Inadequacies in the provision of information to stroke patients and their families

Exploring the needs of stroke patients after discharge from rehabilitation centres in Saudi Arabian communities: An IPA qualitative exploratory study design

There are about 29 strokes per 100,000 people, annually, in the Kingdom of Saudi Arabia (KSA). These patients require long-term rehabilitation services to enhance recovery and independence in the community. Currently there are limited long-term rehabilitation services in KSA and research is needed to establish pathways for provision of community-based rehabilitation (CBR). To develop effective new CBR models, understanding the experiences and needs of stroke patients in KSA who have undergone poststroke care services is essential. This study aims to gain insight into stroke patients' needs after their discharge from rehabilitation centres in Saudi Arabia. An interpretive phenomenological analysis (IPA) study was undertaken using semi-structured interviews. Participants were eligible if they had a stroke, completed their in-hospital rehabilitation sessions and had been discharged within the past three years. Semi-structured interviews were conducted using interview guides. Transcripts were translated and analysed using interpretive phenomenological analysis. Twenty-four (15 males and 9 females) participants were recruited from two hospitals in KSA. The key findings suggested that patients experienced limited community rehabilitation services postdischarge unless they were financially able to pay for private therapy. Coping barriers including Medical, Psychological, Social, and Financial and facilitators including Faith, Recovery, Social support and leisure were identified. Participants suggested strategies to improve services within hospital and community for rehabilitation, needs of staff, access to services and ongoing care. Further work is required to develop, implement and evaluate a community rehabilitation intervention that includes education, and self-management elements to support stroke survivors in the community in KSA.

Informal Caregiver Stroke Program in Geriatric Rehabilitation of Stroke Patients: A Qualitative Study

This study aimed to understand and gain insight into an informal caregiver program for caregivers of older stroke patients, which incorporates both skills training and education, in relation to caregiver burden. Semi-structured, in-depth interviews with individual informal caregivers were conducted at admission, at discharge, and six weeks after discharge. The program consisted of informal caregiver meetings, walk-in days, psychoeducation, and weekend leave after admission to a rehabilitation stroke unit in a nursing home. Eleven informal caregivers participated in the study. The informal caregiver meetings and walk-in days provided more insight into the (level of) functioning of the stroke patients, more skills in guiding them, and better communication with the multidisciplinary care team. During weekend leave, caregivers experienced what their roles as caregivers entailed. Six weeks after discharge, caregivers said that they did not miss any guidance during admission and that they were positive about the future. About half of the caregivers found the caregiver situation disappointing, and combining care tasks with daily tasks appeared to be difficult. Offering informal caregivers a tailor-made program during rehabilitation and good communication helps to diminish caregiver burden in the post-discharge phase when their relatives are back home.

Redesigning Rural Acute Stroke Care: A Person-Centered Approach

Stroke service delivery in rural areas in Australia lacks evidence-based, best practice care protocols as a result of limited resources and opportunity. Healthcare redesign is an approach to improving health services by understanding barriers and enablers to service provision and work with users to develop solutions for improvement. This research aimed to qualitatively evaluate stroke care in rural Tasmania using a person-centered approach, as part of a larger healthcare redesign initiative to improve acute stroke care. Semi-structured interviews, aimed at gaining insight into experiences of healthcare staff and users, were conducted. Thematic analysis revealed three global themes (communication, holistic care, and resourcing) that demonstrated some consistency between healthcare staff and user experience, highlighting that some needs and expectations were not being met. Results of this experiential study provide important perspectives for delivering needs-based improvements in service provision for acute stroke care. Overall, this study showed that systems of stroke care in rural areas could be improved by utilizing a redesign approach including healthcare staff and users in the development of solutions for health service improvement.

The virtual family conference in stroke rehabilitation: Education, preparation, and transition planning

OBJECTIVE

To examine the virtual family conference as an educational, preparatory, and transition planning intervention in stroke rehabilitation.

DESIGN

Observational-cross-sectional study.

SETTING

Inpatient stroke rehabilitation.

SUBJECTS

Eighty-seven carers, participating in 48 conferences, were evaluated.

INTERVENTIONS

The virtual family conference, involving the patient, carer(s), and interdisciplinary rehabilitation team, completed prior to community transition. The conference protocol and framework, consisting of nine primary themes and additional sub-themes, are outlined. Teleconferencing was the utilized virtual modality.

MAIN MEASURES

Carers were assessed via questionnaires regarding pre- and post-conference rated: (1) stroke-related knowledge, (2) satisfaction with information provision, and (3) confidence, preparedness, and stress associated with community transition; by use of the Stroke Knowledge and Community Transition Preparedness Questionnaire, Mant et al. Information Satisfaction Questionnaire, and Kingston Caregiver Stress Scale.

RESULTS

Significant improvement in post-conference carer-rating was noted for knowledge, pertaining to stroke nature/impairments, stroke management/prevention, functional status, and community services. Significant gains were demonstrated in post-conference satisfaction with information provided regarding stroke and discharge planning, across all assessed topics. There was also a significant increase in carer-reported confidence and preparedness for the community transition as well as a significant reduction in self-perceived stress for elements of the caregiving role. Organization of community follow-up care was consistently enabled within the proposed framework.

CONCLUSIONS

The virtual family conference intervention demonstrated efficacy in facilitating carer education and preparation, along with discharge planning prior to community transition from stroke rehabilitation. Thus, illustrating potential benefits of family conferences and feasibility of their virtual application in stroke rehabilitative care.

Perspectives and Experiences of Cardiac Rehabilitation after Stroke—A Qualitative Study

Cardiac rehabilitation (CR) after stroke has been proven to be a safe and feasible secondary prevention intervention. Limited qualitative data capture people’s experiences and perceptions of attending CR following stroke, but with none addressing translational aspects when CR is delivered as routine clinical care. Using a phenomenological, qualitative approach, four semi-structured focus groups were conducted with 15 individuals (60% male) who had completed CR during their stroke care pathway. Our inductive thematic analysis identified five themes. The first centred on recognising stroke as a cardiovascular disease and the applicability of CR post-stroke. The second addressed how peer understanding, camaraderie, and medical supervision created a safe and supportive environment. The third identified how the programme-built confidence supported longer-term healthy lifestyle choices in physical activity, diet, and smoking. The penultimate theme addressed the period from hospital discharge to attending CR as a time of uncertainty where many participants experienced cognitive difficulties, mood disturbances, and mental fatigue without adequate support. Lastly, participants identified unmet needs in their care pathway that included a lack of information about their referral to CR, the programme content, and accessing local supports ahead of CR. Ongoing and unmet needs both during and after CR related to self-management of secondary prevention medications, neurological issues, post-stroke fatigue, and the lack of structured support following CR completion.

