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QUESTION: Which aspects of the process of care help to explain the improved outcomes of patients treated in stroke units?
Case study of 3 care settings for stroke patients.
An elderly care unit (ECU), a general medical ward (GMW), and a stroke unit in teaching hospitals in the same city in the UK.
Nurses, physiotherapists (PTs), occupational therapists (OTs), and consulting physicians were observed caring for patients with stroke.
Using a qualitative non-participant observation method, the researcher recorded full descriptions of everything she saw and heard. Meetings and observation periods were conducted throughout the week, primarily during ward rounds, multidisciplinary team meetings, therapy sessions and assessments, and general activity on early and late shifts during a 2–3 month period in each setting. Observation included 40 hours at both the ECU and GMW, and 66 hours at the stroke unit. Data were content analysed by setting, then by event or activity, and then compared among the 3 settings.
The philosophy of stroke rehabilitation is that nurses liaise with therapists about patients' treatment, then help patients to apply what they learn to daily ward activities. Relationships and functioning between nurses and patients, nurses and therapists, and among multidisciplinary teams were observed in terms of the extent to which this philosophy was applied in practice.
Interactions between nurses and patients in the GMW were observed to be kind, but often “standardised and impersonal,” and patients' independence was rarely encouraged. In the stroke unit, patients were sometimes observed to be ignored, and work was sometimes done “on” rather than “with” a patient. Nurses in the ECU often encouraged patients to do grooming activities independently, and were observed to be “gentle, warm, respectful, and attentive” in their interactions with patients. These nurses also showed a tendency toward “emotional labour”—the giving of oneself in a more personal, rather than standardised way.
Observed communication between nurses and therapists in the ECU was “mutually respectful and full of interest for the patient.” Nurses had worked in the ECU for a long time, so therapists had given them individualised training sessions. PTs communicated with nurses who they felt would use the information and follow a rehabilitation philosophy. In the GMW, therapists reported that rehabilitation was considered secondary to getting a patient medically stable. In the stroke unit, tension was observed between nurses and therapists, and further observation suggested a relationship in which therapists expected nurses to carry out orders rather than to work together.
In the ECU, weekly multidisciplinary team meetings were led by a consultant and focused on practical issues related to patient discharge. Team members were not forthcoming with information during meetings, and therapists did not feel meetings were useful for exchanging information about patients. In the stroke unit, multidisciplinary team meetings were also led by a consultant and focused on rehabilitation and patients' goals. PTs and OTs participated more in meetings than therapists on the ECU, and nurses contributed least and were least comfortable. On the GMW “little formalised communication between the professions” was observed. Different therapists did not work well together and no multidisciplinary team meetings were held.
Improved outcomes in patients treated for stroke may be attributed to the following benefits (found in an elderly care unit and stroke unit): less institutional units, several activities for patients, addressing carers' needs, good communication among therapists, and being headed by a consultant respected by the multidisciplinary team.
In an area which has primarily produced quantitative studies, Pound and Ebrahim's work is groundbreaking in its aim to qualitatively identify critical process components of stroke care that may influence improved rehabilitation outcomes in stroke units versus other settings.
Caution must be exercised in interpreting these findings, however, because of variability in practice models on stroke units throughout the world.1 In this study, a multidisciplinary rather than interdisciplinary model of practice was observed. In a multidisciplinary model, several professions independently provide aspects of care. By comparison, an interdisciplinary model depends on communication and collaboration among caregivers to mutually achieve goals for the patient.
A second caution on generalising from this study is related to the differences in the competency of nursing staff assigned to stroke units. This study suggests that staff competency (basic preparation and specialised training) may have influenced outcomes. The knowledge, skills, and abilities needed to assist patients to regain independence are unique in rehabilitation environments and must be learnt. The authors also comment on the difference in “emotional labour” extended by nurses. This is particularly interesting in that it is unclear whether this is a personal characteristic of some nurses or can be learnt. Finally, the authors touch on the question of nursing leadership for these units in noting that the nurse manager was replaced by a “higher grade nurse.” Nursing leadership on a unit creates the environment and expectations for nursing practice.
Although one cannot generalise from the alleged deficiencies described in the one stroke unit in this study, it seems that patients' emotional wellbeing is an outcome of care processes that should be studied. This component may have long term implications for measuring success of stroke rehabilitation. Further study is indicated to test reproducibility of findings that may unravel the process components that influence stroke outcomes.
Source of funding: the Stroke Association.
For correspondence: Dr Shah Ebrahim, Department of Social Medicine, Canynge Hall, Whiteladies Road, Bristol, UK. Fax +44 (0)117 928 7325.
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