NSG2ANB Nursing

Introduction:

Recovery from stroke is a complex multidisciplinary approach and involves certain goals that target the impairments that arise as a consequence of the disease process (Brewer, Horgan, Hickey, & Williams, 2013). Such goals include speech and learning skills improvement, motor skills such as balance and walking and finally improving functions associated with activities of daily living (Muth, 2016). These goals need to be individualized as stroke manifestations are varied (National Institute for Health and Care Excellence, 2013). The current paper will offer a critical appraisal of a publication on rehabilitation needs post stroke in order to understand and apply evidence to a clinical case of a 67-year-old woman who feels her rehabilitation needs were unmet post-discharge. The article was published in 2015 in the British Medical Journal volume 5 issue 3 by Lisa Ekstam, Ulla Johansson, Susanne Guidetti, Gunilla Eriksson, and Charlotte Ytterberg. It is titled “The combined perceptions of people with stroke and their carers regarding rehabilitation needs 1?year after stroke: a mixed methods study”.  Greenhalgh et al. (2017) model will be used by discussing authorship, research question, design, methodology, and results. Barriers to effecting evidence to practice will also be highlighted.

Critical appraisal

Authorship

Lisa Ekstam, Ulla Johansson, Susanne Guidetti, Gunilla Eriksson, and Charlotte Ytterberg are affiliated with Karolinska Institutet, Karolinska University Hospital, and Uppsala University in various capacities in the fields of clinical research, neurobiology, occupational therapy, and neurology. Their undertaking of this research stems from technical competence and are thus qualified to produce good results. No conflicts of interest were noted even though the article did not officially declare so.

Research questions

The article has stated that it aims to find the relationship between how dyads perceived their rehabilitation needs and factors such as age, sex, stroke severity, use of rehabilitation services and the sense of coherence (SOC). The rationale for the need of such a study was to fill in the gaps in research that existed. Previous research had concluded that stroke patients perceived unmet rehabilitation needs and that the carers who are close to them know of these needs, some even more than the patients themselves. However, insufficient studies had been done to link these rehabilitation needs with the perceptions of both patients and caregivers.

Research design.

The research employed both qualitative and quantitative research designs making it a mixed method design. Qualitative data was needed to form statistical inference, especially with patient factors. The quantitative design, on the other hand, was appropriate as the research was seeking to collect qualitative data that included beliefs, attitudes, and perceptions. This study design was, therefore, suitable as far as the research question is concerned (Webb, Bain, & Page, 2016).

Methodology

The study population included stroke patients and their caregivers and they were identified through the use of secondary data from another prospective study that had followed stroke patients named Life after Stroke phase 1 (LAS-1) study. Afterward, informed consent was sought before data collection was started. The study inclusion and exclusion criteria identified 86 stroke patients who were eligible for the study with their named caregivers. This study sample is however small as the data sought is to be inferred to a large population.

Structured questionnaires and open-ended interviews were the data collection tools of choice. This offers the advantage of being able to collect large data set from a large sample and still be able to keep the data uniform for easier analysis (Rowley, 2012). The open-ended interviews allow the researchers to assess some nonverbal cues that may be important to the study. These were carried out by physiotherapists and occupational therapists who have the knowledge to maneuver the field and ask relevant questions. This The interviews were carried out by qualified research assistants who had to be occupational therapists or physiotherapists. This has a basis in reducing errors due to the “interviewer effect” whereby interviewers affect the data quality intentionally or unintentionally (Winker, Kruse, Menold, & Landrock, 2015).

The data was analyzed through coding of results by different researchers and through the use of content analysis to come up with thematic categories that arose from the qualitative data. This was appropriate considering the type of data collected (Mays, Popay & Pope, 2007).

Limitations of this methodology were that using set answers in the questionnaires narrowed the range of possible responses and may have locked out crucial information. Also, the definition of rehabilitation was not elaborated and the participants gave responses according to their own understanding introducing errors in the responses.

Results

The study found a relationship between stroke severity, caregiver burden, sense of coherence and strategy used to overcome problems and the rehabilitation needs of the dyads. Patients with mild stroke tended to fall into the category of those whose rehabilitation needs were met. There was also less caregiver burden in this group of patients with met needs. They also tended to have a better sense of coherence. However, the perception of rehabilitation needs was not associated with age or gender of the dyads. Half of the dyads perceived that their needs were unmet as per the study. This research results, therefore, answer the research question posed adequately

Barriers to the application of the evidence to practice.

