Advance care planning in stroke: Influence of time on engagement in the process

Purpose Individuals who experience stroke have a higher likelihood of subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, engaging in the process of advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, and the extent to which stroke HCPs engage in conversations around planning for such events. In this study, we sought to understand how the process of ACP unfolded between HCPs and patients post-stroke. Patients and methods Using grounded theory (GT) methodology, we engaged in direct observation of HCP and patient interactions on an acute stroke unit and two stroke rehabilitation units. Using semi-structured interviews, 14 patients and four HCPs were interviewed directly about the ACP process. Results We found that open and continual ACP conversations were not taking place, patients experienced an apparent lack of urgency to engage in ACP, and HCPs were uncomfortable initiating ACP conversations due to the sensitive nature of the topic. Conclusion In this study, we identified lack of engagement in ACP post-stroke, attributable to patient and HCP factors. This encourages us to look further into the process of ACP in order to develop open communication between the patient with stroke, their families, and stroke HCPs.

The World Stroke Organization and nursing [Guest Editorial]

The field of neuroscience nursing and, in particular, nursing people with stroke has evolved significantly over the past two decades. Nurses working with people who have had a stroke and their families are called upon to use advanced assessment skills, apply nursing diagnoses across the whole continuum of care, and identify and implement a wide range of interventions. Indeed, in a recent Canadian study on the implementation of stroke best practices, nurses were identified as playing a leading role in many aspects of stroke care and recovery. As the volume of research evidence across disciplines mounts, nurses are challenged to “keep up on the latest”...

Report: The Canadian Best Practices Educational Toolkits: Translating evidence-based stroke recommendations into practical implementation resources

The Canadian Best Practice Recommendations for Stroke Care are intended to reduce variations in stroke care and facilitate closure of the gap between evidence and practice (Lindsay et al., 2010). The publication of best practice recommendations is only the beginning of this process. The guidelines themselves are not sufficient to change practice and increase consistency in care. Therefore, a key objective of the Canadian Stroke Network (CSN) Best Practices Working Group (BPWG) is to encourage and facilitate ongoing professional development and training for health care professionals providing stroke care. This is addressed through a multi-factorial approach to the creation and dissemination of inter-professional implementation tools and resources. The resources developed by CSN span pre-professional education, ongoing professional development, patient education and may be used to inform systems change. With a focus on knowledge translation, several inter-professional point-of-care tools have been developed by the CSN in collaboration with numerous professional organizations and expert volunteers. These resources are used to facilitate awareness, understanding and applications of evidence-based care across stroke care settings. Similar resources are also developed specifically for stroke patients, their families and informal caregivers, and the general public. With each update of the Canadian Best Practice Recommendations for Stroke Care, the BPWG and topic-specific writing groups propose priority areas for ongoing resource development. In 2010, two of these major educational initiatives were undertaken and recently completed—one to support continuing education for health care professionals regarding secondary stroke prevention and the other to educate families, informal caregivers and the public about pediatric stroke. This paper presents an overview of these two resources, and we encourage health care professionals to integrate these into their personal learning plans and tool kits for patients.

Relationships between biophysical and psychosocial outcomes following minor stroke

This descriptive correlational study examined relationships between mild stroke functional and psychosocial outcomes over the early post-discharge period among dyads of mild stroke patients (n=38) and their spousal caregivers (n=38). We measured patients' functional scores using the modified Rankin Scale; patients' and caregivers' quality of life (QoL) using Stroke Impact Scale and Short-Form 36 respectively, mood using the Beck Depression Inventory-II, and marital function scores using the Family Assessment Device. Spousal caregivers also completed the Bakas Caregiving Outcomes Scale as a measure of caregiver strain. The average age of stroke patients was 64 years and of spousal caregivers 58 years. All stroke patients were male; all spousal caregivers female. At three months post discharge, patient functional status scores had significantly improved from discharge (p=0.026) with a corresponding increase in QoL scores (p=0.012). Functional status was significantly correlated with patient perceptions of QoL at three months (r=.014, p=0.024) and spousal caregiver perceptions of physical domain QoL (r=.-.397, p=0.014). Spousal caregivers' mood at three months post discharge was strongly correlated with their perceptions of marital satisfaction (r=.578, p=0.000) and caregiver strain (r=-.620, p=0.000). In preparing patients for discharge following mild stroke, nurses must consider the psychological and social implications of the recovery process over time for both the patient with stroke and their spousal caregivers.