The experience of close personal relationships after stroke: scoping review and thematic analysis of qualitative literature

Background and Purpose:

Psychosocial difficulties, including changed relationships are among the most pervasive and concerning issues following stroke. This study aimed to collate and thematically analyse qualitative literature describing the experience of close personal relationships from the perspective of stroke survivors.

Method:

Using a scoping review methodology, four databases (CINAHL/EBSCO, MEDLINE/Pubmed, Embase, Psychinfo) were systematically searched, yielding 3100 citations. Following exclusion of duplicates and screening against inclusion criteria at title/abstract and full text levels, 53 articles were included in the review. Data were charted and thematically analysed.

Results:

While research has increased since 2000, longitudinal designs are few. Four overarching themes and 12 subthemes were identified. ‘Social disruption’ described changing social worlds, lost social opportunities and shrinking networks. ‘Changed relationships’ included changed family and spousal relationships and changed parenting relationships. The third theme ‘relationships help’ highlighted positive aspects including belonging, support and a life worth living. The final theme was ‘coping with an altered social world’ and described adjustment and emotional responses.

Conclusions:

Relationships are an important aspect of life post stroke but are subject to changes and challenges. This article brings together a breadth of qualitative data to describe lived experiences. Further research, in particular, longitudinal research is required.

Unmet care needs of community-dwelling stroke survivors: a systematic review of quantitative studies

OBJECTIVES

Understanding the unmet needs of community-dwelling stroke survivors is essential for further intervention. This systematic review was performed to summarise their unmet needs from a quantitative viewpoint.

DESIGN

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

A comprehensive search of six databases was conducted from inception to February 2020: PubMed, EMBASE, CINAHL, PsycINFO, SCOPUS and CBM. The methodological quality of the studies was assessed. Unmet needs were categorised, and a pooled analysis of the main outcomes was conducted.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included quantitative studies focused on the unmet needs of stroke survivors who live at homes rather than in any other institutionalised organisation.

RESULTS

In total, 32 of 2660 studies were included, and 1980 unmet needs were identified. The prevalence of patients with unmet needs ranged from 15.08% to 97.59%, with a median of 67.20%; the median number of unmet needs per patient ranged from 2 to 8 (0-31). The prevalence of unmet needs was high at 6 months post-stroke (62.14%) and 2 years post-stroke (81.37%). After categorisation, the main concerns among these patients were revealed to be information support, physical function and mental health; a few studies reported unmet needs related to leisure exercise, return to work and so on. Additionally, differences in the measurement tools used across studies affect what unmet needs participants report.

CONCLUSIONS

Sufficient, accurate, individualised and dynamic information support is a priority among community-dwelling stroke survivors. Physical function and mental health are also the most significant concerns for re-achieving social participation. It is essential to design and disseminate standard, effective and time-saving tools to assess unmet needs.

TRIAL REGISTRATION NUMBER

CRD42018112181.

Patient perspectives on health-related behavior change after transient ischemic attack or ischemic stroke

OBJECTIVE

Unhealthy lifestyle is common among patients with ischemic stroke or TIA. Hence, health-related behavior change may be an effective way to reduce stroke recurrence. However, this is often difficult to carry out successfully. We aimed to explore patients' perspectives on health-related behavior change, support in this change, and sustain healthy behavior.

METHODS

We conducted a descriptive qualitative study with in-depth, semistructured interviews in eighteen patients with recent TIA or ischemic stroke. Interviews addressed barriers, facilitators, knowledge, and support of health-related behavior change framed by the protection motivation theory. All interviews were transcribed and thematically analyzed.

RESULTS

Patients seem unable to adequately appraise their own health-related behavior. More than half of the patients were satisfied with their lifestyle and felt no urgency to change. Self-efficacy as coping factor was the most important determinant (both barrier and facilitator). Fear as threat factor was named as facilitator for health-related behavior change by half of the patients. Most of the patients did not need support or already received support in changing health behavior. Patients indicated knowledge, guidelines, and social support as most needed to support and preserve a healthy lifestyle.

CONCLUSION

This study suggests that patients with recent TIA or ischemic stroke often do not have a high intention to change health-related behavior. The results fit well within the framework of the protection motivation theory. As many patients seem unable to adequately appraise their health behaviors, interventions should focus on increasing knowledge of healthy behavior and improving self-efficacy and social support.

"Factors influencing sedentary time and physical activity early after stroke: a qualitative study"

PURPOSE

We aimed to understand from the perspective of stroke survivors and their carers (1) factors contributing to sedentary time and physical activity during inpatient rehabilitation and the transition home, and (2) actual and perceived opportunities to reduce sedentary time and increase physical activity.

MATERIAL AND METHODS

Qualitative study with 7 stroke survivor/carer dyads and 8 stroke survivors. Semi-structured interviews were conducted 2-4 weeks after hospital discharge, audio recorded and transcribed prior to thematic analysis.

RESULTS

Stroke survivors were mean age 69 [SD15] years (53% male). Carers were mean age 62 [SD15] years (86% were female). Five themes were identified: (1) Education and guidance about physical activity and sedentary behaviour after stroke is important to build understanding of recovery and secondary prevention, (2) Stroke survivors need clear communication about safety and risk, (3) Return to life participation supports motivation for and engagement in physical activity, 4) Social and professional influences and 5) Opportunities to be physically active.

CONCLUSION

Stroke survivors and their carers need a clearer understanding of the role of physical activity and risks of sedentary time during stroke recovery. Physical activity enablers included consistent communication, building confidence and skills to self-manage activity before discharge.Implications for RehabilitationInpatient rehabilitation and early after discharge may be an important time-point to support stroke survivors to establish long term physical activity behaviours before contact with healthcare professionals reduces.To reduce sedentary behaviour, people need to understand the health benefits of breaking up sedentary time and people who need physical support to stand up will need greater support from health professionals.Being able to imagine a future post-stroke self is important motivation to get up and move. Rehabilitation should help develop a person's vision of their post-stroke self.Managing potential risks in hospital without overly restricting physical activity is important and requires consistent communication from the multi-disciplinary team.Building a person's confidence and skills to self-manage physical activity in the community prior to discharge home may be another key enabler for activity.

Physiotherapists' and occupational therapists' perspectives on information and communication technology in stroke rehabilitation

Aim

The aim of this study was to explore the current and potential use of information and communication technology (ICT) to enhance coherent person-centred rehabilitation after stroke, from the perspectives of physiotherapists and occupational therapists.

Method

Five occupational therapists and four physiotherapists from different phases of the Danish stroke rehabilitation process were included and two focus group interviews were carried out. A grounded theory approach was used throughout the study and a constant comparative method was used in the analysis.

