- Research article
- Open Access
- Published: 01 December 2017
BMC Nursing volume 16, Article number: 72 [2017] Cite this article
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Abstract
Background
Nurses often have difficulties with using interdisciplinary stroke guidelines for patients with stroke as they do not focus sufficiently on nursing. Therefore, the Stroke Nursing Guideline [SNG] was developed and implemented. The aim of this study was to determine the implementation and feasibility of the SNG in terms of changes in documentation and use of the guideline in the care of stroke patients on Neurological and Rehabilitation wards, barriers and facilitators, and nurses’ and auxiliary nurses’ view of the implementation.
Methods
A sequential explorative mixed method design was used including pre-test post-test measures and post intervention focus groups interviews. For the quantitative part retrospective electronic record data of nursing care was collected from 78 patients and prospective measures with Barriers and Facilitators Assessment Instrument [BFAI] and Quality Indicator Tool [QIT] from 33 nursing staff including nurses and auxiliary nurses. In the qualitative part focus groups interviews were conducted with nursing staff on usefulness of the SNG and experiences with implementation.
Results
Improved nursing documentation was found for 23 items [N = 37], which was significant for nine items focusing mobility [p = 0.002, p = 0.024, p = 0.012], pain [p = 0.012], patient teaching [p = 0.001, p = 0.000] and discharge planning [p = 0.000, p = 0.002, p = 0.004]. Improved guideline use was found for 20 QIT-items [N = 30], with significant improvement on six items focusing on mobility [p = 0.023], depression [p = 0.033, p = 0.025, p = 0.046, p = 0.046], discharge planning [p = 0.012]. Facilitating characteristics for change were significantly less for two of four BFAI-subscales, namely Innovation [p = 0.019] and Context [p = 0.001], whereas no change was found for Professional and Patient subscales. The findings of the focus group interviews showed the SNG to be useful, improving and providing consistency in care. The implementation process was found to be successful as essential components of nursing rehabilitation were defined and integrated into daily care.
Conclusion
Nursing staff found the SNG feasible and implementation successful. The SNG improved nursing care, with increased consistency and more rigorous functional exercises than before. The SNG provides nurses and auxiliary nurses with an important means for evidence based care for patients with stroke. Several challenges of implementing this complex nursing intervention surfaced which mandates ongoing attention.
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Background
Stroke generally results in life-altering changes for both patients and their closest family. Patients experience a whole arena of physical and psychosocial impairments [1]. In the long term 25–74% of patients have to rely on assistance of family for the help in basic Activities of Daily Living [ADL’s] like feeding, self-care, and mobility due to the physical impairments, like paralysis of one side of the body, decrease in abilities such as reaching and handling objects [2]. Difficulties with posture and balance make it difficult for patients to walk and mobilize. About one-third of patients are confronted with cognitive impairments such as speaking and comprehending language [3] and many patients have difficulties with memory, which makes it difficult for patients to acquire and maintain new information [4]. Patients are confronted with the huge challenges due to changes in self-identity, role capacity and their abilities to properly function in their personal and social roles as a parent, partner or employee [5]. Stroke rehabilitation is a cyclic process which includes: assessing the needs of the patient, defining realistic and attainable goals, interventions or activities to achieve the goals and reassessment of the progress against the goals [6]. Rehabilitation is provided by an interdisciplinary team of health care professionals, including nurses, physical therapists, occupational therapists and other professionals, who support the patient to regain abilities that were lost. For the patient this is a time-intensive, effortful and often exasperating process [5, 7]. There is strong evidence that task-oriented training aiming to target functional tasks and ADL’s can assist the natural recovery pattern of functional recovery [6]. Task-specific and context-specific training are well accepted evidence based principles in stroke rehabilitation as well as the principle that increased intensity of training facilitates recovery [6, 8, 9]. Goals for training need to be relevant for the patient and occur in the patient’s environment, preferably his home surroundings. Generally, the literature emphasizes that patients with stroke need more rehabilitation training [8, 9].
