Marit Kirkevold

The unfolding illness trajectory of stroke

Purpose: To describe the characteristics of the illness trajectory of stroke during the first year. Method: A qualitative, prospective case study design; repeated in-depth semi-structured interviews with nine mild to moderately affected stroke patients during the course of the first year. A total of 63 interviews were conducted. The interview data were transcribed verbatim and analysed as a text, using a hermeneutic approach. Results: A stroke is not necessarily experienced as an abrupt psychosocial crisis by the stroke patient. The adjustment process seems to be gradually evolving and prolonged over most of the first year following the cerebro-vascular accident (CVA). The illness trajectory may be divided into four phases, each with characteristic tasks and focal points. The adjustment process involves hard physical and psychosocial work on the part of patient. A necessary pre-requisite for adjustment is a realistic conception of the illness and its implications. This takes time and experience to achieve. Conclusions: The adjustment process following stroke is gradual and prolonged. In order to move away from the predominant functional rehabilitation approach towards a more comprehensive and better targeted service, increased understanding of the complexities of the adjustment process is necessary.

The Role of Nursing in the Rehabilitation of Acute Stroke Patients: Toward a Unified Theoretical Perspective

A review of existing literature indicates an uncertainty about the specific therapeutic role of nurses in the rehabilitation of stroke patients. Two different conceptualizations of the nursing role exist, but neither is related to specific rehabilitation goals and patient outcomes. A beginning theoretical account of the specific role of nursing in stroke recovery is offered as a structure to integrate the therapeutic aspects of the coordinating, maintenance and training functions of the nurse. Existing research literature is reviewed to substantiate the account. Further research is needed to develop the specific content and focus of nursing in stroke recovery.

Life Versus Disease in Difficult Diabetes Care: Conflicting Perspectives Disempower Patients and Professionals in Problem Solving

Conflicts in problem solving are known from diabetes research on patients with good glycemic control but have rarely been studied in the care of patients with poor glycemic control. Equally, the different perspectives of health care providers and patients have not been a focus in previous studies. The authors studied the interactions between health care providers and 11 diabetes patients with poor glycemic control in a grounded theory study at a Danish university hospital. Keeping Life and Disease Apart was identified as a core category. It involved a pattern of conflicts both between and within patients and health professionals, which disempowered them in problem solving. Three approaches to problem solving were identified: A compliance-expecting approach kept the pattern unchanged, a failure-expecting approach deadlocked the pattern, and a mutuality-expecting approach appeared to neutralize the conflict.

Depression in acute stroke: prevalence, dominant symptoms and associated factors. A systematic literature review

Purpose. The aim of this review was to provide a comprehensive analysis of the state of knowledge about post-stroke depression (PSD) in the acute phase, focusing on: (a) the prevalence of depressive disorder and depressive symptoms, (b) the dominant depressive symptoms, (c) the factors associated with PSD and (d) the follow-up consequences. Method. A computer-aided search in MEDLINE, CINAHL, PsychInfo, EMBASE, British Nursing index, Pub Med and Ovid Nursing Database was performed. We systematically searched for studies including depression within the first month after stroke. Results. Forty articles including more than 5400 informants from 37 cohorts met the inclusion criteria. Only a few studies aimed to describe the nature of PSD. The prevalence of depressive disorder and depressive symptoms in the acute phase ranged widely from 5% to 54%. Multiple tools were used for measuring depressive symptoms in the acute phase. An association was found between early depressive symptoms and the continuation of PSD 12 months after stroke. There is a correlation between depressive symptoms and mortality at 12 and 24 months. Conclusion. Depressive symptoms are common in the acute phase after stroke and associated with persistency of depression and mortality after 12 months. A gold standard for the measurement of depressive symptoms in relation to stroke is missing. The knowledge of PSD in the acute phase is still limited, and there is a need for continued empirical research on its profile and patterns.

