Nursing Practice

Review
Stroke

Keywords: Stroke/Rehabilitation/
Driving/Vocational rehabilitation
This

article has been double-blind

peer reviewed

Good rehabilitation after stroke can help prevent further strokes from occurring,
help patients to return to work and alleviate psychological problems

Promoting rehabilitation
for stroke survivors
In this article...
 hree key aspects of nurses role in stroke rehabilitation
T
Why addressing psychological factors saves lives
How nurses can help patients back to work
Author Bernard Gibbon is senior lecturer
at University of Manchester; Jo Gibson is
senior lecturer, Clinical Practice Research
Unit at University of Central Lancashire;
Catherine Elizabeth Lightbody is senior
research fellow, Clinical Practice Research
Unit at University of Central Lancashire;
Kathryn Radford is associate professor at
University of Nottingham; Caroline
Watkins is professor of stroke and older
peoples care and school director of
research, Clinical Practice Research Unit at
University of Central Lancashire.
Abstract Gibbon B et al (2012) Promoting
rehabilitation for stroke survivors. Nursing
Times; 108: 47, 1215.
Stroke does not only affect physical health;
it also has an impact on psychological
health and many other aspects of
survivors lives.
Nurses have a central role in stroke
rehabilitation. This article discusses
rehabilitation, the role of the nurse,
psychological care, secondary prevention
and life after stroke. It focuses on resuming
driving and returning to work as these are
particularly important for the one-quarter
of stroke patients who are aged under 65.

Spl

troke continues to be a leading

cause of acquired disability, especially among older people, and
can have a major effect on independent living. There are approximately
110,000 strokes a year in England, and
around 300,000 people are living with
moderate to severe disabilities as a result
of stroke (National Audit Office, 2010).
Eighty-five per cent of strokes are
ischaemic (where a blood clot has blocked
an artery), while 15% involve haemorrhage
into brain tissue.

Around half of stroke survivors are left

dependent on others for everyday activities, and it is estimated that the direct care
cost of stroke is at least 3bn annually
(NAO, 2010).
While significant advances in stroke
treatment and care have led to a reduction
in mortality rates, stroke survivors require
skilled nursing intervention in the rehabilitation phase of recovery (Miller et al,
2010). A rule of thirds applies, with about
one-third of survivors making a full
recovery and another third dying in the
hours, days and weeks immediately following the stroke. The remaining third,
sometimes referred to as the middle third,
can make gains in independence through
rehabilitation programmes.

The multidisciplinary team

Well-staffed and organised stroke units

have been shown to reduce death, dependency and length of inpatient stay after
stroke (Nelson et al, 2007).
All healthcare workers in the multidisciplinary team have a contribution to
make to ensure the team works towards
agreed goals in a consistent and supportive
manner. The physiotherapist is primarily
responsible for devising the plan of physical interventions to prevent complications such as contractures, and to teach
patients to regain balance and the use of
affected limbs. The occupational therapist
works towards promoting independence
in activities of daily living, including personal care activities such as washing and
dressing, and promoting participation in
society through work or driving. Where
necessary, speech and language therapists
assist in issues such as swallowing and
communication, while medical staff take

12 Nursing Times 20.11.12 / Vol 108 No 47 / www.nursingtimes.net

5 key
points

A quarter of
strokes occur
in people aged
under 65
One-third
of stroke
survivors
experience
depression
Recurrence of
stroke could be
reduced by 80%
with optimum
therapy
Vocational
rehabilitation
helps to match
survivors skills
with jobs
The Stroke
Drivers
Screening
Assessment helps
determine safety
to drive

2
3

4
5

Therapy to help
with coordination

Fig 1. Stepped care model for psychological interventions after stroke

Adapted from IAPT model with input from Professor Allan House and Dr Posy Knights

Level 3: Severe and persistent disorders of mood

and/or cognition that are diagnosable and require
specialised intervention, pharmacological
treatment and suicide risk assessment and have
proved resistant to treatment at levels 1 and 2.
These would require the intervention of clinical
psychology (with specialist expertise in stroke) or
neuropsychology and/or psychiatry.
LEVEL 3

Level 2: Mild/moderate symptoms of impaired

mood and/or cognition that interfere with
rehabilitation. These may be addressed by nonpsychology stroke specialist staff, supervised by
clinical psychologists (with special expertise in
stroke) or neuropsychologists.

