Ann Mackenzie

Informal carers of stroke survivors–factors influencing carers: A systematic review of quantitative studies

Purpose. Despite increasing evidence of adverse effects on informal carers of caring for stroke survivors, little is known about the characteristics of carers and survivors that influence carer outcomes. The purpose of this review is to summarize factors influencing outcomes in carers of stroke survivors. Methods. A systematic review of studies identified from English language medicine, nursing and psychology databases from 1996 – 2006 was carried out. Results. Thirty-nine studies were identified. Studies from Europe and the USA investigating negative carer outcomes dominated. Carer psychological characteristics and survivor disability were shown to influence carer outcomes. However, the diversity of carers and outcomes investigated and differences in study timing post-stroke make generalizations difficult. Conclusions. Despite improvements in study design over the last two decades, atheoretical studies employing overlapping concepts and poorly defined participants still dominate. Future studies should have theoretical underpinning and should acknowledge the diversity of carers, survivors and their situations. In addition, future emphasis on positive carer outcomes may improve understanding of protective carer factors.

Predictors of quality of life following stroke

Purpose : To determine the factors predicting quality of life during the course of rehabilitation following stroke. Method : Two hundred and fifteen stroke patients aged 41-93 were studied over a period of three months. Measurement of quality of life, functional ability, social support, demographic and treatment data were taken on admission to the rehabilitation hospital, at two weeks and three months. The instruments used were the Sickness Impact Profile (SIP), the Modified Barthel Index (MBI) and The Social Support Questionnaire, short form (SSQ6). Results : Length of stay, previous stroke, functional ability and social support were found to be significantly correlated with quality of life. Stepwise multiple regression analysis indicated that functional ability, psychological and physical SIP dimensions, social support satisfaction at two weeks and previous stroke explained 47% of the variance in sickness impact at three months following stroke. The factors predicting 53% of the variance in sickness impact at two weeks were baseline functional ability, psychological and physical SIP. Conclusions : The findings indicate that both psychosocial and physical factors are important in predicting quality of life in stroke rehabilitation. Determining such predictors at an early stage will help to guide clinical decisions throughout rehabilitation.

Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring

Purpose. To examine the support required by family carers for stroke survivors. Methods. Forty-two family carers were recruited for surveys of needs, knowledge, satisfaction, and competence in caring before and 4 – 6 weeks after discharge from an Acute Stroke Unit (ASU). Results. Information deficits about dealing with psychological, emotional, and behavioural problems and local service information were priorities before and after discharge. Younger female carers (under 56 years) were least satisfied with communication with ASU staff. Face to face contact was valued. After discharge younger female carers, particularly of non-White ethnic groups, reported lower levels of competence in caring and higher burden. Knowledge of stroke risk factors was low in all groups. High satisfaction with treatment and therapy in the ASU, was not transferred to the community. Carers reported feeling alone and described uncoordinated services. Conclusions. Carers are able to anticipate and prioritise their needs, value communication with staff and involvement with discharge-planning, but particular difficulties were experienced by younger female carers and those from non-White ethnic groups. This requires particular attention when developing targeted interventions for family carers from a mixed ethnic community. In-depth and longitudinal studies are needed to detail psychosocial needs and guide practice particularly amongst non-White family carers.

Positive experiences of caregiving in stroke: a systematic review.

Objective: To identify positive experiences of caregivers, who are unpaid carers not statutory, looking after stroke survivors by systematically reviewing published quantitative and qualitative studies. Data sources: Databases were searched from 1999 to 2009 through Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI), Allied and Complimentary Medicine Database (AHMED), PsychINFO, EMBASE and Social Care Online. Reference tracking of selected papers was carried out and references of recent reviews related to stroke caregiving were also scrutinised. Review methods: The relevance of studies was ascertained by the two authors from abstracts and inclusion and exclusion criteria were then applied. Where there were differences of opinion, full copies were read and consensus achieved by discussion. Results: Three hundred and twenty-three studies were found and nine selected. Exploratory and cross-sectional studies prevailed. A range of positive experiences confirmed the findings of previous studies in both stroke and other long-term illness; care recipients progress was the most common source, other aspects included strengthened relationships, feeling appreciated, increased self-esteem. Positive experiences were associated with coping strategies. Changes in positive experiences over time were noted and differences too, for example, between new and experienced caregivers. Conceptual and methodological issues remain. Conclusions: Caregivers were able to identify positive experiences of caregiving providing a more balanced view of their role. Helping caregivers to identify their own positive experiences will encourage them to manage their situation. Longitudinal research is needed to track changes and positive influences on caregiving. Implications for Rehabilitation There is some evidence that caregivers are able to identify what they value providing a more positive and balanced view of caregiving experiences other than just negative aspects. Positive aspects of coping are associated with positive experiences. Offering training to caregivers of a cognitive and behavioural nature, which includes a focus on positive experiences, may be beneficial and needs further consideration. The diversity of caregivers’ experiences – both positive and negative – should be taken into account by clinicians when supporting them.