Results

Three subcategories were identified from the analysis of interviews with participants: 1) ICT and apps as meaningful and supportive in the rehabilitation process, 2) ICT as a tool in communication and documentation and 3) Barriers to the integration of ICT and apps in the rehabilitation process. From these categories one core category emerged: The potential of a personalized app solution to facilitate coherent person-centred rehabilitation.

Conclusion

ICT was perceived as important to integrate in stroke rehabilitation both for assessment, training and to compensate for remaining deficits. The development of a personalized app solution could accommodate stroke survivors’ and significant others’ need for insight into and overview over the rehabilitation process as well as access to relevant information, which would thereby empower them. Furthermore, a personalized app solution could also facilitate follow-up after discharge and was perceived to ease the communication and documentation within and between sectors, as well as communication with both stroke survivors and significant others.

The Unmet Needs of Stroke Survivors and Stroke Caregivers: A Systematic Narrative Review

INTRODUCTION

Facilitating stroke survivors and their caregivers to lead a fulfilling life after stroke requires service providers to think about their different needs. Poor post stroke care may lead to unmet needs in stroke survivors and stroke caregivers. This may compromise them in leading their lives optimally after stroke.

OBJECTIVES & METHODOLOGY

This systematic narrative review examines articles published from 1990 to 2017, generated from Ovid, MEDLINE, CINAHL, and PubMed. The search was also supplemented by an examination of reference lists for related articles via Scopus. We included 105 articles.

FINDINGS

We found that the type of unmet needs in stroke survivors and the contributing factors were substantially different from their caregivers. The unmet needs in stroke survivors ranged from health-related needs to re-integration into the community; while the unmet needs in stroke caregivers ranged from information needs to support in caring for the stroke survivors and caring for themselves. Additionally, the unmet needs in both groups were associated with different factors.

CONCLUSION

More research is required to understand the unmet needs of stroke survivors and stroke caregivers to improve the overall post-stroke care services.

Illness beliefs and emotional responses in mildly disabled stroke survivors: A qualitative study

Background

As acute stroke services improve, more persons experience mild stroke and need to cope daily with hidden disabilities, which may be influenced by how they perceive stroke, cognitively and emotionally.

Objective

To investigate cognitive illness beliefs and emotional responses in persons with mild stroke and their possible influences on daily coping.

Methods

Semi-structured interviews were conducted with 24 persons with mild stroke, on average 7.5 months (±0.89) after stroke occurrence. A thematic analysis on verbatim transcripts was guided by the Common-Sense Model of Self-Regulation.

Results

All participants experienced difficulties constructing an illness identity at both acute and chronic phase. Behavioral risk factors were less accepted as causes of stroke. Lack (or inappropriate timing) of information from healthcare providers led to limited medication knowledge and low perceived control of stroke recurrence which generated anxiety, fear, and low involvement in coping. Participants who considered stroke a chronic condition experienced more difficulties. Perceived support from relatives and healthcare providers was beneficial for participation in recovery and health behaviour change.

Conclusion

Despite having mildly disabilities, participants reported difficulties developing illness beliefs conducive to coping, and dealing with their emotional responses. These elements should be considered in tailored programs to improve coping with hidden disabilities post-stroke.

Michigan Stroke Transitions Trial

BACKGROUND

To test whether access to home-based social worker-led case management (SWCM) program or SWCM program combined with a website providing stroke-related information improves patient-reported outcomes in patients with stroke, relative to usual care.

METHODS AND RESULTS

The MISTT (Michigan Stroke Transitions Trial), an open (unblinded) 3-group parallel-design clinical trial, randomized 265 acute patients with stroke to 3 treatment groups: Usual Care (group-1), SWCM (group-2), and SWCM+MISTT website (group-3). Patients were discharged directly home or returned home within 4 weeks of discharge to a rehabilitation facility. The SWCM program provided in-home and phone-based case management services. The website provided patient-orientated information covering stroke education, prevention, recovery, and community resources. Both interventions were provided for up to 90 days. Outcomes data were collected by telephone at 7 and 90 days. Primary patient-reported outcomes included Patient-Reported Outcomes Measurement Information System Global-10 Quality-of-Life (Physical and Mental Health subscales) and the Patient Activation Measure. Treatment efficacy was determined by comparing the change in mean response (90 days minus 7 days) between the 3 treatment groups using a group-by-time interaction. Subjects were aged 66 years on average, 49% were female, 21% nonwhite, and 86% had ischemic stroke. There were statistically significant changes in Patient-Reported Outcomes Measurement Information System Physical Health ( P=0.003) and Patient Activation Measure ( P=0.042), but not Patient-Reported Outcomes Measurement Information System Mental Health ( P=0.56). The mean change in Patient-Reported Outcomes Measurement Information System Physical Health scores for group-3 (SWCM+MISTT Website) was significantly higher than both group-2 (SWCM; difference, +2.4; 95% CI, 0.46-4.34; P=0.02) and group-1 (usual care; difference, +3.4; 95% CI, 1.41-5.33; P<0.001). The mean change in Patient Activation Measure scores for group-3 was significantly higher than group-2 (+6.7; 95% CI, 1.26-12.08; P=0.02) and marginally higher than group-1 (+5.0; 95% CI, -0.47 to 10.52; P=0.07).

CONCLUSIONS

An intervention that combined SWCM with access to online stroke-related information produced greater gains in patient-reported physical health and activation compared with usual care or case management alone. There was no intervention effect on mental health.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02653170.

"Just got to live life as it comes": A case study of the spousal-dyad longitudinal mild stroke transitional experience

Objective: To longitudinally explore the transition home for a spousal dyad following mild stroke, in the context of a mild stroke-specific health service. Research Design: A case study approach, using an Interpretative Phenomenological Analysis (IPA), was identified as suitable for this study, as it enabled the essence of the phenomenon to be examined. Method: Participants were purposively chosen from a Randomised Control Trial (RCT), to reflect the average age, gender and marital status of the mild stroke population. The participants were a male (age 64) and his wife (age 62). Participants received the RCT intervention. Semi-structured interviews were completed separately with participants at 1-, 3-, 6- and 9- months post stroke. Results: Two themes were identified: (1) The Unexpected, Undesirable and Short-Lived, and (2) The New 'Normal'. The first theme reflects the confusion, adjustment and adaptation that occurred for the couple, especially during the first month at home. The second represents the couple's journey back to their everyday lives following hospital discharge, but also the questions and changes that remained present at 9-months post-discharge. Conclusions: Themes demonstrate an ongoing process of adjustment and the contextual nature of the transitional experience. Results also indicate the need to ensure that individuals have access to mild-stroke specific information across the transition continuum.

Seeking normality: Parents' experiences of childhood stroke

BACKGROUND

Incidence of paediatric stroke has been estimated to range from 1.2 to 13 per 100,000 children under 18 years of age. It is a significant cause of long-term morbidity in children with long-term impacts on physical, cognitive, psychological, and social outcomes. However, little is known about the experiences of parents caring for a child with stroke. Such information is needed to inform the development of child- and family-centred care.