Many clinicians involved in the rehabilitation process of stroke patients saw the need for continued research and application of evidence to practice (Scurlock-Evans, Upton, & Upton, 2014). However, the uptake of such evidence-based models has been slow despite positive attitudes towards the benefits of using evidence (Upton, Stephens, Williams, & Scurlock-Evans, 2014). A systematic review of literature on by Baatiema et al. (2017) revealed that some of the barriers to putting evidence to practice included organizational barriers at the institutional level, low awareness among professionals, too much familiarity with current practice leading to reluctance in adopting new practices, limited facilities, and the complex nature of stroke care and research.  

Developing clinical policies from new research is complex, hard and usually, need institutional support. If this support is missing then the new evidence won’t be implemented or made into clinical policy (Scurlock-Evans, Upton, & Upton, 2014).

At the individual level, the main barriers were lack of time to research best evidence, lack of access to available research, or simply unwillingness to check best practice evidence (Upton, Stephens, Williams, & Scurlock-Evans, 2014). Most training and academic programs for such health professionals do not include research skills and use of evidence-based practices (da Silva, Costa, Garcia, & Costa, 2015).

Conclusion:

The journal article was a quality written publication with a concise aim supported by a clear rationale behind it. The study design used of mixed methods was appropriate for the research question that seeks to find qualitative data about perceptions of dyads on their rehabilitation needs.

Identified limitations included a small sample that is that does prove beyond doubt that the results are due to chance and makes statistical inference biased. Data collection tools should have been standardized for the entire population as the caregivers were not assessed using the sense of coherence tool.

The identified barriers to putting this evidence into practice were organizational barriers at the institutional level, low awareness among professionals, too much familiarity with current practice leading to reluctance in adopting new practices, limited facilities, and the complex nature of stroke care and research.  

References:

Baatiema, L., Otim, M. E., Mnatzaganian, G., Aikins, A. D. G., Coombes, J., & Somerset, S. (2017). Health professionals’ views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review. Implementation Science, 12(1), 74.

Brewer, L., Horgan, F., Hickey, A., & Williams, D. (2013). Stroke rehabilitation: recent advances and future therapies. QJM: An International Journal of Medicine, 106(1), 11-25. doi:10.1093/qjmed/hcs174

da Silva, T. M., Costa, L. D. C. M., Garcia, A. N., & Costa, L. O. P. (2015). What do physical therapists think about evidence-based practice? A systematic review. Manual therapy, 20(3), 388-401.

Ekstam, L., Johansson, U., Guidetti, S., Eriksson, G., & Ytterberg, C. (2015). The combined perceptions of people with stroke and their carers regarding rehabilitation needs 1?year after stroke: a mixed methods study. BMJ Open, 5(2)

Muth, C. C. (2016). Recovery after stroke. JAMA, 316(22), 2440-2440. doi:10.1001/jama.2016.16901

National Institute for Health and Care Excellence. (2013). NICE guidelines [CG162]. Stroke rehabilitation: long-term rehabilitation after stroke. National Institute for Health and Care Excellence, published June 2013.

Pope, C., Mays, N., & Popay, J. (2007). Synthesizing qualitative and quantitative health evidence: A guide to methods: A guide to methods. McGraw-Hill Education (UK).

Rowley, J. (2012). Conducting research interviews. Management Research Review, 35(3/4), 260-271.

Schmidt, N. A., & Brown, J. M. (2014). Evidence-based practice for nurses. Jones & Bartlett Publishers.

Scurlock-Evans, L., Upton, P., & Upton, D. (2014). Evidence-based practice in physiotherapy: a systematic review of barriers, enablers and interventions. Physiotherapy, 100(3), 208-219.

Upton, D., Stephens, D., Williams, B., & Scurlock-Evans, L. (2014). Occupational therapists’ attitudes, knowledge, and implementation of evidence-based practice: a systematic review of published research. British Journal of Occupational Therapy, 77(1), 24-38.

Webb, P., Bain, C., & Page, A. (2016). Essential epidemiology: an introduction for students and health professionals. Cambridge University Press.

Winker, P., Kruse, K. W., Menold, N., & Landrock, U. (2015). Interviewer effects in real and falsified interviews: Results from a large-scale experiment. Statistical Journal of the IAOS, 31(3), 423-434.