Nurses' accountability for stroke quality of care: part one: Review of the literature on nursing-sensitive patient outcomes

Over the past decade, an exciting area of research has emerged that demonstrates strong links between specific nursing care activities and patient outcomes. This body of research has resulted in the identification of a set of "nursing-sensitive outcomes"(NSOs). These NSOs may be interpreted with more meaning when they are linked to evidence-based best practice guidelines, which provide a structured means of ensuring care is consistent among all health care team members, across geographic locations, and across care settings. Uptake of evidence-based best practices at the point of care has been shown to have a measurable positive impact on processes of care and patient outcomes. The purpose of this paper is to present a systematic, narrative review of the literature regarding the clinical effectiveness of nursing management strategies on stroke patient outcomes sensitive to nursing interventions. Subsequent investigation will explore current applications of nursing-sensitive outcomes to patients with stroke, and identify and validate measurable NSOs within stroke care delivery.

Quality of life and caregiver outcomes following decompressive hemicraniectomy for severe stroke: A narrative literature review

AIMS The aim of this narrative review of the literature was to examine the current state of knowledge regarding the impact of aggressive surgical interventions for severe stroke on patient and caregiver quality of life and caregiver outcomes. BACKGROUND Decompressive hemicraniectomy (DHC) is a surgical therapeutic option for treatment of massive middle cerebral artery infarction (MCA), lobar intracerebral hemorrhage (ICH), and severe aneurysmal subarachnoid hemorrhage (aSAH). Decompressive hemicraniectomy has been shown to be effective in reducing mortality in these three life-threatening conditions. Significant functional impairment is an experience common to many severe stroke survivors worldwide and close relatives experience decision-making difficulty when confronted with making life or death choices related to surgical intervention for severe stroke. DATA SOURCES Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PsychInfo. REVIEW METHODS A narrative review methodology was utilized in this review of the literature related to long-term outcomes following decompressive hemicraniectomy for stroke. The key words decompressive hemicraniectomy, severe stroke, middle cerebral artery stroke, subarachnoid hemorrhage, lobar ICH, intracerebral hemorrhage, quality of life, and caregivers, literature review were combined to search the databases. RESULTS Good functional outcomes following DHC for life-threatening stroke have been shown to be associated with younger age and few co-morbid conditions. It was also apparent that quality of life was reduced for many stroke survivors, although not assessed routinely in studies. Caregiver burden has not been systematically studied in this population. CONCLUSION Most patients and caregivers in the studies reviewed agreed with the original decision to undergo DHC and would make the same decision again. However, little is known about quality of life for both patients and caregivers and caregiver burden over the long-term post-surgery. Further research is needed to generate information and interventions for the management of ongoing patient and carer recovery following DHC for severe stroke.

Functional and psychosocial outcomes 1 year after mild stroke

Background Mild stroke survivors are generally discharged from acute care within a few days of the stroke event, often without rehabilitation follow-up. We aimed to examine the recovery trajectory for male patients and their wife-caregivers during the 12 months postdischarge. Methods A descriptive study was undertaken to examine functional outcomes, quality of life (QOL), depression, caregiver strain, and marital function in a prospective cohort of male survivors of mild stroke and their wife-caregivers during the 12 months postdischarge. Data from each point in time were summarized and repeated measures analyses undertaken. Logistic regression was used to determine which baseline demographic and biopsychosocial variables influenced or predicted marital functioning 1 year postdischarge. Results A total of 38 male patients (mean age 63.4 years) and their wife-caregivers (mean age 58.5 years) were examined. The median discharge National Institutes of Health Stroke Scale score was 1.5, modified Rankin Scale score was 1.0, Barthel Index was 100.0, and Stroke Impact Scale-16v2 score was 78.5. The patients' modified Rankin Scale (function) and QOL scores improved significantly over time (F (2) = 4.583, P = .017; and F (6) = 5.632, P < .001, respectively). However, the wife-caregiver QOL scores did not change. Multivariate analysis revealed overall worsening of depression for both the patient and wife-caregivers (F (6, 32) = 3.087, P = .017) and marital function (F (6, 32) = 3.961, P = .004), although the wife-caregivers' perceptions of caregiver strain improved (F (6, 32) = 3.923, P = .007). None of the measured variables were associated with marital functioning 1 year postdischarge. Conclusions Despite improvement in patients' functional status, other patient and wife-caregiver psychosocial outcomes during the 12 months postdischarge may be negatively affected. Thus, attention needs to focus on recovery beyond functional outcomes.