METHODS

We conducted in-depth interviews with parents of children with stroke. Participants were purposively sampled from three regional specialist services in England, based on the age of the child at stroke onset and time since first stroke. Interviews used a topic guide and were audio recorded and transcribed in full. Thematic analysis was conducted to develop an account that reflected patients' experiences from their own perspectives.

RESULTS

Twelve parents participated with five children classified as having no to mild deficits and seven with moderate to severe deficits. Parents were concerned about the effects of stroke on the child's psychological, cognitive, and social well-being. Significant impacts on parents own well-being and on the family were reported. Although most experienced good quality acute care, meeting the child's needs after hospital discharge was problematic, with low levels of awareness of paediatric stroke among professionals and difficulties accessing relevant information and services. Meeting special education needs was variable. Parents were proactive in seeking to establish a sense of normality for the child and themselves.

CONCLUSIONS

The findings illuminate a wider picture of paediatric stroke than indicated by clinical outcomes alone. Parents' experiences varied according to the child's needs but also family's situation and geographical location. Particular attention should be paid to co-ordinating services to meet multiple needs after discharge from hospital.

Coproduction of a Theory-Based Digital Resource for Unpaid Carers (The Care Companion): Mixed-Methods Study

BACKGROUND

Family and other unpaid carers are crucial to supporting the growing population of older people that are living outside residential care with frailty and comorbidities. The burden associated with caring affects carers' well-being, thus limiting the sustainability of such care. There is a need for accessible, flexible, and responsive interventions that promote carers' coping and resilience, and hence support maintenance of the health, well-being, and independence of the cared-for person.

OBJECTIVE

This study aimed to coproduce a digital program for carers to promote resilience and coping through supporting effective use of information and other Web-based resources. Its overlapping stages comprised the following: understanding the ways in which Web-based interventions may address challenges faced by carers, identifying target behaviors for the intervention, identifying intervention components, and developing the intervention prototype.

METHODS

The study was informed by person-based theories of coproduction and involved substantial patient and public involvement. It drew on the Behavior Change Wheel framework to support a systematic focus on behavioral issues relevant to caring. It comprised scoping literature reviews, interviews, and focus groups with carers and organizational stakeholders, and an agile, lean approach to information technology development. Qualitative data were analyzed using a thematic approach.

RESULTS

Four behavioral challenges were identified: burden of care, lack of knowledge, self-efficacy, and lack of time. Local health and social care services for carers were only being accessed by a minority of carers. Carers appreciated the potential value of Web-based resources but described difficulty identifying reliable information at times of need. Key aspects of behavior change relevant to addressing these challenges were education (increasing knowledge and understanding), enablement (increasing means and reducing barriers for undertaking caring roles), and persuasion (changing beliefs and encouraging action toward active use of the intervention). In collaboration with carers, this was used to define requirements for the program. A resources library was created to link to websites, Web-based guidance, videos, and other material that addressed condition-specific and generic information. Each resource was classified according to a taxonomy itemizing over 30 different subcategories of need under the headings Care Needs (of the cared-for person), General Information and Advice, and Sustaining the Carer. In addition, features such as a journal and mood monitor were incorporated to address other enablement challenges. The need for proactive, personalized prompts emerged; the program regularly prompts the carer to revisit and update their profile, which, together with their previous use of the intervention, drives notifications about resources and actions that may be of value.

CONCLUSIONS

The person-based approach allowed an in-depth understanding of the biopsychosocial context of caring to inform the production of an engaging, relevant, applicable, and feasible Web-based intervention. User acceptance and feasibility testing is currently underway.

Needs of Stroke Survivors as Perceived by Their Caregivers: A Scoping Review

OBJECTIVE

Caregivers usually are not involved while planning the stroke survivor's medical and rehabilitation goals and interventions. This review aimed to identify the needs of stroke survivors as perceived by their caregivers.

DESIGN

A literature search from 2003 to 2014 was conducted using Medline, CINAHL, PsychINFO, and Google Scholar. Sixty-six studies were included. Most studies excluded did not encompass caregivers' perspectives. Four reviewers screened the titles, abstracts, and full texts of the articles for inclusion. The data extracted from these studies were synthetized into metathemes.

RESULTS

Fifty-two qualitative, ten quantitative survey, and four mixed-methods studies were included in the final synthesis. The studies came from 11 countries. The data synthesis produced following three metathemes: (a) body functional needs, including psychological function, physical function, cognitive function, and uncertainty related to function; (b) activity and participatory needs, including healthy lifestyle, physical activities, speech, independence, cognitive activities, and uncertainty related to activities and participation; and (c) environmental needs, encompassing support, services, safety, accommodation and accessibility, and uncertainty related to environmental factors.

CONCLUSIONS

This scoping review identified a range of needs of stroke survivors as perceived by their caregivers. Incorporating the caregiver's preferences and values into clinical decisions may improve outcomes among stroke survivors.

Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

Background

For some stroke patients and caregivers, navigating the transition between hospital discharge and returning home is associated with substantial psychosocial and health-related challenges. Currently, no evidence-based standard of care exists that addresses the concerns of stroke patients and caregivers during the transition period. Objectives of the Michigan Stroke Transitions Trial (MISTT) are to test the impact of a social worker home-based case management program, as well as an online information and support resource, on patient and caregiver outcomes after returning home.

Methods

The Michigan Stroke Transitions Trial is a randomized, pragmatic, open (un-blinded), 3-group parallel designed superiority trial conducted in 3 Michigan hospitals. Eligible participants are adult acute stroke patients discharged home directly or within 4 weeks of being discharged to a rehabilitation facility. The patient’s primary caregiver is also invited to participate. Patients are randomized on the day they return home using a randomized block design. Consented patients discharged to a rehabilitation facility who do not go home within 4 weeks are dropped from the study.

The 2 study interventions begin within a week of returning home and conclude 3 months later. The 3-group design compares usual care to either a home-based social worker stroke case management (SWSCM) program, or a combination of the SWSCM program plus access to an online information and support resource (MISTT website). Outcomes data are collected at 7-days and 90-days by trained telephone interviewers. Primary patient outcomes include the PROMIS global 10 score (a generic Quality of Life scale), and the Patient Activation Measure (PAM). Caregiver outcomes include the Bakas Caregiving Outcomes Scale. Final analysis will be based on 214 randomized acute stroke patients. To accommodate subjects excluded due to prolonged rehabilitation stays, as well as those lost-to-follow-up, up to 315 patients will be consented.

Discussion

The MISTT study will determine if a home-based case management program designed around the needs and preferences of stroke patients and caregivers, alone or in combination with a patient-centered online information and support resource can improve stroke survivor and caregiver outcomes 3 months after returning home.