LEVEL 2

Level 1: Sub-threshold problems at a level

common to many or most people with stroke
General difficulties in coping and perceived
consequences for the persons lifestyle and
identity. Mild and transitory symptoms of mood
and/or cognitive disorders such as a fatalistic
attitude to the outcome of stroke, which have
little impact on engagement in rehabilitation.
Support could be provided by peers and stroke
specialist staff.

LEVEL 1

Source: NHS Improvement (2011)

the lead on investigations and medical

treatments. All interventions in stroke
rehabilitation are centred on maximising
neuroplasticity the brains ability to
restructure itself through training and
practice. In some instances, other health
professionals, such as clinical psycholo-

Box 1. nurse role in

stroke rehabilitation
Provider of care aiding with
nutrition, hydration, elimination and
hygiene
Facilitator of personal recovery
maintaining and promoting the
emotional and social aspects of
recovery and the development of
coping strategies, and encouraging the
patient in activities of daily living
Manager of multidisciplinary
provision liaising, organising and
mediating between the patient and
carers (personal and professional)
Source: Burton (2000)

gists, may be required to assist in the rehabilitation programme.

Nurses not only have a care management role, but also take responsibility for
promoting recovery and preventing complications, for example through pressure
area care, positioning for therapeutic benefit, breathing and leg exercises, and promoting and managing continence. Their
role is central to stroke rehabilitation and
nursing intervention is significant in
terms of improving outcomes for stroke
survivors and their carers, and reducing
the costs associated with inpatient stay.
This role is diffuse and complex and has
been described as comprising three main
domains of care provider, facilitator and
manager each with a number of
subcategories (Burton, 2000) (Box 1).

Psychological care

Psychological problems following stroke

may include depression, anxiety, emotionalism and post-traumatic stress disorder.
About one third of survivors will experience depression at some point, but it
often remains undiagnosed or inadequately treated (Hackett et al, 2005). Early

psychological problems interfere with

recovery, with depressed stroke survivors
lacking the motivation to participate in
rehabilitation. In the longer term, those
who are depressed fail to engage in leisure
and social activities, have increased
healthcare use and are more likely to
die early (Williams et al, 2004).
All members of the multidisciplinary
team need to be able to recognise psychological problems following a stroke and
understand their role in managing these
problems. In terms of assessment, the
single question: Do you often feel sad or
depressed? is accurate in identifying possible depression following a stroke (Watkins et al, 2007), while the Signs of Depression Scale (Lightbody et al, 2007) may be
useful in those with cognitive and communication problems. NHS Improvement
advocates a stepped care model, in which
nurses have an important role involving
assessment, watchful waiting, support,
psycho-education, active monitoring and
referral (NHS Improvement, 2011) (Fig 1).
Nurses can provide generic support
through active listening, education and
signposting to potential support services.

www.nursingtimes.net / Vol 108 No 47 / Nursing Times 20.11.12 13

Nursing Practice
Review
Listening to patients accounts of their
journeys acknowledges them as individuals and can give an appreciation of the
challenges they face. Emotional challenges
of stroke may include fear, anxiety, frustration, loss of confidence, a sense of loss, and
uncertainty and disappointment around
recovery. Stroke survivors have reported
information, problem-solving strategies
and engagement in activities as extremely
helpful in their recovery and assisting with
acceptance (ChNg et al, 2008).
There are some simple strategies that
nurses can use to identify difficulties and
provide support. Asking open-ended questions facilitates dialogue and enables
patients to talk more freely about their
worries and concerns, while providing
clear explanations and reassurance may
help manage confusion and uncertainty.
Supporting patients to think about their
own solutions to identified problems, and
highlighting strengths and success may
help promote more positive mood states
after stroke.
Rehabilitation should incorporate support for adaptation and readjustment, so
that patients can move towards meaningful, realistic individual goals for
recovery as they come to terms with the
complexities and uncertainties of life
afterstroke.

