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

OBJECTIVES

Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke.

DESIGN

Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis.

SETTING

Mixed acute and rehabilitation stroke ward.

PARTICIPANTS

Stroke patients and nursing staff that experienced an enhanced continence care intervention.

RESULTS

Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence.

CONCLUSION

Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.

Measuring stroke patients' health status in the early post-stroke phase using the SF36

This paper aims to explore the self-perceived health status of stroke patients, the factors that contribute to the perception and the relevance of the findings to researchers and practitioners. Outcomes were measured at one, three and six months post-stroke for 153 stroke patients and pre-morbid characteristics were gathered from GPs. Health status was measured using the Short Form 36 (SF36). Stroke patients' health status was significantly worse than a general population for four health dimensions (physical functioning, role physical, vitality and social functioning). Regression analyses with the SF36 profile scores as dependent variables revealed one model where associations between independent and dependent variables were relatively strong (physical functioning), the remaining seven models yielded weak associations. Self-perceived health status was not strongly related to impairment, disability or cognitive function. There are implications for researchers and practitioners across a range of professions. Researchers should aim to identify factors that explain stroke patients' perception of their own health and the impact of their perception on rehabilitation. Practitioners should consider the possible effects of low vitality on treatment concordance.

What is the association between the different components of stroke rehabilitation and health outcomes?

OBJECTIVES

To describe the rehabilitation input stroke patients received from health professionals during the early post stroke period and to explore possible associations between health outcomes and these rehabilitation inputs.

DESIGN

Community-based study with prospective identification of stroke patients from a random sample of 24 general practices stratified by geographical area and practice size.

SETTING

Ayrshire and Arran Health Board area, West of Scotland.

INTERVENTIONS

All physiotherapy, occupational therapy, dietetics, podiatry, speech and language therapy and community nursing inputs given to stroke patients in the course of normal treatment were recorded.

OUTCOME MEASURES

Barthel Index and Medical Outcomes Study Short Form-36 (SF-36). Both recorded at one, three and six months post stroke.

RESULTS

Of the 152 people providing data, more had received physiotherapy than any other rehabilitation input at all three follow-ups (81%, 47%, 39%), with occupational therapy being the next most common service (65%, 44%, 25%). Amount of rehabilitation input was significantly negatively correlated with health outcomes measured at each discrete time point: those patients with the poorest outcomes received greatest input. However, regression analysis of change in outcome scores showed that increasing amounts of rehabilitation input were significantly associated with a reduction in disability, particularly between one and three months post stroke.

CONCLUSIONS

Not only have we shown that those stroke patients with poorest outcomes received most rehabilitation input, but, from analysis of the individual rehabilitation inputs, we have identified some rehabilitation inputs that significantly predict improved outcomes. This suggests that there would be merit in further investigation of these associations.

Incidence, hospital admission rate, and health outcomes following stroke in Ayrshire and Arran

OBJECTIVE

To describe the incidence, hospital admission rate and health outcomes following stroke in Ayrshire and Arran.

DESIGN

Community based study with prospective identification of stroke patients from a random sample of general practices stratified by geographical area and practice size.

SETTING

Ayrshire and Arran Health Board area, West of Scotland.

SUBJECTS

All stroke patients from the 24 general practices in the sample.

MAIN OUTCOME MEASURES

Barthel Index, Canadian Neurological Scale, Mini-mental State Examination, SF-36.

RESULTS

The incidence of stroke was 2.33 per 1000 for both first and recurrent events and 78% of people were admitted to hospital following their stroke. Those admitted to hospital had significantly poorer outcomes in the early post-stroke period (first six months).

CONCLUSION

Our study provides recent figures for the incidence and hospital admission rates following stroke. We speculate that our rates may be typical for the NHS in Scotland at present.