Experiences of male patients and wife-caregivers in the first year post-discharge following minor stroke: A descriptive qualitative study

Background Most patients with minor stroke are discharged directly home from acute care, under the assumption that little will be required in the way of adaptation and adjustment because informal caregivers will manage the stroke recovery process. We explored male patients with minor stroke and their wife-caregivers' perceptions of factors affecting quality of life and caregiver strain encountered during the first year post-discharge. Methods Data were obtained from responses to two open-ended questions, part of quality of life and caregiver strain scales administered to participants in a larger descriptive study. Conventional content analysis was used to assess narrative accounts of living with minor stroke provided by 26 male patients and their wife-caregivers over a period of 1-year post-discharge. Results Two major themes that emerged from these data were 'being vulnerable' and 'realization'. Subthemes that arose within the vulnerability theme included changes to patients' masculine image and wife-caregivers' assumption of a hyper-vigilance role. In terms of 'realization' patients and their wife-caregivers shared 'loss' as well as 'changing self and relationships'. Patients in this study focused primarily on their physical recovery and their perceptions of necessary changes. Wife-caregivers were actively involved in managing the day-to-day demands that stroke placed on individual, family and social roles. Conclusions We conclude that patients and wife-caregivers expend considerable time and energy reestablishing control of their lives following minor stroke in an attempt to incorporate changes to self and their relationship into the fabric of their lives.

The organisational context of nursing care in stroke units: A case study approach

Background Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. Design A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Findings Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

Smell and taste dysfunction following minor stroke: A case report

Smell (olfactory) and taste (gustatory) are key senses in the regulation of nourishment and individual safety. Olfactory and gustatory dysfunctions have been infrequently reported together in patients following stroke (Landis et al., 2006; Leopold et al., 2006). This case report details two patients who experienced smell and taste dysfunction following minor stroke events. Symptoms reported included hyposmia (diminished sense of smell) and anosmia (complete loss of smell), and dysgeusia (distorted taste). Patients' sense of smell and taste were assessed in an ambulatory care stroke prevention clinic eight months following their strokes. Patient A presented with minor stroke due to a lesion in the anterior circulation, patient B with a lesion in the posterior circulation. Both patients reported intense olfactory and gustatory dysfunction immediately following their strokes. Examination revealed a general inability to detect subtle odours and the ability to identify only 'sweet' tastes for both patients. In addition, both patients reported heavily salting or sweetening their food to mask the distorted and unpleasant taste, which also impacted comorbid conditions such as hypertension and diabetes. Patients and their spouses reported a decrease in their appreciation of family-related activities due to the patients' olfactory and gustatory dysfunction. Patients reported weight loss, lack of energy and strength, likely due to poor nutrition. Olfactory and gustatory dysfunctions are potentially deleterious outcomes following minor stroke and should be assessed by health care professionals prior to patient discharge. Assistance may be required to promote the health and well-being of patients and their carers if smell and taste are impacted by the stroke event.

Education in stroke prevention: Efficacy of an educational counselling intervention to increase knowledge in stroke survivors

BACKGROUND Motivational interviewing and stages of change are approaches to increasing knowledge and effecting behavioural change. This study examined the application of this approach on stroke knowledge acquisition and changing individual lifestyle risk factors in an outpatient clinic. METHODS RCT in which 200 participants were allocated to an education-counselling interview (ECI) or a control group. ECI group participants mapped their individual risk factors on a stage of change model and received an appointment to the next group lifestyle class. Participants completed a stroke knowledge questionnaire at baseline (T1), post-appointment, and three months (T3) post-appointment. Passive to active changes in lifestyle behaviour were self-reported at three months. RESULTS There was a statistically significant difference between groups from T1 toT3 in stroke knowledge (p < 0.001). While there was a significant shift from a passive to active stage of change for the overall study sample (p < 0.000), there was no significant difference between groups on the identified risk factors. CONCLUSIONS Although contact with patients in ambulatory clinical settings is limited due to time constraints, it is still possible to improve knowledge and initiate lifestyle changes utilizing motivational interviewing and a stage of change model. Stroke nurses may wish to consider these techniques in their practice setting.

