promoting psychosocial well-being in the first year after a stroke. Data were collected through qualitative interviews and participant observation; they were then analyzed from a hermeneutic-phenomenological perspective. The experience of coconstructing stories made an important contribution to improving the participant's psychological well-being. The shared construction of the participant's story evolved as a cumulative process, and it was facilitated by the establishment of trust in the participant-nurse relationship, the systematic use of worksheets and supported conversations, and a specific focus on psychosocial topics and structural organization.
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Affiliation(s)
- Berit Arnesveen Bronken
- Department of Nursing Science, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.
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Psychosocial well-being in persons with aphasia participating in a nursing intervention after stroke. Nurs Res Pract 2012; 2012:568242. [PMID: 22888417 PMCID: PMC3409547 DOI: 10.1155/2012/568242] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/10/2012] [Indexed: 11/17/2022] Open
Abstract
The psychosocial adjustment process after stroke is complicated and protracted. The language is the most important tool for making sense of experiences and for human interplay, making persons with aphasia especially prone to psychosocial problems. Persons with aphasia are systematically excluded from research projects due to methodological challenges. This study explored how seven persons with aphasia experienced participating in a complex nursing intervention aimed at supporting the psychosocial adjustment process and promoting psychosocial well-being. The intervention was organized as an individual, dialogue-based collaboration process based upon ideas from “Guided self-determination.” The content addressed psychosocial issues as mood, social relationships, meaningful activities, identity, and body changes. Principles from “Supported conversation for adults with aphasia” were used to facilitate the conversations. The data were obtained by participant observation during the intervention, qualitative interviews 2 weeks, 6 months, and 12 months after the intervention and by standardized clinical instruments prior to the intervention and at 2 weeks and 12 months after the intervention. Assistance in narrating about themselves and their experiences with illness, psychological support and motivation to move on during the difficult adjustment process, and exchange of knowledge and information were experienced as beneficial and important by the participants in this study.
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Mauk KL, Lemley C, Pierce J, Schmidt NA. The Mauk Model for Poststroke Recovery: assessing the phases. Rehabil Nurs 2011; 36:241-7. [PMID: 22073503 DOI: 10.1002/j.2048-7940.2011.tb00089.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Despite the estimated 795,000 strokes occurring in America annually (American Heart Association, 2009), few practical models guide nurses when they provide quality care to stroke survivors. The Mauk Model for Poststroke Recovery is a theoretical framework concerning six phases of poststroke recovery. The purpose of this article is to discuss a pilot study detailing the ways in which nursing students used the Mauk model to identify these phases of stroke recovery via patient case examples. A sample of 30 volunteer nursing students read five case studies and determined the phase of stroke recovery. Descriptive statistics about sample characteristics and frequencies were calculated using SPSS 14 for Windows. Nearly 57% (n = 17) of the students rated all of the case studies to the correct phase. Ways in which the model might be clarified and used as a valuable tool when assessing the phase of stroke recovery are described.
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Eilertsen G, Kirkevold M, Bjørk IT. Recovering from a stroke: a longitudinal, qualitative study of older Norwegian women. J Clin Nurs 2011; 19:2004-13. [PMID: 20920026 DOI: 10.1111/j.1365-2702.2009.03138.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To illuminate older women's experiences and the characteristics of the recovery process following a stroke. BACKGROUND Patients with stroke face serious challenges related to bodily changes, existential aspects and daily life after stroke. Few qualitative longitudinal studies have examined the recovery process from the perspective of the patient. Knowledge about older women's experiences in coping with life after a stroke is limited. DESIGN Prospective, longitudinal, case-study design. METHODS Six women aged 68-83 suffering from first-time stroke were recruited from two stroke units. Each participant was interviewed in-depth 12-14 times during the first two years post stroke. The interviews addressed how they experienced their body, their self-understanding, daily life and how this had changed over time. Most interviews took place in the participants' homes. Gadamer's philosophical hermeneutics informed the analyses. RESULTS Post stroke recovery was slow and complex and evolved through four distinct phases. In the first phase (0-2 months post stroke), the participants' main concerns were their bodily changes; in the second phase (2-6 months), activities of daily life; in the third phase (6-12 months), self-understanding and in the fourth phase (12-24 months), going on with life. The transition between phases was gradual. CONCLUSION Recovery from stroke evolves over time through four distinct phases, which differ depending on significant experiences and associated meanings. Psychological and social resources are equally critical in the women's process of recovery. RELEVANCE TO CLINICAL PRACTICE The four phases of rehabilitation suggest at what points various concerns require increased therapeutic attention. Psychological and social resources must be vitalised at an early phase similar to bodily resources. This knowledge may assist professionals in offering adequate help throughout the recovery process even beyond the established rehabilitation period.
