Caring for continence in stroke care settings: a qualitative study of patients' and staff perspectives on the implementation of a new continence care intervention

The struggle is real-A mixed qualitative methods synthesis of challenges in nursing care in activities of daily living

INTRODUCTION

Supporting care receivers in Activities of Daily Living (ADL), irrespective of diagnosis, setting, or cultural background, lies at the heart of fundamental nursing care. The pursuit of quality ADL care becomes increasingly challenging with the changing complexity of care needs. ADL care delivery is often undervalued and is considered a low-status task despite its crucial importance to care receivers. This study aims to synthesize challenges in ADL care irrespective of the care setting.

METHODS

In the mixed qualitative methods study, we used expert panel consultations, world café sessions, and a rapid literature review. For data analysis, we simultaneously analyzed the three data sets using inductive and deductive inquiry.

RESULTS

We identified four challenges and their corresponding subthemes. They are (1) Undervalued common-sense work versus complex, high-skilled care provision; (2) Limitations in professional reflective clinical decision-making; (3) Missed opportunities for shared ADL decisions; and (4) Meeting ADL care needs in a high-throughput system.

CONCLUSION

These challenges reveal the complexity of ADL care and how its paradoxical narrative relates to the conditions in which nursing professionals struggle to create opportunities, for reflective clinical reasoning and shared ADL decisions, by facing organizational and environmental barriers.

CLINICAL RELEVANCE

This study is relevant to nursing professionals, care organizations, policymakers, and researchers aiming to improve ADL care and provide insights into challenges in ADL care. This study forms the starting point for a changing narrative on ADL nursing care and subsequent quality improvements in the form of, for example, guidelines for nursing professionals.

Promoting urinary continence in people suffering a stroke: Effectiveness of a complex intervention-An intervention study

Aim

The study aimed to implement and measure effectiveness of a systematic continence management intervention in people suffering a stroke in undertaking rehabilitation.

Design

An intervention study was conducted.

Methods

In the first part of the study, patients were included in the control group and observed. After the training of the nursing staff, participants were assigned to the intervention group. The intervention consisted of screening, assessment, treatment, communication and evaluation.

Results

Forty‐six patients took part in the study, of which 35 were in the control and 11 in the intervention groups. Within the two groups, significant improvements in outcomes were mostly seen during the study. For the Incontinence Quality of Life Social Embarrassment scale, a significantly higher increase was observed for the intervention group. The improvement between admission and discharge in the intervention group was notably larger for the outcome's incontinence and quality of life.

Testing and e-learning activity designed to enhance student nurses understanding of continence and mobility

OBJECTIVES

The aim of this study was to test if the e-learning activity that we developed could improve student nurses' knowledge of continence and mobility and whether or not students would find the style of learning beneficial.

METHODS

A quasi-experimental pre-post-test design was used to test if the continence and mobility e-learning activity could improve student nurses' knowledge about assessing and managing the needs of continence and mobility. An 18-item true/false knowledge of continence quiz was completed by 116 student nurses and a Likert style feedback learning survey was completed by 135 nursing students.

RESULTS

There was a statistically significant increase in students' knowledge about continence and its relationship to mobility following the e-learning activity. The e-learning activity also enhanced students' knowledge, confidence and perceptions about older people.

CONCLUSIONS

The e-learning activity we developed has the potential to improve nursing students' knowledge about continence and mobility in an enjoyable manner.

Exploring patient perspectives of barriers and facilitators to participating in hospital-based stroke rehabilitation

BACKGROUND

Patient participation is recognized as an important element of rehabilitation. However, few studies have used a qualitative lens to specifically examine factors influencing patient participation in stroke rehabilitation.

AIM

The purpose of this study was to investigate patient perspectives of barriers and facilitators to participating in hospital-based stroke rehabilitation.

METHODS

Semi-structured interviews were conducted with 11 patients, with confirmed diagnoses of stroke, recruited from three separate rehabilitation settings. Analysis of the interviews was guided by a process of interpretive description to identify key barriers and facilitators to participation in stroke rehabilitation.

RESULTS

Four main themes and corresponding sub-themes were constructed concerning participation in rehabilitation: (i) Environmental Factors, (ii) Components of Therapy, (iii) Physical and Emotional Well-Being, and (iv) Personal Motivators. An exploratory model of personalized rehabilitation emerged, integrating the themes emerging from the data.

DISCUSSION

Personalized rehabilitation can be considered in comparison to person-centred care principles. The barriers and enablers experienced by patients in this study contribute to the existing knowledge of the patient experience of stroke rehabilitation and may be used to inform clinical practices and future research.Implications for RehabilitationThe surrounding environments can facilitate participation in rehabilitation using strategies to reduce noise and disruption and also by encouraging social interactions among patients.Increasing the frequency and consistency of communication with patients about rehabilitation goals and progress could enhance participation.Designing interventions to include activities that are meaningful and focused on the resumption of valued life roles is key to participation.Therapy intensity, time spent sedentary, and the emotional impact of stroke are aspects of rehabilitation patient's feel are neglected.

Factors affecting the delivery of complex rehabilitation interventions in research with neurologically impaired adults: a systematic review

BACKGROUND

Rehabilitation research does not always improve patient outcomes because of difficulties implementing complex health interventions. Identifying barriers and facilitators to implementation fidelity is critical. Not reporting implementation issues wastes research resources and risks erroneously attributing effectiveness when interventions are not implemented as planned, particularly progressing from single to multicentre trials. The Consolidated Framework for Implementation Research (CFIR) and Conceptual Framework for Implementation Fidelity (CFIF) facilitate identification of barriers and facilitators. This review sought to identify barriers and facilitators (determinants) affecting implementation in trials of complex rehabilitation interventions for adults with long-term neurological conditions (LTNC) and describe implementation issues.