Reliability of point-of-care testing of INR in acute stroke

Background In the emergency department, portable point-of-care testing (POCT) coagulation devices may facilitate stroke patient care by providing rapid International Normalized Ratio (INR) measurement. The objective of this study was to evaluate the reliability, validity, and impact on clinical decision-making of a POCT device for INR testing in the setting of acute ischemic stroke (AIS). Methods A total of 150 patients (50 healthy volunteers, 51 anticoagulated patients, 49 AIS patients) were assessed in a tertiary care facility. The INR's were measured using the Roche Coaguchek S and the standard laboratory technique. Results The interclass correlation coefficient and 95% confidence interval between overall POCT device and standard laboratory value INRs was high (0.932 (0.69 - 0.78). In the AIS group alone, the correlation coefficient and 95% CI was also high 0.937 (0.59 - 0.74) and diagnostic accuracy of the POCT device was 94%. Conclusions When used by a trained health professional in the emergency department to assess INR in acute ischemic stroke patients, the CoaguChek S is reliable and provides rapid results. However, as concordance with laboratory INR values decreases with higher INR values, it is recommended that with CoaguChek S INRs in the > 1.5 range, a standard laboratory measurement be used to confirm the results.

Gender-specific differences of interaction between obesity and air pollution on stroke and cardiovascular diseases in Chinese adults from a high pollution range area: A large population based cross sectional study

Background Little information exists regarding the interaction effects of obesity with long-term air pollution exposure on cardiovascular diseases (CVDs) and stroke in areas of high pollution. The aim of the present study is to examine whether obesity modifies CVD-related associations among people living in an industrial province of northeast China. Methods We studied 24,845 Chinese adults, aged 18 to 74 years old, from three Northeastern Chinese cities in 2009 utilizing a cross-sectional study design. Body weight and height were measured by trained observers. Overweight and obesity were defined as a body mass index (BMI) between 25–29.9 and ≥ 30 kg/m2, respectively. Prevalence rate and related risk factors of cardiovascular and cerebrovascular diseases were investigated by a questionnaire. Three-year (2006–2008) average concentrations of particulate matter (PM10), sulfur dioxide (SO2), nitrogen dioxides (NO2), and ozone (O3) were measured by fixed monitoring stations. All the participants lived within 1 km of air monitoring sites. Two-level logistic regression (personal level and district-specific pollutant level) was used to examine these effects, controlling for covariates. Results We observed significant interactions between exposure and obesity on CVDs and stroke. The associations between annual pollutant concentrations and CVDs and stroke were strongest in obese subjects (OR 1.15–1.47 for stroke, 1.33–1.59 for CVDs), less strong in overweight subjects (OR 1.22–1.35 for stroke, 1.07–1.13 for CVDs), and weakest in normal weight subjects (OR ranged from 0.98–1.01 for stroke, 0.93–1.15 for CVDs). When stratified by gender, these interactions were significant only in women. Conclusions Study findings indicate that being overweight and obese may enhance the effects of air pollution on the prevalence of CVDs and stroke in Northeastern metropolitan China. Further studies will be needed to investigate the temporality of BMI relative to exposure and onset of disease.

A feasibility and pilot randomized controlled trial of the "Timing it Right Stroke Family Support Program"

- Objective Examine feasibility of conducting a randomized controlled trial of the Timing it Right Stroke Family Support Program (TIRSFSP) and collect pilot data. - Design Multi-site mixed method randomized controlled trial. - Setting Acute and community care in three Canadian cities. - Subjects Caregivers were family members or friends providing care to individuals who experienced their first stroke. - Intervention The TIRSFSP offered in two formats, self-directed by the caregiver or stroke support person-directed over time, were compared to standard care. - Main Measures Caregivers completed baseline and follow-up measures 1, 3 and 6 months post-stroke including Centre for Epidemiological Studies Depression, Positive Affect, Social Support, and Mastery Scales. We completed in-depth qualitative interviews with caregivers and maintained intervention records describing support provided to each caregiver. - Results Thirty-one caregivers received standard care (n=10), self-directed (n=10), or stroke support person-directed (n=11) interventions. We retained 77% of the sample through 6-months. Key areas of support derived from intervention records (n=11) related to caregiver wellbeing, caregiving strategies, patient wellbeing, community re-integration, and service delivery. Compared to standard care, caregivers receiving the stroke support person-directed intervention reported improvements in perceived support (estimate 3.1, P=.04) and mastery (estimate .35, P=.06). Qualitative caregiver interviews (n=19) reflected the complex interaction between caregiver needs, preferences and available options when reporting on level of satisfaction. - Conclusions Preliminary findings suggest the research design is feasible, caregivers’ needs are complex, and the support intervention may enhance caregivers’ perceived support and mastery. The intervention will be tested further in a large scale trial.