Secondary prevention

Stroke survivors are at high risk for immediate or long-term recurrence. The risk of a
second event is around 10% at seven days
and 20% at three months; by five years it is
estimated that 30-43% will have had a further stroke (Intercollegiate Stroke Working
Party, 2012). There is also a high risk of further cardiovascular events.
Risk factor modification is therefore
essential after stroke or transient
ischaemic attack to reduce mortality and
morbidity from stroke recurrence. However, fewer than 50% of stroke survivors in
the UK feel they have been informed effectively about preventing recurrences
(NAO,2010).
Before risk factor modification can be
planned, it is essential to establish the aetiology of the stroke. The national clinical
guideline for stroke outlines the assessments and interventions that may be
needed (Box 2) (ISWP, 2012). Some of these
apply to all stroke survivors, but it is
important to conduct an individual assessment and to devise an appropriate plan of
intervention. It has been estimated that
optimum secondary prevention (including
dietary modification, exercise and antithrombotic, antihypertensive and statin

therapy) could reduce the incidence of

recurrent vascular events by 80% (Hackam
and Spence, 2007). However, uptake and
adherence to secondary prevention is often
poor (Lummis et al, 2008).
Medication regimens after an ischaemic
stroke will normally include antihypertensives, antithrombotic agents (unless the
person is prescribed oral anticoagulants),
and lipid-lowering therapy (ISWP, 2012).
Antihypertensives and statins are effective
in reducing stroke risk, even in people who
do not have an elevated blood pressure or
an abnormal lipid profile. The recommended firstline antithrombotic therapy
is clopidogrel (75mg daily). Aspirin and
dipyridamole in combination is only recommended if clopidogrel is contraindicated or not tolerated (ISWP, 2012).
Secondary prevention measures are
usually started while patients are in hospital, and are continued in outpatient and
primary care settings. Nurses working in
any of these settings can contribute to
uptake and adherence. In the inpatient setting, routine medication rounds can be
used as an opportunity to discuss medication regimens.
Some potential difficulties with regimens can also be identified at this time,
such as dysphagia, cognitive impairment,
visual problems and fine motor co-ordination. However, other difficulties may
not become apparent until after discharge.
It is important to ask survivors (and
families, where appropriate), about any
problems they are experiencing with their
medication.
Medication adherence is known to be
poor after stroke, partly because of myriad
physical and cognitive problems, but also

Box 2. Identifying risk

of recurrence
Within one week, every patient who has
had a stroke should be investigated for:
Raised blood pressure (over 130/90)
Hyperlipidaemia
Diabetes mellitus
Those with ischaemic stroke should be
checked for:
Atrial fibrillation and other cardiac
arrhythmias
Structural cardiac disease
Carotid artery stenosis
If no common cause is identified,
patients should be investigated for rarer
causes.
Adapted from ISWP (2012)

14 Nursing Times 20.11.12 / Vol 108 No 47 / www.nursingtimes.net

because of the long-term nature of treatment, the lack of immediate obvious benefit from medication such as statins and
antihypertensives, and the complexity of
post-stroke
medication
regimens
(Lummis et al, 2008). Survivors may be
reluctant to admit that they are not taking
medications as prescribed, so it is important to ask directly and to give permission for them to acknowledge problems,
by using a non-judgemental approach.
Nurses also have an important role in
assessing other risk factors for recurrent
stroke, such as smoking, inactivity, dietary
factors, obesity and excess alcohol intake.
Intervention plans may be initiated in the
inpatient setting and continued in outpatients or primary care. Scheduled poststroke reviews at six weeks and six months
provide an ideal opportunity to do this,
and may be supplemented by opportunistic advice (such as when attending for a
flu vaccination).