Neuroscience nurses in stroke care are increasingly adapting to Evidence Based Practice integrating the best available evidence from well-designed studies with clinician’s expertise and with information about patient preferences and values in making the best clinical decisions [10]. Although many Interdisciplinary Stroke Practice Guidelines have been developed for the rehabilitation and management of patients with stroke, these guidelines are often not routinely incorporated into daily nursing practice. Among the reason for this is the fact that these guidelines often lack information about early detection of problems using valid and reliable instruments and interventions relevant and feasible for nurses to use in the daily context of stroke care and are not routinely incorporated into the daily patient care [4, 11, 12]. In an attempt to provide information on various important areas in stroke care, nurses, patients and health care professionals in Iceland and the Netherlands collaborated in developing the Clinical Nursing Rehabilitation Stroke Guideline Stroke [CNRS-Guideline] [13]. Systematic reviews were conducted on interventions and instruments feasible for nurses to use in following areas: mobility and ADL [9], communication and aphasia [3], depression [in patients with/without aphasia] [14, 15], falls [16], neglect [17], self-efficacy [18]. A feasibility study provided evidence for the usability of this guideline for patients and nurses in Dutch stroke settings [19]. Continuing work is taking place and studies are conducted with nurses on identification of symptoms of depression in patients with stroke [20, 21] and aphasia [22, 23], neglect and how to develop and use technical applications in the rehabilitation of patients with stroke residing at home. Based on this work, the Stroke Nursing Guideline [SNG] was developed and adapted including recommendations targeting among other important elements like mobility and ADL, falls, depression, pain and education of patients and family [24].
Nurses, as key members of the rehabilitation team, provide nursing specific rehabilitation through the continuum of care [8, 9]. They train patients in activities of daily living, as training needs to be functional, task oriented as well as context specific [6, 8, 9]. As patients with stroke need more training, they play an essential role in creating more opportunities for patients to exercise and practice functional tasks outside and in-between formal therapy sessions [9]. Accordingly nurses need to maximize their contribution in activation of patients and integration of functional and task oriented training exercises in simple activities, targeting mobility and ADL in the context of daily nursing care in order to increase the intensity and duration of rehabilitation exercise and training.
Painful shoulder is a common, complex and distressing complication after stroke which interferes with patients' recovery. Many patients experience painful shoulder in the early stage of stroke, which continues into the chronic stage, with an incidence ranging from 12 to 58% [25]. Although various therapeutic treatments have been developed, outcome studies show contrasting findings [25, 26].
Depression is a frequent complication after stroke affecting up to one third of patients [27]. Depression after stroke negatively impacts patients’ participation in rehabilitation, leads to worse functional outcome [28, 29] and higher mortality [30]. Although various guidelines recommend screening for depression in all stroke patients [4], depression after stroke remains unrecognized, undiagnosed and under treated [28]. Nurses routinely screen patients for depression which increases the early recognition of depression [31] and they effectively identify depression after stroke using the Patient Health Questionnaire [20, 21, 32].
Falls are common among stroke patients with prevalence ranging from10 to 73% [16, 33, 34]. The various risk factors for falls reported include: instability when walking, weakness of the lower leg muscles, urinary incontinence, frequent need to go to the toilet, confusion, depression and medication [16], a Barthel Index score below 15, time since stroke longer than 12 weeks, first fall associated with visuospatial neglect [35] older age, increased length of stay [36], greater stroke severity, history of anxiety, history of fear of falling [37], lower functional status and lower cognitive status [38]. Although moderate evidence was found for the ability of instruments to predict risk of fall in patients after stroke, the literature recommends preventive screening for risk of falls and to provide preventive measures for risk of falls in all phases after stroke [16, 33,34,35,36,37,38].
Education is an important aspect in the care of patients and families during the stroke recovery [39]. Due to the complexity of the impairments and the huge changes in life after the stroke incident, patients and caregivers have diverse educational needs which often are not met [40]. Patients and caregivers reported that they need education about the clinical aspects of stroke, stroke prevention, treatment and functional recovery and caregivers also need information concerning moving and lifting patients, exercises, psychological changes and nutritional issues after stroke, that is tailored to their situation [40]. Lack of knowledge about stroke can lead to misconceptions, anxiety, fear, poor health status and emotional problems [39, 40]. Therefore patients and caregivers need more and thorough education, tailored to their needs, after the stroke.
The Medical Research Council emphasizes the importance of evaluating feasibility and implementation of complex interventions like guidelines, in terms of acceptance by health care professionals, the nursing staff knowledge and skills and the facilities needed for implementation [41, 42]. Feasibility is referred to as the quality of being useful and practical and involves study of the applicability or practicality, which can be assessed by considering the acceptability of the guideline to clients and staff administering it, the costs and the ease of integrating it into clinical settings [43]. Implementation is defined as the introduction of an innovation in daily routines, demanding effective communication, and removing obstacles [12]. Unfortunately, the literature shows that implementation of CPGs is often not achieved and not following the evidence-based CPGs leads to suboptimal care for many patients [12]. Despite the evidence found for the usability of the earlier CNRS guideline, the fact that it was extensive and included many recommendations was found difficult for implementation [19].