Trial registration

ClinicalTrials.gov: NCT02653170 (Protocol ID: 135457). Registered April 9, 2015.

Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction

Background and purpose

Interventions are needed to improve stroke literacy among recent stroke survivors. We developed an educational video for patients hospitalized with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).

Methods

A 5-minute stroke education video was shown to our AIS and ICH patients admitted from March to June 2015. Demographics and a 5-minute protocol Montreal Cognitive Assessment were also collected. Questions related to stroke knowledge, self-efficacy, and patient satisfaction were answered before, immediately after, and 30 days after the video.

Results

Among 250 screened, 102 patients consented, and 93 completed the video intervention. There was a significant difference between pre-video median knowledge score of 6 (IQR 4–7) and the post-video score of 7 (IQR 6–8; p<0.001) and between pre-video and the 30 day score of 7 (IQR 5–8; p = 0.04). There was a significant difference between the proportion of patients who were very certain in recognizing symptoms of a stroke pre- and post-video, which was maintained at 30-days (35.5% vs. 53.5%, p = 0.01; 35.5% vs. 54.4%, p = 0.02). The proportion who were “very satisfied” with their education post-video (74.2%) was significantly higher than pre-video (49.5%, p<0.01), and this was maintained at 30 days (75.4%, p<0.01). There was no association between MoCA scores and stroke knowledge acquisition or retention. There was no association between stroke knowledge acquisition and rates of home blood pressure monitoring or primary care provider follow-up.

Conclusions

An educational video was associated with improved stroke knowledge, self-efficacy in recognizing stroke symptoms, and satisfaction with education in hospitalized stroke patients, which was maintained at 30 days after discharge.

Patient Perceptions of the Quality of Information Provided in a Hospital Stroke Rehabilitation Unit

This study explored the extent, source and format of the information received by stroke rehabilitation patients and their perceptions of the quality of that information. Additionally, the readability levels of the written materials received were assessed. Fifteen patients were interviewed approximately 1.8 months post-inpatient rehabilitation.

Occupational therapists were the principal sources of information about returning home, equipment/ assistive devices, activities/exercise after stroke and the physical effects of stroke. The patients wanted additional information on the following topics that occupational therapists can address: treatments after stroke, the causes of stroke, risk factors/future prevention, stroke support groups, what to expect in rehabilitation and emotional problems/ difficulties during recovery.

Most information was verbal. Although 70% of the patients felt that they had not received enough information and 87% identified gaps in what they had received, the information was considered relevant to their needs, easy to read/understand and helpful in coping with lifestyle changes. Two-thirds had received written information, written at an average grade 12 equivalent; this was a level too high for educating lay people about health.

The implications for occupational therapists are that general information may be being provided at the expense of the information of most importance to the patients. Occupational therapists should assess and address patients' informational needs and identify the patients' preferred formats for receiving the information. The assessment of readability is also useful.

High-quality Health Information Provision for Stroke Patients

OBJECTIVE

High-quality information provision can allow stroke patients to effectively participate in healthcare decision-making, better manage the stroke, and make a good recovery. In this study, we reviewed information needs of stroke patients, methods for providing information to patients, and considerations needed by the information providers.

DATA SOURCES

The literature concerning or including information provision for patients with stroke in English was collected from PubMed published from 1990 to 2015.

STUDY SELECTION

We included all the relevant articles on information provision for stroke patients in English, with no limitation of study design.

RESULTS

Stroke is a major public health concern worldwide. High-quality and effective health information provision plays an essential role in helping patients to actively take part in decision-making and healthcare, and empowering them to effectively self-manage their long-standing chronic conditions. Different methods for providing information to patients have their relative merits and suitability, and as a result, the effective strategies taken by health professionals may include providing high-quality information, meeting patients' individual needs, using suitable methods in providing information, and maintaining active involvement of patients.

CONCLUSIONS

It is suggested that to enable stroke patients to access high-quality health information, greater efforts need to be made to ensure patients to receive accurate and current evidence-based information which meets their individual needs. Health professionals should use suitable information delivery methods, and actively involve stroke patients in information provision.

A randomized trial to evaluate an education programme for patients and carers after stroke

Objectives: To evaluate the effectiveness of an education programme for patients and carers recovering from stroke.

Design: Randomized controlled trial.

Subjects and setting: One hundred and seventy patients admitted to a stroke rehabilitation unit and 97 carers of these patients.

Interventions: The intervention group received a specifically designed stroke information manual and were invited to attend education meetings every two weeks with members of their multidisciplinary team. The control group received usual practice.

Measures: Primary outcome was knowledge of stroke and stroke services. Secondary outcomes were handicap (London Handicap Scale), physical function (Barthel Index), social function (Frenchay Activities Index), mood (Hospital Anxiety and Depression Scale) and satisfaction (Pound Scale). Carer mood was measured by the General Health Questionnaire-28.

Results: There was no statistical evidence for a treatment effect on knowledge but there were trends that favoured the intervention. The education programme was associated with a significantly greater reduction in patient anxiety score at both three months (p=0.034) and six months (p=0.021) and consequently fewer ‘cases’ (Hospital Anxiety and Depression Scale anxiety subscale score ≥ 11). There were no other significant statistical differences between the patient or carer groups for other outcomes, although there were trends in favour of the education programme.

Conclusion: An education programme delivered within a stroke unit did not result in improved knowledge about stroke and stroke services but there was a significant reduction in patient anxiety at six months post stroke onset.

Interventions for adult family carers of people who have had a stroke: a systematic review

Objective: A systematic review of the effectiveness of interventions for adult family carers of people with stroke, and an exploratory examination of the relationship between the conceptual basis of these interventions and their effectiveness.

Data sources: Seventeen electronic databases and grey literature sources were searched, including ASSIA, BNI, Cochrane Library, CINAHL, EMBASE, MEDLINE, PsycINFO, Social Science Citation Index and the Science Citation Index, HMIC and the National Research Register. Authors of unpublished material were contacted for data and additional publications. Reference and citation tracking was performed on included publications.

Review methods: Inclusion criteria: randomized controlled trials of interventions aimed primarily at adult family carers of people post stroke; carers were the primary sample; primary outcomes reported were for carers. Two independent reviewers screened titles and abstracts to identify publications and extract data. Quality assessment was performed to weight study findings.

Results: Eight papers were found reporting on six complex, generally heterogeneous, interventions: caregiver training; education and counselling; social problem-solving partnerships, delivered principally by telephone; a psycho-educational telephone support group; a nurse-led support and education programme; and a support programme, delivered either to groups in hospital or individuals during home visits. Half of the interventions were based on stress-coping theories; the remainder did not identify a conceptual basis for the intervention.