Stroke patients' informal caregivers. Patient, caregiver, and service factors that affect caregiver strain

BACKGROUND AND PURPOSE

Research has revealed that caring for a stroke patient can result in caregiver strain and a myriad of other difficulties for caregivers. This study aims to identify the level of strain experienced by caregivers in the early months after stroke and to assess the relationship between caregiver strain and caregiver characteristics, patient characteristics, and service inputs.

METHODS

Stroke patients were identified through a random stratified sample of general practices. Patients were asked to identify their principal informal caregiver. Strain was measured with the Caregiver Strain Index, and all data were collected from caregivers at 1, 3, and 6 months after the patient's stroke. Multiple regression analysis was used to examine the factors associated with caregiver strain.

RESULTS

Six months after stroke, 37% of caregivers were experiencing considerable strain. The amount of time a caregiver spent helping a stroke patient, the amount of time the caregiver spent with the patient, and the caregiver's health were all significantly associated with the level of strain experienced. Although none of the services or patient factors tested in this study were consistently associated with strain, an indicator of stroke severity was significant at each time point.

CONCLUSIONS

Caregivers are experiencing strain, which has implications for research and service provision. Service providers need to identify caregivers at risk of greater strain and to help caregivers work through situations that services cannot alter. Research is needed to identify services that are effective in strain alleviation. Future research should also aim to identify the interface between patient characteristics and strain, burden, and depression and particularly to assess the caregiver's perception of these relationships.

A descriptive survey to identify the perceived skills and community skill requirements of mental health staff

Throughout the 1990s mental health care has shifted from a hospital to a community-based service. Government policy indicates that staff require further education as a result of the shift to community care. However, none of the United Kingdom policy documents or mental health literature prescribes what education is required. Consequently this multidisciplinary study aimed to identify what skills, if any, were required by hospital-based staff to move to a community-based working environment. Study findings suggest advantages in perceiving skills as overlapping and interconnecting. Five common core skills and skill differences between professional groups are identified. It is argued that core skills are central and common to all groups and specialist skills are those that distinguish professional groups one from another and different grades of staff within professional groups. While problems of multidisciplinary education are considered, nevertheless a case is made for educating staff in core skills within a multidisciplinary environment which may be beneficial in achieving community care goals.

Analgesic dose-response relationship of ibuprofen 50, 100, 200, and 400 mg after surgical removal of third molars: a single-dose, randomized, placebo-controlled, and double-blind study of 304 patients

The purpose of this single-dose, randomized, placebo-controlled, and double-blind study was to evaluate the analgesic dose-response relationship of 50-mg, 100-mg, 200-mg, and 400-mg doses of ibuprofen after third molar surgery. Patients were instructed to take a single dose of either placebo or 50 mg, 100 mg, 200 mg, or 400 mg of ibuprofen when the postoperative pain was moderate to severe. Acetaminophen 500 mg was used as a rescue medication. Pain intensity, pain relief, and any possible adverse events were recorded on self-administered questionnaires hourly for 6 hours after intake of study medication. If rescue medication was taken, the time of intake was registered. A total of 304 patients entered the study, and 258 complied with the protocol. A positive analgesic dose-response relationship of 50-mg, 100-mg, 200-mg, and 400-mg doses of ibuprofen was observed when evaluated by pain intensity difference, sum of pain intensity difference, pain relief, total pain relief, and survival distribution of patients not taking rescue medication. Although significant pain relief was seen after a dose of 50 mg ibuprofen, ibuprofen 400 mg provided maximum pain relief and the longest duration of analgesic effect. Mild transient adverse events were reported by 6.8% of the patients. However, there was no significant difference in frequency between the placebo and 50 mg, 100 mg, 200 mg, and 400 mg ibuprofen dose groups.