Based on this background the aim of this study was to investigate the implementation and feasibility of the use of a Stroke Nursing Guideline [SNG] focusing on mobility ADL, depression, pain, falls, education and discharge planning, used by nurses and auxiliary nurses in the daily care of patients with stroke and stating the following research questions: a] What is the difference in nursing staff documentation of the screening and application of interventions for activities of daily living, mobility, depression, pain, falls, patient education and discharge planning of patients who receive rehabilitation nursing care before and after implementing the SNG? b] What are the nurses’ and auxiliary nurses’ view on the acceptability of using the SNG in supporting the provision of daily nursing care? c] What are the nurses’ and auxiliary nurses’ views on barriers and facilitators to implementing and embedding the SNG within routine daily nursing care?
Methods
This study used a sequential explorative mixed method design [44], including pre-test post-test measures [45] and focus group interviews [44]. The pre-test post-test was chosen to measure the difference in nursing staff documentation of the screening and application of interventions, whereas the focus group interviews explored the nurses’ and auxiliary nurses’ views of implementing and using the SNG. The study was conducted in three phases: In phase one [February 2012 to February 2013] pre-test retrospective patient record data were collected from: a] patients’ electronic nursing documentation system [ENDS-system] on screening and application of key interventions in stroke care which included items focusing on: activities of daily living, falls, pain, depression, patient education and discharge planning, and b] registered nurses and auxiliary nurses answers on the Barriers and Facilitators Assessment Instrument [BFAI] [46] and the Quality Indicators Tool [QIT] reflecting the SNG. In phase two [April 2013 to the end of December 2013] the SNG was implemented using evidence based strategies including education and training, opinion leaders, posters and reminders [47, 48]. In phase three [February 2014 to February 2015], the posttest measurements were conducted with nurses and auxiliary nurses and patients assigned to the intervention group [February 2014 to February 2015]. The focus group interviews were conducted with a subgroup of nurses and auxiliary nurses in October and November 2014 [Fig. 1]. Hereafter, nurses and auxiliary nurses are generally referred to as nursing staff. To provide thorough reporting of the study both STROBE and COREQ statements were used [Additional file 1].
Fig. 1
Flowchart of study design
Full size image
Setting and participants
The study was conducted at neurology and rehabilitation wards of a university hospital in Iceland. Patient records were extracted from all patients diagnosed with stroke, older than 18 years of age, admitted to the acute neurological ward and subsequently transferred to the rehabilitation ward for 12 months prior to implementation and for12 months after implementation. Excluded were patients who died while admitted to the wards. Data were retrieved from 78 patients [34 in the pretest and 44 in the posttest].
All nursing staff, which included registered nurses and auxiliary nurses working on the participating wards [N = 40, nurses = 22 and auxiliary nurses = 18], were invited to take part in the study and signed informed consent. Thirty-three nursing staff responded to the pre-test questionnaires, whereas 25 responded to the post-test questionnaires [18 nurses/15 nursing auxiliaries/pretest and 13 nurses/12 nursing auxiliaries/posttest]. Sixteen nurses and auxiliary nurses [N = 8 each group, respectively] took part in three focus group interviews.
The stroke nursing guideline
The Stroke Nursing Guideline [SNG] aims to provide an overview of evidence based recommendations for the daily nursing care and rehabilitation of patients with stroke. The SNG was developed based on systematic reviews and studies focusing on following areas: mobility and ADL [8, 9], falls [16, 33,34,35,36,37,38, 49, 50], pain [25], depressive symptoms [14, 15, 20, 21, 28,29,30,31,32], education [39, 40, 51], as well as the CNRS-Guideline [13]. The authors, who all have extensive experience in stroke care and research, made the first selection of important interventions based on the literature, which were formulated as recommendations for the SNG.