Conclusions: Some benefits were reported for all interventions, although trials were generally of low quality, preventing firm conclusions being drawn. The presence of a conceptual basis for interventions does not appear to influence effectiveness.

The impact of a community re-engagement cue to action trigger tool on re-engaging in activities post-stroke: a mixed-methods study

OBJECTIVES

This study evaluated the guided use of the Community Re-engagement Cue to Action Trigger Tool (CRCATT), a patient-mediated question prompt list, and its impact on self-reported re-engagement in activities post-stroke.

METHODS

A multi-site, single-blind randomized controlled study in which 77 persons with stroke participated from three rehab organizations in Toronto, Canada. Of the 77 participants, a total 57 within the two groups completed the study and Reintegration to Normal Living Index (mailed response questionnaire) and a sub-set of all participants participated in qualitative interviews. Data collection occurred 3-4 months after enrollment. Quantitative responses were analyzed in SPSS (Chicago, IL, USA) for descriptive frequencies and differences between groups. Qualitative responses were analyzed using an inductive approach with thematic analytic procedures.

RESULTS

No between group differences were observed due to small sample size. A multi-variable regression model including age, gender, level of education, treatment group, and language, suggests those with higher education are more likely to participate in activities. Interview analysis revealed participants' ability to recover and re-engage is influenced by an interplay of the CRCATT with external factors. These factors include social support, interactions with providers, and ability to access information.

CONCLUSION

The CRCATT was perceived as a useful tool as it assisted persons with stroke to take a more self-directed role in their care by asking relevant questions and anticipating their needs. The tool complemented the external factors that persons with stroke draw on to support recovery and participate in activities post-stroke.

A systematic review of the economic evidence for interventions for family carers of stroke patients

OBJECTIVES

To examine the economic evidence for interventions aimed at family carers of stroke patients.

DATA SOURCES

Searches (limited to those published in English since 1990) were performed in key databases along with hand searches of relevant papers.

REVIEW METHODS

Papers were restricted to studies including any economic data (broadly defined) for any intervention targeting carers explicitly or explicitly referring to a carer element, beyond involving carers in the care or intervention for patients (i.e. more than just carers being invited to observe an intervention targeted at the patient). Two reviewers independently screened full papers and extracted data using guidance from the National Institute for Health and Care Excellence, and quality assessment using the Newcastle-Ottawa Quality Assessment Scale (cohort studies), the Delphi list (randomised controlled trials) and guidelines on economic quality from the British Medical Journal. Data were reviewed descriptively as meta analyses were inappropriate due to non-comparability of studies.

RESULTS

Ten papers were included in the review. These were heterogeneous in their design, intervention and economic analyses making comparison difficult. Only three of the ten papers included economic evaluations. All three reported that the intervention was less costly and had better or equivalent outcomes than the control comparator although two of these were based on the same intervention using the same dataset.

CONCLUSION

There is some limited evidence that interventions for family carers of stroke patients are effective and cost effective. However, due to variation in the types of interventions examined, little can be concluded regarding implications for clinical practice.

An Educational Intervention for Stroke Rehabilitation Patients and Their Families: Healthy Living After Stroke

The education of stroke patients and their families on prevention of recurrent stroke is a rehabilitation challenge. The principal objective of this article is to share a process for creating a stroke education program that improves patient and caregiver knowledge of secondary prevention, stroke signs and symptoms, modifiable risk factors, and maintenance of functional independence. During stroke recovery, patient education is a continuous journey. The education program needs to take into consideration the individual's readiness to learn, unique learning styles, and timing of sessions. In our educational program, Healthy Living After Stroke, we used the stroke team to develop different venues of learning.

The Language of Recovery: How Effective Communication of Information Is Crucial to Restructuring Post-Stroke Life

BACKGROUND

Providing appropriate and effective information to people with stroke and their families has been identified as a key component to successful practice. Researchers continue to focus on "lack of information" as being the lack of specific technical medical information rather than the communication of practical knowledge and how people use that knowledge to restructure life after stroke. To meet patients' expectations and achieve better outcomes in stroke, professionals need access to communication theory, research, and training.

OBJECTIVES

Improve stroke communication systematically.

METHOD

This article will examine stroke communication using a three-part framework: 1. Utilize theory to clearly conceptualize how communication influences stroke outcome. 2. Identify components and mechanisms of communication content to positively influence stroke outcome. 3. Develop goals and strategies for putting content skills into stroke communication practice.

CONCLUSION

Relatively little is known about the content and structure of informal communication transactions between stroke survivors, families, and health care professionals and how they accommodate (or resist) realignment of identity after stroke. The professional discourse attempts to ensure realistic expectations of recovery whereas stroke survivors and families complain about the negative discourses, how possibilities for life after stroke are presented, and the hopelessness that this creates. More research is required into how these different discourses affect outcomes.

Written Education Materials for Stroke Patients and Their Carers: Perspectives and Practices of Health Professionals

Inadequacies in the provision of written education materials to stroke patients and their carers have been reported. In this study, 20 stroke team health professionals were surveyed regarding their use of and perspectives on written education materials. Seventy percent of participants provided materials to 25% or fewer stroke patients and 90% believed that patients and carers are only occasionally or rarely provided with sufficient written information. Health professionals were uncertain which team members provided written information and identified the need to improve the quality of materials used. Stroke teams should implement a system that facilitates the routine provision of quality written materials to patients and carers, communication among team members, and documentation and verbal reinforcement of the information provided.

Collaborative interaction points in post-discharge stroke care

Introduction

Lack of appropriate electronic tools for supporting patient involvement and collaboration with care professionals is a problem in health care.

Methods

Care and rehabilitation processes of post-discharge stroke patients were analysed using the concept of interaction points where patients, next-of-kin and care professionals interact and exchange information. Thirteen interviews with care professionals and five non-participatory observations were performed. Data were analysed using content analysis and modelling of interaction points in the patient journey.

Results

Patient participation and interaction patterns vary; patients requiring home care have a passive role and next-of-kin or nurses become advocates by coordinating care on behalf of the patient, whereas patients who are able to visit primary care coordinate their own care by initiating interactions. Important categories of participation include the following: participation in care planning, in monitoring risk factors and in rehabilitation planning.

Conclusions

Designing a supportive electronic tool requires understanding the interactions and patients’ activity levels at each interaction point. A tool for patients with higher activity level should support them to coordinate their own care, whereas for a less-active patient group, the tool could focus on supporting next-of-kin and care professionals in motivating, guiding and including passive patients in their care and rehabilitation processes.

Adherence to medication and self-management in stroke patients

BACKGROUND

Stroke is the third most common cause of mortality and one of the leading causes of adult physical disability in England. Medical treatment is imperative for the management of stroke and the risk reduction of recurrent stroke. The success of a medical treatment is determined largely by adherence. However, research has shown that adherence to medication in patients who have had a stroke is often suboptimal. Self-management interventions have been shown to improve adherence in long-term conditions. The impact of self-management interventions specifically on adherence to stroke medication is unknown.

