Beruflich Dokumente
Kultur Dokumente
Authors:
Zeliha Tulek, RN, PhD, Assistant Professor, Istanbul University Florence Nightingale Faculty
Ingrid Poulsen, RN, PhD, Associate Professor, RUBRIC (Research Unit on Brain Injury
Rigshospitalet, Denmark
Katrin Gillis, RN, MSc, Assistant, Department of Public Health, University Centre for
Nursing and Midwifery, Ghent University / Lecturer, Odisee University College, Department
Ann-Cathrin Jönsson, RN, PhD, Associate Professor, Department of Health Sciences, Lund
Zeliha Tulek, RN, PhD, Assistant Professor, Istanbul Universitesi Florence Nightingale
Accepted Article
Hemsirelik Fakultesi Abidei Hurriyet Cd. 34381 Sisli, Istanbul, Turkey.
Contributions
Study design: ZT, ACJ, IP, KG; data collection: ZT, ACJ, IP, KG; data analysis: ZT;
manuscript preparation: ZT, ACJ, IP, KG. All authors read and approved the final
manuscript.
Conflict of interest
ABSTRACT
Aims and objectives. To conduct a survey of the clinical nursing practice in European
countries in accordance with the European Stroke Strategies (ESS) 2006, and to examine to
what extent the ESS have been implemented in stroke care nursing in Europe.
Background. Stroke is a leading cause of death and disability globally. Optimal organisation
Methods. A questionnaire comprising 61 questions based on the ESS and scientific evidence
Neuroscience Nurses, who sent the questionnaire to nurses active in stroke care. The
Management of acute stroke and prevention including basic care and nursing, and Secondary
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prevention.
Results. Ninety-two nurses in stroke care in 11 European countries participated in the survey.
Within the first 48 hours after stroke onset, 95% monitor patients regularly, 94% start
mobilization after 24 hours when patients are stable and 89% assess patients’ ability to
swallow. Change of position for immobile patients is followed by 73%, and post-void
residual urine volume is measured by 85%. Some aspects needed improvement, for example
staff education (70%), education for patients/families/carers (55%), and individual care plans
Conclusions. The participating European countries comply well with the ESS guidelines,
particularly in the acute stroke care, but not all stroke units have reached optimal
Relevance to clinical practice. Our study may provide clinical administrators and nurses in
stroke care with information that may contribute to improved compliance with the European
A majority of the participants in this survey reported good nursing practice, but ratio
be updated regularly.
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INTRODUCTION
Stroke is a global health problem, even though age-standardized mortality rates of stroke
have decreased in the past two decades (Krishnamurthi et al. 2013). The number of people
who have a stroke annually and live with the consequences or die from stroke is increasing in
relation to the population growth and aging (Feigin et al. 2015). Stroke is the third leading
cause of disability-adjusted life years worldwide with a considerable increase (19%) over two
decades (Murray et al. 2012). Furthermore, stroke is an important public health issue,
because it has been shown to be a preventable and treatable disease (Jauch et al. 2013).
priority.
BACKGROUND
Stroke is one of the leading causes of death and disability in Europe, and the burden of the
disease is expected to increase in Europe (Kjellström et al. 2007, Bejot et al. 2016). Based on
this fact a Pan-European Consensus Meeting on Stroke Management was arranged for the
first time in 1995 in Helsingborg, Sweden, to examine the evidence-based knowledge and set
targets for 2005 in the management of stroke (Aboderin et al. 1996). In 2006, a second
Consensus Conference was arranged in Helsingborg to update the evidence in stroke care,
and to set new targets. The conference was organized by the International Society of Internal
Medicine, endorsed by the European Stroke Council and the International Stroke Society, and
co-sponsored by the WHO Regional Office for Europe. It was arranged in collaboration with
needed to be emphasized in the acute care as well as the post-discharge care. At the final
plenary session, the participants adopted the Helsingborg Declaration 2006 on European
Stroke Strategies (ESS), and the participants agreed upon the Helsingborg Declaration Goals
for 2015. The main areas of stroke management included in the declaration were organization
stroke outcome and quality assessment (Kjellström et al. 2007). Attention was paid to
identify what goals were reached, what worked and what did not, and barriers for
including stroke care, and the need to educate clinical nurse specialists regularly in this field.
This has also been reported from studies confirming the importance of nurses in stroke care
to assess the patients’ swallowing function (Westergren 2006), nutritional screening (Smith
2016), to measure the post-void residual urine volume (Gilbert 2005), and to follow the
weight to detect malnutrition (Jönsson et al. 2008). The role of the nurse is also important in
the follow-up of recovery (Jönsson et al. 2014), risk factors and medication compliance
(Irewall et al. 2015), and to facilitate transition from hospital to community care (Condon et
al. 2016).