Among important aspect of implementation and acceptability of new guidelines like the SNG is the fact that all professionals involved in the care of patients with stroke agree and support the guideline. Therefore, we approached a group of 20 interdisciplinary professional experts, to critically review the content, readability, layout and usability of the guideline. These experts included: nine nurses and of these seven worked on the wards, all with BSc degree in nursing and long experience in neuroscience nursing, of these four had a MSc degree and two had a PhD degree; six physical therapists, two occupational therapists; one psychologist; one rehabilitation physician and one neurologist. These professionals all agreed on the content of the guideline recommendations and their comments mainly focused on the readability, layout and usability of the SNG. There were no specific differences between the professionals in their views about the SNG and based on the expert feedback, the guideline was adapted and optimized.
The final SNG included a total of 23 recommendations focusing on assessment and therapeutic interventions categorized in the following areas: 1] activities of daily living and mobility and falls [14 recommendations], 2] pain/shoulder pain [3 recommendations]; 3] depression [3 recommendations]; 4] patient education [2 recommendations] and 5] discharge planning [1 recommendation]. The guideline also included thorough instructions with photos on how to use the recommendations, with chapters on: background information, definition of concepts, flow-scheme of how to use the guideline, recommendations for the assessment of various outcomes including: mobility and activities of daily living using, the Functional Independence Measure [FIM] [52]; risk of falls using the Morse Fall Scale [MFS] [49]; shoulder pain using a visual analogue scale; depressive symptoms with Patient Health Questionnaire-9 [PHQ-9] [53, 54] and recommendations focusing on therapeutic interventions for the aforementioned areas as well as appendices with the instruments and instructions with photos on how to assist patients with mobility, exercises and positioning. The SNG guideline was made ready to use in a digital, online form as well as a 32 page manual including a plasticized card [pocket size] which was available for all staff.
Data collection
Patient data were retrieved from the ENDS-system including: demographic and health care data: age, sex, living situation, height, weight, health history, the clinical diagnosis of stroke and the type of stroke [provided by a neurologist, based on a CT-scan or an MRI]. Also, the following data concerning 37 items on screening and application of key interventions in stroke care were retrieved from the ENDS-system:
- a]
activities of daily living and mobility [8 items] screened with the Functional Independence Measure [FIM] [52] within 72 h of admission, including diagnosis of mobility and ADL, evaluation of care, limitation in self-care, mobilization facilitation within 24 h, frequency of training exercises, walking exercises, training of ADL activities.
- b]
fall and fall risk [1 item] screened within 72 h using the Morse Fall Scale [MFS] [49], consisting of six items reflecting risk factors of falling: [i] history of falling, [ii] secondary diagnosis, [iii] ambulatory aids, [iv] intravenous therapy, [v] type of gait and [vi] mental status. Total score ranges between 0 and 125 [49]. MFS had been translated into Icelandic [MFS-I] and piloted with the nurses to determine their understanding of wording of items. Interrater reliability was examined and the level of agreement was 84% [K = 0.68] [49].
- c]
pain assessment and pain treatment with special focus on shoulder pain [14 items]: Patients were asked about pain/shoulder pain and pain assessment was conducted using a visual analogue scale and the following interventions were provided: pain treatment [warm cold packages, massage], pain medication given, non-pharmacological treatment given, comforting, massage, relaxation, distraction, pain treatment never given, evaluation of pharmacological pain treatment].
- d]
patient screening for depressive symptoms [4 items]: Patients were asked about psychological distress, nursing diagnosis of depression, consultation of other professionals for the diagnosis and treatment. Depression was screened with the Patient Health Questionnaire-9 [PHQ-9]. The scores are summed to produce a value ranging from 0 [no depression] to 27 [all symptoms occurring nearly every day [53, 54]. Symptoms of depression with the PHQ-9 was only screened in the posttest because no depression scale existed in the electronic documentation system prior to the implementation.
- e]
patient [and family] received education [4 items] including standard information about stroke and rehabilitation, education brochure received, education repeated and tailored to the patient’s [and family] needs.
- f]
discharge planning [6 items] which included: basic discharge planning using electronic patient record, quality discharge planning, patient discharge interview, social support recommended/planned, aftercare recommended/planned, written recommendations.
Demographic data of the nurses and auxiliary nurses were collected including: age, gender, education, experience/length of time working in stroke rehabilitation [0–2 years, 3–10 years, >10 years], current function [full time equivalent], courses on nursing stroke rehabilitation.