Case management: A review of the definitions and practices

Case management has been suggested as an innovative strategy which facilitates the linking of quality and cost-effective care. However, there is little consensus about what is actually being introduced under the name of case management. It is suggested that this absence of a clear understanding of case management has been an obstacle in moving forward case management practice and research. This paper presents a critical review of the confusion surrounding case management with an attempt to unravel issues relevant to the implementation of case management into community nursing practice in Hong Kong. It is concluded that there is a need for different definitions of case management as a result of the differences in the cultural and health care context in which it is being practised. Also, if case management programmes are to be advanced, there needs to be more co-ordinated effort in researching not only the expected outcomes but also the structures and processes of these programmes so that findings of similar case management programmes can be compared for ways of future improvement.

An exploratory study of anxiety in carers of stroke survivors.

AIMS AND OBJECTIVES To investigate anxiety in informal carers of stroke survivors in the first three months after discharge. BACKGROUND Informal carers, also called caregivers, play a vital role in supporting stroke survivors. However, caring for stroke survivors can have adverse consequences amongst carers such as burden, stress and reduced quality of life. Emotional distress is also commonly reported but anxiety has received less attention than depression. DESIGN Prospective, longitudinal, descriptive study. METHOD Forty-five carers completed the Hospital Anxiety and Depression Scale on two occasions - within one month and at three months after discharge from stroke and rehabilitation units. RESULTS Carers were more likely to have scores indicating anxiety than depression. In the first month, half the carers (51·1%) scored in the cut-off for anxiety and a third were in the cut-off for depression (31·1%). At three months, the picture was very similar with nearly identical proportions in the anxious and depressed categories (48·9% and 28·9%, respectively). Changes in numbers of cases of anxiety and depression and in mean anxiety scores were non-significant but there was a significant decrease in depression scores (p=0·048). Fourteen carers (31·1%) at one month and eleven (24·4%) at three months fell into both anxious and depressed categories. CONCLUSIONS Anxiety is a relatively neglected emotional outcome in stroke carers. Our study suggests anxiety is an important issue very early in caring whilst other research suggests it remains prevalent for many months. Given the significant role carers play in rehabilitation of stroke survivors, greater recognition of their emotional state is required. Further, longitudinal research with larger sample sizes from a range of geographical areas and improved understanding of factors associated with anxiety is needed. RELEVANCE TO CLINICAL PRACTICE Nurses working in the community are ideally placed to identify and support carers suffering from anxiety.

Effects of a Care Protocol on Care Outcomes in Older Nursing Home Patients with Chronic Obstructive Pulmonary Disease

OBJECTIVES: To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD).

Caring for relatives with serious mental illness at home: the experiences of family carers in Hong Kong.

This article describes a study recently carried out in Hong Kong. The aim of the study was to gain an understanding of the experiences of Chinese family carers in giving care to a relative with serious mental illness at home. Eight primary carers were selected, and data were collected through audiotaped, semistructured interviews in Cantonese. Five main categories emerged from the data: emotional impact, coping and adaptation, psychosocial effect, social support needs, and perceptions of mental illness and mental health services. Conclusions highlight the need for family-oriented mental health services to be developed and for further research to identify the specific nursing interventions that are effective in helping to sustain family caregiving in Chinese families.

Dietary intake, nutritional status and rehabilitation outcomes of stroke patients in hospital

BACKGROUND Nutrition affects rehabilitation through its influence on physical and mental functioning, although little attention has been paid to effects on rehabilitation outcomes. The present study aimed to describe nutritional status and food consumption in stroke patients within 2 weeks of hospital admission and before discharge, as well as to investigate the effects of nutritional and dietary factors on rehabilitation outcomes. METHODS One hundred patients from a consecutive cohort admitted to a metropolitan hospital with acute stroke were recruited and assessed by a single researcher, with 38 reassessed at discharge. Nutritional status was assessed using Mini-Nutritional Assessment and anthropometric indices and dietary intake was assessed by 1-day weighed dietary records. Rehabilitation outcomes were changes in Barthel index scores and the rehabilitation efficiency index. RESULTS Few (n = 9; 10%) consumed ≥100% of the estimated average requirement (EAR) for energy within 2 weeks of admission and 13 (33%) had energy intakes <50% of EAR before discharge. A small but increasing proportion (7% at admission, 13% at discharge) were identified as being malnourished across the inpatient stay. Younger age, lower Barthel index and a higher energy intake in the early stages of admission predicted the extent and rate of restoration of functional abilities by discharge (F = 7.503, P = 0.001; F = 14.558, P < 0.001). CONCLUSIONS Given a general finding of nutritional deterioration identified for these patients, as well as the identification of energy intake as a modifiable influence on the extent and rate of recovery, there is clearly scope for the multidisciplinary development of nutritional support for stroke patients to improve rehabilitation outcomes.

An exploration of the carers' perceptions of caregiving and caring responsibilities in Chinese families.

This qualitative study carried out with 10 Chinese families in Hong Kong describes caregiving and caring from the perceptions of the primary carers. Semi-structured interviews were carried out to gain personal accounts of experiences of primary carers caring for dependent family members. The analysis resulted in categories identifying and explaining the needs of primary carers. Suggestions for practice are made.