OBJECTIVE

To review systematically the impact that self-management interventions have on adherence to stroke medication.

METHOD

The online databases that were systematically searched included PsychINFO, MEDLINE, EMBASE, Scopus, Cochrane Database of Systematic Reviews, CINAHL and Web of Science. Reference lists of retrieved studies were hand-searched.

RESULTS

Six studies met the criteria for inclusion in the systematic review. Self-management interventions for stroke patients were effective in improving adherence to stroke medication in the short term. However, in the longer term, these benefits were not maintained.

CONCLUSIONS

Applying self-management interventions to improve medication adherence in stroke patients across integrated clinical settings shows promise. However, further development of such interventions and research is recommended, with more stringent methodologies and longer follow-up periods.

Ethical issues relating to the inclusion of relatives as clients in the post-stroke rehabilitation process as perceived by patients, relatives and health professionals

OBJECTIVE

To document the ethical issues regarding the systematic inclusion of relatives as clients in the post-stroke rehabilitation process.

METHODS

A two-phase qualitative design consisting of in-depth interviews with relatives and stroke-clients (Phase 1) and three focus groups with relatives, stroke-clients and health professionals (Phase 2). Data was audio recorded. Transcribed interviews and focus groups content were rigorously analyzed by two team members.

RESULTS

The interview sample was composed of 25 relatives and of 16 individuals with a first stroke whereas the three focus group sample size varied from 5 to 7 participants. Four main themes emerged: (1) overemphasis of caregiving role with an unclear legitimacy of relative to also be a client; (2) communication as a key issue to foster respect and a family-centered approach; (3) availability and attitudes of health professionals as a facilitator or a barrier to a family-centered approach; and (4) constant presence of relatives as a protective factor or creating a perverse effect.

CONCLUSION/PRACTICE IMPLICATIONS

The needs of relatives are well known. The next step is to legitimize their right to receive services and to acknowledge the combined clinical and ethical value of including them post-stroke. Interdisciplinary health care approaches and communication skills should be addressed.

Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation

PURPOSE

To identify the incidence of adverse events (AE) that occurred in stroke survivors during the first year following discharge from inpatient rehabilitation and to determine the type and patterns of AE.

METHODS

Data were collected for 12 months on events resulting in admissions to the emergency department, hospital, long-term care facility, or death. Descriptive statistics were used to depict the patterns of AE and univariate comparisons were made of the differences between survivors who did or did not experience one or more AE.

RESULTS

Of the 159 participants, 50% reported a total of 163 AE. Most AE (82.2%) were unexpected and the majority occurred during the first 6 months; 12 recurrent strokes and 6 transient ischemic attacks occcurred.

CONCLUSIONS

Education on prevention and treatment of common AE is important prior to discharge. Anticipatory guidance may help survivors and caregivers modify their lifestyle and prevent common AE.

A Qualitative Study into Stroke Caregivers' Educational Needs — Perspectives of Caregivers and Healthcare Professionals

Background:

Healthcare professionals (HCPs) often provide information based on what they thought caregivers would need and like to know, rather than on the latter's perceived or actual needs. The current descriptive study was undertaken to find out more about HCP's and caregivers' perceptions of educational needs while the stroke survivor is still being cared for in an acute hospital.

Methods:

Ten caregivers, five nurses, and two neurologists were interviewed about their perceptions of educational needs during the stroke survivors' stay in acute care. All interviews were audiotaped, transcribed verbatim, and then analysed to identify main patterns of responses. The Framework Approach, which involves the steps of familiarisation, identifying a thematic framework, indexing, charting, mapping, and interpretation was used to inform the analysis.

Results:

Caregivers and HCPs agreed on the need for information on disease progression, prevention of recurrence, practical and emotional care. However, HCPs felt caregivers should also know about medication, which was not mentioned by any of the caregivers. Caregivers preferred “hands-on experience” and “hearing” from HCP to print materials. While some caregivers felt that their active involvement in caregiving training was not required if a foreign domestic worker (FDW) was to be hired, HCPs interviewed felt strongly that next-of-kin should, nonetheless, be trained as well.

Conclusion:

The expressed needs on stroke education did not differ greatly between caregivers and HCPs. Perhaps unique to the Singapore context, is the availability of FDWs to take on the care-giving role. HCPs should be aware of differences in expectations in the level of involvement of family members in the presence of a FDW.

The implementation of evidence-based rehabilitation services for stroke survivors living in the community: the results of a Delphi consensus process

BACKGROUND

Recovery from stroke requires the provision of specialist rehabilitative care, yet there is a lack of research evidence on optimal methods of delivery and inequitable service provision across countries. Following consensus on Early Supported Discharge, our aim was to define core components of evidence-based community stroke services.

DESIGN

We used a modified Delphi approach with a purposive sample of 26 UK-based expert panellists (10 academics, 15 stroke service leads or commissioners, one stroke survivor). Statements based on research literature and policy documents were generated by an independent, mixed academic and service improvement team of nine. In three rounds of consultation panellists indicated their level of agreement with statements. Free text comments were analysed thematically.

RESULTS

Consensus of opinion (>70% agreement) was obtained on 76 of 80 statements. Panellists agreed that stroke specialist care tailored to clinical need should be provided following discharge from hospital. Flexible care pathways should be commissioned and provided through strategic and collaborative leadership across health and social care. Teams need to deliver stroke specialist rehabilitation, handing over responsibility to non-specialist services when patient rehabilitation goals have been met. Lack of consensus on whether to provide services exclusively for stroke patients and the need of support for carers highlights areas for further research.

CONCLUSIONS

Consensus on the provision of evidence-based community stroke rehabilitation has been reached. Commissioning services with a clearly defined remit, which can deliver tailored care to individual stroke patients, is a challenge that needs further exploration.

An assessment of the quality of information on stroke and speech and language difficulty web sites

Online healthcare information is used by patients, their carers and families (PCF) experiencing speech and language difficulties (SLD) after a stroke. This information may be of variable quality. Tools have been designed to assess the risk of poor information quality, evaluating both generic and specific concepts, yet none focuses on stroke. The readability of information is also an issue when communication disorders are under consideration. The study investigated the quality and readability of information on 51 web sites pertaining to SLD following a stroke. These were assessed using two generic evaluation tools (DISCERN and the HON Code), readability tests (Flesch Reading Ease and Flesch-Kincaid Grade Level) and a specifically designed Stroke Tool based on the reported information needs of stroke PCF experiencing SLD. The tools themselves were then evaluated for their feasibility, reliability and validity. In common with previous studies, the information quality of the selected web sites was found to be extremely variable with only 59% achieving a score of 50% or more using HON, only 37% using DISCERN, and 49% using the Stroke Tool. Readability is generally very poor with only 6% of web sites scoring below the recommended grade 7. The tools did not correlate well, suggesting that they measure different domains of quality. The Internet may be a valuable resource for stroke PCF; however, the variable quality of information means that cautious use is recommended. The readability of information is a more serious issue that needs addressing by web site developers.