It is also important for nurses to consider the psychological factors that may influence the
recovery already in the acute stroke care. Post-stroke depression in the acute phase may be
related to the loss of physical abilities as well as anxiety regarding the living situation for the
stroke and may influence psychological factors, particularly among those with affected
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sensory-motor function in the upper extremity at stroke onset (Lindgren et al. 2012). In
addition, other types of pain are common after stroke (Jönsson et al. 2006) and may be an
The European Association of Neuroscience Nurses (EANN) has about 2500 members in
Europe covering 16 countries.The goal of the EANN is to provide a forum for collaboration
(www.eann.info). In European countries where a neuroscience nursing association has not yet
Since the EANN participated in setting the Helsingborg Declaration Goals for 2015, the aim
was to conduct a survey of the clinical nursing practice in European countries in accordance
with the European Stroke Strategies (ESS) 2006, and to examine to what extent the ESS have
METHODS
Study Design
questionnaire based on the ESS and evidence-based nursing practice in stroke care was
developed by the four members of the EANN Scientific Committee including three of the
stroke, and prevention (Kjellström et al. 2007). The questionnaire consisted of 61 questions.
questions included an option marked “other” where the participant could write a personal
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reply.
Participants
The study was presented to the representatives of the member countries at an annual EANN
board meeting and the questionnaire (in English) was distributed to the board members.
Member countries who were informed when the study was introduced were Austria, Belgium,
Croatia, Denmark, Finland, Iceland, Italy, Malta, the Netherlands, Norway, Poland, Serbia,
Sweden, Switzerland, Turkey and UK. A majority of the participating member countries used
the English version, but the questionnaire was translated from English into Dutch, French and
Turkish in the Netherlands, Belgium and Turkey to ensure that all participating nurses could
with knowledge in both languages. The EANN representatives in the participating countries
sent the questionnaire to nurses in stroke care by e-mail. A description of the background and
Ethical considerations
This study fulfilled all ethical requirements as detailed in the Declaration of Helsinki.
Information about the study was included with the questionnaire, and by replying to the
questions, the participant denoted consent. Only health professionals were involved, and it
was the nurses’ voluntary choice to participate in the study with total anonymity achieved by
Data is presented by descriptive statistics including mean, standard deviation, range, number
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and percentage. The analysis was carried out using the SPSS 21.0 software (IBM, NY).
RESULTS
represented Sweden (n=23), Belgium (n=15), Denmark (n=11), the United Kingdom (n=11),
Norway (n=10), Turkey (n=10), Malta (n=6), the Netherlands (n=2), Switzerland (n=2),
Iceland (n=1) and Serbia (n=1). Characteristics of the 92 participants are presented in Table
1. A majority of the participants (n=72) were working in stroke units, 12 in neurology clinic,
participants were clinical nurse specialists, 25 head nurses, 21 bed-side nurses (RN), 2
Organization of stroke services including basic requirements for stroke care, criteria fulfilled
for participating stroke units, and team members representing different professions trained in
stroke care are specified in Table 2. A majority (88%, n=80) reported that specialized stroke
care including rehabilitation is available for all stroke patients, and 91% (n=84) had
interdisciplinary stroke teams. Even though a majority of the participating units met the
criteria for stroke units, improvement was needed to enhance the following factors in
advanced stroke care: regular staff education in stroke care (70%, n=64), education for
patients/families/carers (55%, n=51) and individual care plans for secondary prevention
recommended to be included in the stroke team, but the number of social workers (67%,
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n=60), psychologists (43%, n=39) and oral hygienists (9%, n=8) was lower.
Clinical practice of nurses regarding management of acute stroke in stroke units or other units
with stroke care are presented in Table 3. A majority of the participants (95%, n=87) reported
that patients’ level of consciousness and physical abilities are monitored regularly within the
first 48 hours after stroke onset, and 94% (n=85) stated that patients are mobilized when they
are stable. For patients with urinary incontinence, 42% (n=39) of the nurses stated that they
use permanent catheters, and 85% (n=77) measure residual urine volume to detect urinary
problems. Bedside swallowing is assessed within 24 hours by 89% (n=75), 46% (n=38)
assessed by nurses, and 54% (n=45) in collaboration between nurses and other members in
the team. Assessment of ability to eat was performed by 98% (n=89), oral health daily by
92% (n=81), and pain assessment by 66% (n=59) of the nurses. Change of position for
immobile patients was documented by 73% (n=66). A majority of the participants stated that
written information and/or psychosocial support for patients and their families during the
Secondary Prevention
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Since stroke patients usually have been prescribed new medications or had their prescriptions
changed after stroke it is important for nurses in collaboration with physicians to follow up
the results and control whether the treatment goals have been reached. A program for
secondary prevention has been established in accordance with the ESS covering follow-up of
the main risk factors, i.e. hypertension, smoking, atrial fibrillation or other cardiac diseases,
and diabetes as reported by 76-83% of the respondents (Table 3). Regarding follow-up of
nutritional status measured as weight loss (51%, n=45) and overweight (61%, n=54) the
proportion was lower and lack of physical exercise was reported by 53% (n=47). Supportive
counselling is an important factor not only in the acute stroke care, but also in the post-stroke
nursing care including risk factors such as smoking, nutritional problems, and possible
DISCUSSION
To our knowledge, this is the first evaluation of stroke care nursing practice in relation to the