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Hoogerdijk B, Runge U, Haugboelle J. The adaptation process after traumatic brain injury An individual and ongoing occupational struggle to gain a new identity. Scand J Occup Ther 2010; 18:122-32. [DOI: 10.3109/11038121003645985] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The role of nursing in the rehabilitation of stroke survivors: an extended theoretical account. ANS Adv Nurs Sci 2010; 33:E27-40. [PMID: 20154522 DOI: 10.1097/ans.0b013e3181cd837f] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This article provides a critique and theoretical extension of a work that sought to describe the contribution of nurses to stroke rehabilitation. At the time, the role of nursing was considered important but therapeutically nonspecific. Stroke nursing research has increased significantly and so has research focusing on the patient experiences of the adjustment and rehabilitation processes following a stroke. These developments provide significant new insights that may refine and extend the original understanding of the role of nursing in stroke rehabilitation. This article proposes an extended theoretical framework of the role of nursing in stroke recovery and rehabilitation.
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Kessler D, Dubouloz CJ, Urbanowski R, Egan M. Meaning perspective transformation following stroke: the process of change. Disabil Rehabil 2009; 31:1056-65. [PMID: 19280437 DOI: 10.1080/09638280802509512] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Transformative Learning in an educational theory that posits that individuals learn and grow when their meaning perspectives (frames of reference for interpreting an experience based on knowledge, feelings, values and beliefs) are reformulated following a critical event. This theory has become quite influential in the exploration of adaptation to chronic illness. This study explored whether the change that occurs following stroke follows a process similar to transformative learning. METHOD Grounded Theory approach was used to explore changes in meaning perspective among 12 people who were members of stroke support organisations, had a stroke at least 1 year prior to the study and described themselves as viewing life positively following stroke. Constant comparison analysis of interviews with these individuals was used to explore their experience following stroke. RESULTS Meaning perspective transformation occurred with four factors contributing to transformation: triggers, support, knowledge and choices to action. A substantive grounded theory of the process of meaning perspective transformation following stroke is presented, which illustrates the interaction of these contributing factors in initiating and facilitating the transformation process. CONCLUSION Transformative learning can offer insight into how people who have experienced stroke learn, rebuild competence and re-engage in valued activities.
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Affiliation(s)
- Dorothy Kessler
- Occupational Therapy Service, Bruyère Continuing Care, Ottawa, ON, Canada.
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Bennett B, Barnston S, Smith R. Emotional support after stroke, part 1: Two models from hospital practice. ACTA ACUST UNITED AC 2007. [DOI: 10.12968/bjnn.2007.3.1.22724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bev Bennett
- School of Nursing and Midwifery, Sheffield University, Humphry Davy House, Golden Smithies Lane, Manvers, Rotherham, South Yorkshire S63 7ER,
| | - Sue Barnston
- Sheffield Teaching Hospitals NHS Foundation Trust, Ward 01, Royal Hallamshire Hospital, Glossop Road, Sheffield, South Yorkshire S10 2JF and
| | - Rachael Smith
- Integrated Specialist Stroke Unit, Stepping Hill Hospital, Poplar Grove, Stepping Hill, Stockport, Cheshire SK2 7JE
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Abstract
Stroke continues to be the third leading cause of death in the United States. According to the National Stroke Association (NSA, 2004) and the American Heart Association (AHA, 2004), there are over 750,000 new or recurrent strokes per year, with many resulting in residual disability. Stroke survivors often deal with the physical, psychosocial, and emotional consequences of stroke long after they have left the safety of professional rehabilitation. Patient instruction from nurses prior to discharge, while necessary, may be done at a point in the recovery process when the stroke survivor is not ready to learn how to deal with such consequences. Using the Mauk Model for Poststroke Recovery, nurses can identify which phase of recovery a survivor is in, and thus tailor care to his or her needs. The purpose of this article is to use the Mauk Model for Poststroke Recovery to present nursing interventions that are appropriate to each of the previously identified six phases of stroke recovery.
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Lobeck M, Thompson AR, Shankland MC. The experience of stroke for men in retirement transition. QUALITATIVE HEALTH RESEARCH 2005; 15:1022-36. [PMID: 16221877 DOI: 10.1177/1049732305280772] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
In this study, the authors aimed to explore how men manage when two significant life events, stroke and retirement, occur within a close time proximity. They selected 7 men purposively who were either in the process of planning to retire or had just retired when they had suffered a stroke, and used interpretive phenomenological analysis to guide data collection and to analyze the resulting transcripts. The authors derived three interrelated processes with eight subthemes. The three themes were associated with ambivalence about retirement, the impact of the stroke, and healing and adjustment. The themes suggested that significant interplay existed between the meanings made of the two life events. The emergent themes implied that stroke had a profound impact on the men's lives and affected them on a number of levels. The experience of suffering a stroke also led to some positive reframing of life.