Barriers and facilitators for implementation were measured with the Barriers and Facilitators Assessment Instrument [BFAI] [46], with 27 questions, addressing four domains: characteristics of the innovation i.e. the guideline; characteristics of the care provider, patient characteristics and context [organizational, social, political factors]. The questions are positively as well as negatively formulated on a five-point Likert scale, ranging from 5 [strongly agree] to 1 [strongly disagree]. The BFAI is a standardized and reliable instrument, with an item response of >90%, with each item having a distinctive character and was found to be useful for evaluating barriers and facilitators and with Cronbach’s alpha for the four domains ranging from 0.63 to 0.68 [46].
The use of the guideline was measured with a Qualitative Indicator Tool [QIT], developed by the authors, based on the SNG recommendations as and included 30 statements, for the nurses. The QIT statements focused on the main areas of the SNG: a] mobility and activities of daily living [7], b] falls [1], c] depression [9], d] pain/shoulder pain [5], e] patient education [5] and f] discharge planning [3] and inquired if the nurses provided care according to the SNG-recommendations and were phrased in line with the following statement as an example: “I conduct assessment of mobility and self-care activities on admission with a] the FIM-scale, b] the scale in the electronic patient health records, c] both FIM scale and the scale in the electronic patient health records”, which were scored on a five point Likert scale [almost never or 90%]. The face validity of the QIT was evaluated by a group of five experts and included clinical nurse specialists and nurse researchers with extensive experience in stroke nursing and rehabilitation, who reviewed the statements and concluded that the 30 statements were relevant for the daily care and rehabilitation of patients with stroke. Further psychometric testing of the QIT needs to be conducted.
Focus group interviews
Three Focus Group Interviews were conducted with eight nurses and eight auxiliary nurses after the implementation [44]. The interviews were chaired and conducted by a clinical nurse specialist in geriatric nursing, who is a seasoned researcher and has experience with focus group discussion, but was not involved in this study in other ways. An assistant observed and took notes on the interviews, how participants responded to questions and how the discussion evolved. The project manager [IB] invited participants to the interviews but did not take part in them. In the first interview seven nurses [N = 2] and nurse auxiliaries [N = 5] took part, in the second interview four nurses [N = 4] and no auxiliary nurses took part, whereas in the third interview five nurses [N = 2] and nurse auxiliaries [N = 3] took part. An interview guide was used to guide the interviews. The findings of the previous interviews were used to guide discussion in the subsequent interviews [Additional file 2].
Procedure
Phase 1. Pre-test
Quantitative data of the pre-test group of patients were collected from the Ends-system prior to the implementation of the SNG. Pre-test measures of the nurses and auxiliary nurses were collected as well, after presenting the study including the purpose and procedures in a meeting with the nurses, nurse auxiliaries and managers of the ward.
Phase 2. Implementation
The SNG was implemented in the course of nine months using the following implementation strategies which were based on the literature [47, 48]: a] Stroke Nursing Guideline: all the registered nurses and auxiliary nurses received both a printed and plasticised version as well as a digital version. b] Education and Training sessions: All the registered nurses and auxiliary nurses as well as other professionals were invited to take part in one of two, four hour education and training session in how to use the recommendations, the screenings instruments and interventions recommended. This training was strongly recommended for the nurses and the nurse auxiliaries. c] Opinion leaders: seven nurses [5 registered nurses and 2 auxiliary nurses] took on the role of an opinion leader. The opinion leaders were experts in the content and application of the guideline. They followed up on the implementation of the guideline, observed if recommendations were used and gave advice to other colleagues concerning the application of the recommendations. d] Posters and reminders: Posters and reminders were placed on the walls of the wards to remind the nurses on using the guideline and e] E-mails: Regular e-mails were sent to all the registered nurses and auxiliary nurses explaining the intervention protocol and the recommendations.
Phase 3. Post-test
After the implementation period, the post-test data collection took place. The same data were collected as in the pre-test. In addition, focus group interviews were conducted with a subgroup of nurses and auxiliary nurses. The focus group interviews took place in a quiet room within the nursing science department and not within the hospital wards.
Data analysis
Quantitative data were analyzed using descriptive statistics to describe the characteristics of the patients including means [SD], medians [IQR] or n [%]. Frequencies and percentages were reported for the recommendations used, perceived barrier quality indicators were analyzed and reported for both control and comparison group. Associations were calculated for specific patients’ health problems and specific recommendations using Fisher’s exact Test [2-sided] and Spearman’s rho. All data were assessed for normality, which was taken into account when choosing the appropriated statistical method used. For analyzing the Perceived barriers and facilitators measured with the BFAI, the items 4–15 and 17–27 were revised so that a higher score reflected positive and low score negative view of participants. A p-value of