Dimensions of Post-Stroke Fatigue: A Two-Year Follow-Up Study

Background: The aim of this study was to examine the course of poststroke fatigue in a cohort of first-time stroke patients compared to the general population, and to identify clinically relevant features of post-stroke fatigue. Methods: We performed a follow-up study of 165 patients with first-time stroke admitted to acute stroke units at the Aarhus University Hospital, Denmark. A reference group of 1,069 persons was sampled from the general population. Fatigue was assessed using the Multidimensional Fatigue Inventory (MFI-20) covering five scales of fatigue (General Fatigue, Physical Fatigue, Reduced Activity, Reduced Motivation, and Mental Fatigue). Results: Compared to the general population, stroke patients reported higher levels of Physical Fatigue. Minor or no differences were found for the other fatigue scales. Pathological fatigue, defined as a score ≧12 on the General Fatigue scale, was reported by 59% (95% CI: 51–66%), 44% (95% CI: 36–51%), 38% (95% CI: 31–46%), and 40% (95% CI: 32–48%) of stroke patients 10 days, 3 months, 1 year, and 2 years following hospitalization for stroke, respectively. Post-stroke fatigue levels decreased after three months and remained stable throughout the remainder of follow-up. Poor functional outcome was consistently associated with increased levels of fatigue. Conclusions: Post-stroke fatigue is a common condition primarily characterized by increased levels of Physical Fatigue. The pathological mechanisms underlying post-stroke fatigue and its clinical implications require further study.

Post‐stroke fatigue and return to work: a 2‐year follow‐up

Andersen G, Christensen D, Kirkevold M, Johnsen SP. Post‐stroke fatigue and return to work: a 2‐year follow‐up. 
Acta Neurol Scand: 2012: 125: 248–253. 
© 2011 John Wiley & Sons A/S.

Therapeutic horticulture in clinical depression: a prospective study of active components

AIM This paper is a report of a study conducted to assess change in depression severity, perceived attentional capacity and rumination (brooding) in individuals with clinical depression during a therapeutic horticulture programme and to investigate if the changes were mediated by experiences of being away and fascination. BACKGROUND Individuals with clinical depression suffer from distortion of attention and rumination. Interventions can help to disrupt maladaptive rumination and promote restoration of depleted attentional capacity. METHOD A single-group study was conducted with a convenience sample of 28 people with clinical depression in 2009. Data were collected before, twice during, and immediately after a 12-week therapeutic horticulture programme, and at 3-month follow-up. Assessment instruments were the Beck Depression Inventory, Attentional Function Index, Brooding Scale, and Being Away and Fascination subscales from the Perceived Restorativeness Scale. FINDINGS Mean Beck Depression Inventory scores declined by 4.5 points during the intervention (F = 5.49, P = 0.002). The decline was clinically relevant for 50% of participants. Attentional Function Index scores increased (F = 4.14, P = 0.009), while Brooding scores decreased (F = 4.51, P = 0.015). The changes in Beck Depression Inventory and Attentional Function Index scores were mediated by increases in Being Away and Fascination, and decline in Beck Depression Inventory scores was also mediated by decline in Brooding. Participants maintained their improvements in Beck Depression Inventory scores at 3-month follow-up. CONCLUSION Being away and fascination appear to work as active components in a therapeutic horticulture intervention for clinical depression.

How do persons with dementia participate in decision making related to health and daily care? A multi-case study

BackgroundMany countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities.The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making.MethodsThis Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate.A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach.ResultsProfessional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered.ConclusionsPersons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context.

Realizing Empowerment in Difficult Diabetes Care: A Guided Self-Determination Intervention

Although health professionals advocate empowerment in patient care, they often fail to realize it in practice. Through grounded theories we previously explained why barriers to empowerment were seldom overcome in diabetes care. Zoffmann used these theories as a basis for developing a decision-making and problem-solving method called guided self-determination (GSD). To realize empowerment, health professionals need detailed knowledge of the barriers, their own roles in these barriers, ways to overcome them, and recognizable evidence of having succeeded. Through theory-driven, qualitative evaluation, the previously developed grounded theories helped us recognize changes consistent with empowerment in dyads of nurses and patients with poorly controlled type 1 diabetes. By completing GSD reflection, patients remarkably improved their ability to identify, express, and share unique and unexpected difficulties related to living with diabetes. As signs of empowerment, patients and health professionals accomplished shared decision making, resolved life–disease conflicts, and established meaningful and effective relationships.

FIGHTING BACK—STRUGGLING TO CONTINUE LIFE AND PRESERVE THE SELF FOLLOWING A STROKE

The aim of this longitudinal phenomenological study was to explore how female stroke survivors experienced their life following a stroke and how they managed their altered situation. Twenty-five women suffering first-time stroke were interviewed in depth three times during the first one and a half years after the stroke. Applying the method of Giorgi, we found that there was a lengthy struggle to continue life and preserve the self following the stroke. The struggle was closely related to their deeply rooted identity as mothers, wives, grandmothers, and housewives. The situation of women following a stroke needs particular attention because their needs may conflict with their female caring roles. On the other hand, supporting them in transforming these roles may secure their sense of self and a continued meaningful life.