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Affiliation(s)
- Margarita Lobeck
- Department of Trauma Care, Reconstructive Plastic and Burns Surgery, Northern General Hospital, Sheffield, UK
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TAKAHASHI R, LIEHR P, NISHIMURA C, ITO M, SUMMERS LC. Meaning of health for Japanese elders who have had a stroke. Jpn J Nurs Sci 2005. [DOI: 10.1111/j.1742-7924.2005.00032.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ahmed S, Mayo NE, Wood-Dauphinee S, Hanley JA, Cohen SR. Response shift influenced estimates of change in health-related quality of life poststroke. J Clin Epidemiol 2004; 57:561-70. [PMID: 15246124 DOI: 10.1016/j.jclinepi.2003.11.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2003] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The interpretability of changes in perceived health status over time is threatened if people experience a response shift. This study assessed whether the recovery process following stroke altered individuals' perceptions of past health status and the impact that change in internal standards (response shift) had on ratings over time. We hypothesized that individuals with stroke would experience changes in internal standards, not experienced by the control group. Two other hypotheses related to objective criterion measures also were tested. STUDY DESIGN AND SETTING Individuals were recruited through a randomized trial of acute poststroke care. Health status was evaluated at baseline (within the first week poststroke), 6 and 24 weeks later using the EQ VAS. At 6 and 24 weeks, subjects were asked to retrospectively re-evaluate their health status for the preceding evaluation using the then test technique. RESULTS The pattern of mean scores was indicative of changes in internal standards among individuals with stroke but not for the control group. Memory had an impact on estimates of response shift. Hypotheses related to the objective criterion measures were not supported. CONCLUSION The results suggest that there was a change in internal standards, and that measures of improvement in health status are different based on prospective as compared to retrospective ratings. Further understanding of the impact of recall on the assessment of response shift using the then test is needed to validate the use of this technique.
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Affiliation(s)
- Sara Ahmed
- Division of Clinical Epidemiology, Royal Victoria Hospital, 687 Pine Avenue West, Ross 4.29, Montreal, Quebec, H3A 1A1, Canada.
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Abstract
BACKGROUND AND PURPOSE Qualitative studies are increasingly used to investigate social processes and phenomena influencing health behaviors and service provision. We aimed to identify the scope of published qualitative studies of stroke, consider their relevance to development and delivery of services for people with stroke, and make recommendations for future work. METHODS Literature review of published articles was identified by systematically searching online literature databases using keywords from the start of each database until 2002. Articles were reviewed by 2 authors, using a standardized matrix for data extraction. The 2003 European Stroke Initiative recommendations for stroke management were used to categorize the literature for consideration of its contribution to stroke research. RESULTS We included 95 articles. Their empirical contribution includes an emphasis on recording the "human" experience of stroke; identification of needs as perceived by patients and their families, differences in priorities between patients and professionals, and barriers to best-quality care. We identified 12 papers that were specifically undertaken to develop or evaluate interventions. CONCLUSIONS Qualitative studies have addressed a wide range of issues related to the impact of stroke on individuals and caregivers, and to the organization and delivery of services. Significant problems remain in ensuring the delivery of best-quality stroke care, which such studies have the potential to address. Maximizing this potential requires greater collaboration between nonclinical and clinical scientists, service providers, and users to formulate research questions of interest as well as new research strategies, such as meta-analysis, to pool qualitative research findings and multisited investigations.
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Affiliation(s)
- Christopher McKevitt
- Department of Public Health Sciences, King's College London, Capital House, 42 Weston Street, London SE1 3QD, UK.
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Kvigne K, Kirkevold M. Living with bodily strangeness: women's experiences of their changing and unpredictable body following a stroke. QUALITATIVE HEALTH RESEARCH 2003; 13:1291-1310. [PMID: 14606414 DOI: 10.1177/1049732303257224] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The authors' aim in this phenomenologial and feminist study was to gain a deeper understanding of how female stroke survivors experienced their body after a stroke. They recruited 25 women in a rural area in eastern Norway who had suffered a first-time stroke and interviewed them in depth three times each during the first 1 1/2 to 2 years following the stroke. The data analysis was inspired by phenomenological method. The stroke survivors' experiences of their bodies were characterized by profound, disturbing, and, in part, unintelligible changes during the onset and the process of recovery from the stroke. Their experiences can be summarized under three major themes: The Unpredictable Body, The Demanding Body, and The Extended Body.
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Affiliation(s)
- Kari Kvigne
- Hedmark University College, Faculty of Social Work, 2418 Elverum, Norway
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