METHODS

Implementation, complex health interventions and LTNC search terms were developed. Studies of all designs were eligible. Searches involved 11 databases, trial registries and citations. After screening titles and abstracts, two reviewers independently shortlisted studies. A third resolved discrepancies. One reviewer extracted data in two stages; 1) descriptive study data, 2) units of text describing determinants. Data were synthesised by (1) mapping determinants to CFIF and CFIR and (2) thematic analysis.

RESULTS

Forty-three studies, from 7434 records, reported implementation determinants; 41 reported both barriers and facilitators. Most implied determinants but five used implementation theory to inform recording. More barriers than facilitators were mapped onto CFIF and CFIR constructs. "Patient needs and resources", "readiness for implementation", "knowledge and beliefs about the intervention", "facilitation strategies", "participant responsiveness" were the most frequently mapped constructs. Constructs relating to the quality of intervention delivery, organisational/contextual aspects and trial-related issues were rarely tapped. Thematic analysis revealed the most frequently reported determinants related to adherence, intervention perceptions and attrition.

CONCLUSIONS

This review has described the barriers and facilitators identified in studies implementing complex interventions for people with LTNCs. Early adoption of implementation frameworks by trialists can simplify identification and reporting of factors affecting delivery of new complex rehabilitation interventions. It is vital to learn from previous experiences to prevent unnecessary repetitions of implementation failure at both trial and service provision levels. Reported facilitators can provide strategies for overcoming implementation issues. Reporting gaps may be due to the lack of standardised reporting methods, researcher ignorance and historical reporting requirements.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42015020423.

Urinary incontinence in stroke survivors - Development of a programme theory

AIMS AND OBJECTIVES

To develop, in an inpatient rehabilitation setting, a programme theory that promotes continence in people who have suffered a stroke.

BACKGROUND

Urinary incontinence in stroke survivors impacts the quality of life, rehabilitation outcomes and ultimately incurred costs of the patient. Different approaches are available for developing and testing complex interventions.

DESIGN

Building a research-based programme theory.

METHODS

To elaborate the intervention, a guidance for developing a complex intervention for nursing was chosen and the sources that should be considered were defined. Subsequently, a research-based programme theory was generated that was represented via a theoretical approach logic model. This study was guided by the checklist for reporting theory of change in public health interventions.

RESULTS

The intervention consists of six parts with three outcome chains on interconnected levels, which are oriented towards patients and nurses. The important aspects of the programme theory are communication, individually tailored measures and the definition of interdisciplinary objectives.

CONCLUSION

Developing a programme theory and representing it via a logic model help clarify the initial intervention and ensure that implementation strategies are well thought out.

RELEVANCE TO CLINICAL PRACTICE

By employing detailed reflection and using previous research, it is expected that the intervention can be implemented successfully and its effectiveness can be investigated in more depth.

Urinary incontience after stroke

Normal bladder function is achieved by most in childhood. Stroke affects 15 million people worldwide every year, with incontinence affecting over half these individuals in the initial post-stroke phase. Statistically it has been shown that incontinence can increase the morbidity risk of stroke victims. The social taboo surrounding continence issues has been a challenge for many years with individuals experiencing shame and isolation. This article looks at the normal physiology associated with continence and stroke. It suggests possible treatment options during the post-stroke rehabilitation phase to encourage improved patient experience and professionals' confidence and knowledge base when treating this group of patients.

Post-Cerebrovascular Accident Unpredictable Incontinence: A Qualitative Analysis of an Interdisciplinary Rehabilitation Team's Perspective

PURPOSE

This study investigates experiences of the interdisciplinary rehabilitation team in the treatment of patients with urinary incontinence after stroke.

DESIGN

A qualitative approach was chosen. Ten members of an interdisciplinary treatment team were interviewed in a neurological inpatient rehabilitation setting.

METHODS

Data were obtained via focus groups with nurses, physicians, physiotherapists, and occupational therapists in a rehabilitation clinic. The analysis followed the principles of qualitative content analysis.

FINDINGS

According to the interdisciplinary treatment team, professionals and patients prioritize incontinence treatment differently. Challenges surrounding collaboration, communication, structural conditions, and the perception of intervention success were identified as barriers to promoting continence.

CONCLUSION

To overcome this discrepancy in treatment priority, awareness of poststroke urinary incontinence must be improved.

CLINICAL RELEVANCE

A key component is communication about urinary incontinence with patients and among team members.

(Can) Not talk about it - Urinary incontinence from the point of view of stroke survivors: a qualitative study

PURPOSE

The current study intends to gain an in-depth understanding of stroke survivors' lived experience of urinary incontinence and its treatment in an inpatient rehabilitation clinic.

METHODS

A qualitative approach was chosen. Semi-structured individual interviews with ten stroke survivors suffering from urinary incontinence were conducted in an inpatient rehabilitation clinic and analysed using qualitative content analysis with an inductive approach.

RESULTS

'(Can) not talk about it' was identified as the first main category. The affected persons do not talk about urinary incontinence because they are ashamed. At the same time, no one asks them about this issue. Psychological strain is so high that patients feel the need to talk about incontinence, but from their point of view, conversations with nurses - if they indeed occur - are superficial or nurses do not listen. Therefore, patients' needs and concerns are not properly considered. 'Trying to command incontinence' was also identified as a main category. Participants reported that they try to command incontinence and to develop their own strategies in order to hide urinary incontinence and prevent shameful situations. However, this proved mostly unsuccessful and resulted in resignation to their condition.

CONCLUSION

It is important to raise awareness within the treatment team of urinary incontinence in stroke survivors. Team members should be able to communicate about urinary incontinence in an open and empathic way. Obviously, there is great potential for supporting stroke survivors in dealing with incontinence.