Life after stroke

Stroke has an impact on physical and emotional health, on survivors relationships

with people close to them, and on their
ability to live their lives as they did before
their stroke.
For many, returning to work and
resuming driving are key goals of recovery
and primary rehabilitation, particularly in
light of the increase in retirement age, and
the fact that a quarter of strokes occur in
people aged under 65, many of whom have
dependants (Daniel et al, 2009).
Returning to work
The National Stroke Strategy (DH, 2007)
and the national clinical guideline for
stroke (ICSWP, 2008) state that stroke survivors should have access to vocational
rehabilitation services, enabling them to
participate in paid, supported or voluntary
employment. However, not everybody can
access this type of service. Where it is provided, it is rarely organised in a way that
maximises survivors opportunities to
work with their existing employers (Playford et al, 2011).
Survivors are often discharged from
hospital without advice about work, and
those with severe disability may be prematurely written off by health professionals
who assume returning to work means
returning to the same job with the same
responsibilities (Barker, 2006). A different
role with different responsibilities can be
negotiated with an existing employer, provided that the employers door is kept open
so that all options can be explored.
Nurses have an important role to play

For articles on neurology care,

go to nursingtimes.net/neurology

the point of stroke and nurses have a pivotal role to play.

Patient uses weights after having a stroke:

rehabilitation should start in hospital

while patients are still on the ward in identifying hidden disabilities, such as cognitive, visual or hearing problems, and
referring for comprehensive screening and
follow-up by rehabilitation services. This
is particularly relevant for those with less
disabling strokes who are keen to return
home and manage their own return
towork.
Nurses should also be aware of and
signpost stroke survivors to other services
to support them in their work decisions.
These include benefits and employment
advisers, and third-sector services such
the Stroke Associations Return to Work
and Back to Life services, which explore
alternative work and leisure options
when returning to paid work is no longer
the goal.
Perhaps more importantly, nurses
should be aware of the developing expertise in vocational rehabilitation. This is
concerned with finding ways to match
stroke survivors abilities and limitations
to the demands of job and work environments after careful assessment of each
(Tyerman and Meehan, 2004). It involves
working with survivors and their families
to manage the physical, cognitive and
emotional consequences of stroke, and
working with employers to facilitate a
return to work.
Although detailed work assessments
are typically conducted by occupational
therapists, ensuring that stroke survivors
have the opportunity to work is everybodys job. Without timely referral for support to keep them in existing jobs and
make informed choices about work, their
options may be greatly reduced. Vocational
rehabilitation therefore needs to start at

Driving after stroke

Most people who were driving before their
stroke want to resume. Driving increases
independence and opportunities to participate in work and leisure activities, and
losing this ability results in a poorer
quality of life. Driving also provides a solution to mobility problems, which make
using other forms of transport difficult.
At some point during the stroke survivors recovery, the question will arise as to
whether they are fit to resume driving. In
the UK, licence holders have to notify the
Driver Vehicle and Licensing Authority
(DVLA) if they have a disability that affects
or may in future affect their safety as a
driver. They are not allowed to drive for
one month after stroke but may resume
once their clinical recovery is satisfactory.
Residual motor function deficits, cognitive impairment and visual field loss all
affect fitness to drive. While clear DVLA
rules govern vision, and physical disabilities can often be compensated for by
vehicle adaptations, cognitive impairments (frequently overlooked in routine
clinical practice) present a problem. As
with work, these hidden disabilities mean
stroke survivors may resume driving
without advice or assessment.
The Stroke Drivers Screening Assessment (SDSA) is a cognitive screening test
for drivers who have had a stroke (Lincoln
et al, 2010). The test, which predominantly
measures executive abilities, takes less
than 25 minutes to complete and can be
administered in clinics or peoples homes
without any additional training. It can
help to identify which survivors require
further assessment at a specialist driving
assessment centre, and introduces standardised cognitive assessment to existing
procedures.

Conclusion

Many stroke survivors can make significant gains following stroke with a planned
rehabilitation programme delivered by a
multiprofessional team in conjunction
with the individual and their carers. The
nurse plays a key role in the team as a provider of care, a facilitator of personal
recovery and of multidisciplinary care,
and can therefore promote survivors
return towards independent living.
Where psychological care is concerned,
nurses have an important role that involves
assessment,
reassessment,
support,
psycho-education, active monitoring
andreferral.

They also play an important part in

helping to prevent stroke recurrence, particularly in assessing and advising on risk
factors, and ensuring adherence to medication regimens.
Nurses can play a part right from
the outset in taking a positive attitude to
the future, considering what would facilitate stroke survivors return to work and
whether cognitive abilities preclude them
from driving. NT
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