Evaluation of an ICF-based patient education programme for stroke patients: a randomized, single-blinded, controlled, multicentre trial of the effects on self-efficacy, life satisfaction and functioning

OBJECTIVE

There is a current need for interventions that provide information to stroke survivors in a patient-centred, interactive, personalized and flexible manner. To this purpose, a standardized but content-flexible patient education programme based on the International Classification of Functioning, Disability and Health (ICF) was developed. This study evaluated the effect of this programme on perceived self-efficacy.

DESIGN

Single-blind, randomized, multi-centre controlled trial.

METHODS

Stroke patients undergoing neurological rehabilitation were enrolled. Perceived self-efficacy was measured with the Liverpool Self-Efficacy Scale. Secondary outcomes were life satisfaction and self-perception of the impact of the stroke on life, measured with the WHOQOL and the Stroke Impact Scale, respectively. Data obtained at baseline, post-intervention and 6-month follow-up were analysed using multi-level models of change.

RESULTS

Two hundred and thirteen patients received either the ICF-based patient education (n = 110) or an attention-placebo (n = 103) control intervention. Over time, patients' self-efficacy (p < .01) and participation (p < .01) improved, while emotional functioning (p < .01) deteriorated, although no significant between-group differences were observed. Explorative analyses showed that gender, loci of control, difficulty in accessing health services after discharge and life satisfaction were significant predictors of self-efficacy.

CONCLUSION

There was no significant benefit of the ICF-based patient education in comparison with an attention-placebo control group. Considering the importance of the programme for the further implementation of the ICF and the need of developing effective health education interventions for stroke, the methodology used was reviewed and an updated version proposed.

Community re-engagement and interprofessional education: the impact on health care providers and persons living with stroke

PURPOSE

This study evaluated the impact of an educational intervention that integrates concepts of a community re-engagement framework (CR) and interprofessional collaboration (IPC) on health care providers' (HCP) practice with persons living with stroke (PLS).

METHOD

A mixed-methods design was used in which HCPs (n = 67) and PLS (n = 29) participated from 9 organizations across the care continuum. Pre- and postintervention surveys and interviews were conducted with the HCPs. One-on-one interviews with stroke clients were also conducted pre and post intervention. Quantitative responses were analyzed in SPSS (Chicago, Illinois, USA) for descriptive frequencies and differences between pre- and postintervention groups. Qualitative open-ended responses were thematically coded using NVivo7.

RESULTS

Significant increases occurred in HCPs' knowledge of CR, confidence levels in working with PLS, enhanced understanding of the complex needs of PLS, and positive self-reported impacts on practice. PLS reported positive perceptions of care pre and post intervention.

CONCLUSIONS

The intervention provided HCPs with a common language and framework to work collaboratively and holistically in delivering care consistent with stroke best practices.

Educational needs of patients with a stroke and their caregivers: a systematic review of the literature

OBJECTIVE

To systematically review the research on stroke patients' and caregivers' educational needs.

METHODS

A search of the literature prior to and including the year January 2009 was conducted using Medline, CINAHL, EMBASE, PsychINFO and the Cochrane Library, yielding 959 articles. Of these, 21 studies were included in the review.

RESULTS

Stroke patients and caregivers reported many and diverse educational needs, which often were not met. The educational needs of stroke patients and caregivers concerned knowledge about the clinical aspects of stroke, prevention, treatment and functional recovery. The most commonly reported needs of caregivers involved patients' moving and lifting, exercises, psychological changes and nutritional issues. Patients and caregivers wanted information that was tailored to their situation.

CONCLUSION

Patients and caregivers have many unmet educational needs. The findings call for improved education of patients and caregivers on various issues that are specific to the various recovery phases after stroke.

PRACTICE IMPLICATIONS

The findings of this review can be used to develop educational interventions for stroke patients and caregivers. Further research is needed to investigate the feasibility and effects of educational interventions and whether they meet the educational needs of patients and caregivers.

Health education in patients with a recent stroke or transient ischaemic attack: a comprehensive review

Health education aims at the acquisition of skills and attitudes to modify behaviour that influences health, leads to a modification of risk factors and ultimately to a decrease in disability and case fatality from stroke. Health education is an underdeveloped but important aspect of stroke care. Health education could promote compliance and healthy behaviour, improve patients' understanding of their health status and treatment options and facilitate communication. We reviewed the effect of health education in stroke and transient ischaemic attack patients, aiming at feasibility, effectiveness at the level of knowledge, attitude and skills, health behaviour changes and stroke outcome. We also describe the current status of health education for patients with recent coronary artery disease and public health education in stroke. Basic knowledge of stroke and transient ischaemic attack patients of their disease and associated risk factors is not sufficient. This is also observed in patients with coronary artery disease and in the general population. A beneficial effect of health education in stroke and transient ischaemic attack patients on health behaviour, risk reduction or stroke outcome has not been proven. Trials in patients with coronary artery disease, however, have shown that health education could result in a change of lifestyle. No specific method is superior, although the individualised, repetitive and active methods appear more successful. More intervention studies of health education in stroke and transient ischaemic attack patients are needed. Future trials should be large, have a long follow-up, should use an intensive and repetitive approach and involve patients' relatives to induce and maintain a healthy lifestyle.

The effect of motivational interviewing after ischemic stroke on patient knowledge and patient satisfaction with care: a pilot study

Knowledge of the warning signs of stroke may reduce the incidence of having a second stroke by receiving medical intervention in a timely manner. The need for stroke education is paramount to empower stroke patients to recognize the signs and symptoms of an impending stroke. The purpose of this pilot study was to develop and to evaluate the effectiveness of an educational method of providing stroke education in an acute care setting. Twenty patients were recruited and randomized to two groups. Group 1 received the standard of care: verbal and written education at the time of discharge by the discharge nurse. Group 2 received individualized protocol-driven verbal and written education with their caregiver present within the context of the Therapeutic Alliance Model using motivational interviewing techniques. Each group was sent a Stroke Knowledge Test and a patient satisfaction survey at 1 month. Results indicate that the enhanced education group received improved scores on the Stroke Knowledge Test and had better patient satisfaction scores regarding stroke education. An enhanced educational method using motivational interviewing and an individualized protocol-driven education intervention given to both the patient and a caregiver enhance stroke knowledge and patient satisfaction after discharge from the acute care setting.