A descriptive study of multidisciplinary mental health staff moving to the community: the demographic and educational issues

Mental health care philosophy has moved from the containment of patients within institutions to the integration of clients within the community. 'Caring for People' (a Department of Health report) and the subsequent legislation enshrined the philosophical shift in law. Previous policy reports had indicated that staff required training to move from hospital-based service to a community-based service, but did not propose content, and no systematic study of the needs of mental health staff has been carried out. Therefore, this study aimed to identify the skill and information needs of a group of multidisciplinary staff in preparation for the movement from hospital to community settings. The study design was a descriptive survey sampling of a total multidisciplinary population in Scotland. Data were collected using questionnaires and semistructured interviews with a small volunteer subsample of respondents. This paper presents the first set of study findings related to the demographic and educational issues. Differences between hospital and community staff and between health care assistants and qualified staff are demonstrated for demographic and educational factors. Proposals are made for managers, professionals, educators and researchers.

A randomized, double-blind, placebo-controlled, dose-response study of the analgesic effect of lornoxicam after surgical removal of mandibular third molars

The aim of the present study was to investigate the dose-effect relationship of single doses of 4 to 32 mg of lornoxicam (LNX), a new nonsteroidal antiinflammatory drug belonging to the oxicam group, compared with placebo and 10 mg ketorolac (KET) in the treatment of pain after oral surgery. Also, it was the aim of the study to evaluate the relationship between adverse events and different doses of LNX. After the surgical removal of a mandibular third molar, test medication was taken when the patients experienced at least moderate pain. After medication, pain relief, pain intensity, and any discomfort from the medication were noted in a questionnaire. Paracetamol was used as rescue medication. A total of 278 patients completed the study according to the protocol. The primary efficacy parameter was total pain relief after 6 hours, and all active treatments showed significantly better effect than placebo, with LNX 16 and 32 mg being significantly superior to LNX 4 mg. All other efficacy parameters showed the same dose-effect relationship. A total of 37 adverse events were reported evenly distributed in the 6 treatment groups; only 3 of these were considered severe, and all disappeared without treatment. In conclusion, the study showed a dose-effect relationship of LNX without a rise in adverse events. The effect of 10 mg KET seemed to be at the level of 8 to 16 mg LNX.

Effects of gavage versus dosed feed administration on the toxicokinetics of benzyl acetate in rats and mice

Effects of gavage versus dosed feed administration on the toxicokinetics of benzyl acetate were studied in male F344 rats and B6C3F1 mice. Benzyl acetate was rapidly hydrolysed to benzyl alcohol and then oxidized to benzoic acid. After gavage administration of benzyl acetate in corn oil at 500 mg/kg (rats) and 1000 mg/kg (mice), high benzoic acid plasma concentrations were observed. In contrast, much lower benzoic acid plasma concentrations were found after dosed feed administration at about 615 mg/kg/day for rats and about 850 mg/kg/day for mice. Results show that although the daily doses of benzyl acetate are comparable, bolus gavage administration effectively saturated the benzoic acid elimination pathway whereas dosed feed administration did not. In contrast, hippuric acid plasma concentrations were similar after both gavage and dosed feed administration due to the depletion of the glycine supply pool. Study results could explain the different toxicity and carcinogenicity responses of benzyl acetate observed in 2-yr chronic gavage and dosed feed studies.

Oxypurine and 6-thiopurine nucleoside triphosphate formation in human erythrocytes

A variety of oxypurines and 6-thiopurines could be transformed by intact erythrocytes to their nucleoside triphosphate forms when incubations were extended for up to 24 hrs. The specific nucleotide monophosphate kinases which accomplish these reactions in erythrocytes were not identified but their ability to utilize 6-thioIMP, 6-thioXMP and 6-methylthioGMP as substrates, albeit very slowly, is clearly implied by these results. S-methylation of 6-thiopurines was demonstrated in erythrocytes incubated with physiological amounts of methionine-(CH3-3H). 6-Methylthioguanosine triphosphate and 6-methylmercaptopurine riboside triphosphate were formed in micromolar amounts, probably from the corresponding thiopurine nucleotides by methyl transfer from S-adenosylmethionine.