European Stroke Strategies. Our results show that the strategies seem to be implemented in
most countries participating in the survey. However, there is a scope for improved adherence
to guidelines in some areas of nursing practice for stroke patients. Since it has been reported
that implementation of guidelines increase quality of care and outcome after stroke including
(Donnellan et al. 2013 A, Hubbard et al. 2012). Some adherence studies conducted in Europe
were carried out among neurologists or therapists (Hadely et al. 2014, Donohue et al. 2014,
of studies including interventions in nursing care. From an interview study with stakeholders
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and interdisciplinary team members it was found that, barriers to adherence to guidelines
were lack of resources, and insufficient training and education (Donnellan et al. 2013 B). It
has also been raised that it is vital that nurses maintain compliance with practice guidelines,
research and skills, and social media has been found to have a potential in terms of
Our study was carried out in eleven European countries, but our sample was not homogenous
in terms of education and nurse specialist competence. Despite agreed standards for nursing
(Lahtinen et al. 2013), there were differences in education level of nurses. However a large
majority of the respondents had a Bachelor (n=53) or Master (n=22) degree, and only 17 of
the nurses had high school education. Those who had their basic education in nursing on high
school level, i.e. no Bachelor or Master level, had probably studied before the Bologna
declaration had been agreed upon by the European countries. Nurse specialist education is
important in stroke care and and the number of specialist nurses is low in several of the
participating countries as confirmed in this study. This indicates a need to further develop the
availability of education in this field as described in a Polish study (Slusarz et al. 2012).
The European Stroke Strategies include several interdisciplinary areas related to stroke care,
but in our study the focus was mainly on nursing care components of the ESS, e.g. the nurses’
assessment and management of common health problems in stroke care. Careful monitoring
of patients’ neurological impairments and level of consciousness is a vital issue in the acute
stroke care and it creates a rationale for establishment of stroke units (Kjellström et al. 2007,
that the acute care nursing practice within the first 48 hours after stroke onset was well in
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accordance with the evidence-based guidelines and the ESS.
A common problem after stroke is urinary incontinence, which may last long-term (Pizzi et
al. 2014). However, although many participants for assessment of this problem followed the
guidelines, the case was not the same for management of the problem. Most of the nurses
(85%) reported that they measure postvoid residual volume of urine, which is positive.
However, as many as 42% of the nurses stated that they used permanent (indwelling) catheter
for patients, which indeed is not recommended (Jauch et al. 2013). One explanation for that
could be that they may not have a formal urinary incontinence assessment plan in their units
as concluded from a survey of 41 stroke units (Jordan et al. 2011). Another explanation could
be that they may not have enough time to implement post-void residual volume measurement
and optimal interventions when needed due to shortage of staff. A British study estimated
that time not only for therapy, but also for nursing care was inadequate, because stroke
patients received low levels of care by registered nurses and almost half of the nurses
providing care were assistant nurses (Rudd et al. 2009). An audit in Ireland confirmed these
results reporting inadequate staff resources and significant variability in the availability of
specialist staff (Horgan et al. 2011). Other reasons for lack of good practice regarding urinary
incontinence might be the fact that promotion of urinary continence is not a priority area of
Only 83 of the participants replied yes to the question concerning standard assessment of
swallowing; only 38 were done by nurses, and 45 by other team members. However, a study
has shown good agreement between assessments of swallowing done by nurses and speech
participating nurses, but assessment of pain (66%) and documentation of position change for
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immobile patients (73%) were conducted to a lower degree. Already in 1992, it was reported
that immobility after stroke might cause pain related to pressure on the skin and
when the patient is immobile in bed (Coletta et al. 1992). Our survey showed that
information and/or psychosocial support to patients and their families was mainly given by
nurses. Since supportive counselling is important in the acute as well as the post-acute
nursing care, it is disappointing that 13% of the patients could not receive any information
and support, which is particularly important for survivors affected by this severe disease.
Our survey indicates that secondary prevention after stroke is not optimal in all represented
units. The need to optimize secondary prevention has been confirmed by an international
through the development of a Post Stroke Checklist to improve long-term stroke management
(Ward et al. 2014). The ICARUSS model (Integrated Care for the Reduction of Secondary
Stroke) including early prescription of medications by the medical staff, and promotion of
lifestyle changes by a nurse coordinator has been reported to reduce the risk for recurrent
stroke (Joubert et al. 2009). Development of a nurse-led post acute stroke clinic has also been
factors, including cognitive and psychological difficulties (Crowe 2009). Another good
aiming at lifestyle changes that resulted in reduced blood pressure, increased physical
activity, and motivating patients to adhere to treatment (Drevenhorn et al. 2012). The nurses’
role in secondary prevention after stroke by assessing and advising on risk factors and
(Gibbon et al. 2012). Although the nurses’ interventions in the acute stroke care is the most
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dominant part in our survey, these studies confirm the importance of the nurse’s role in health
LIMITATIONS
A number of limitations should be considered when results of this survey are interpreted. A
considerable limitation is that in some countries there were several participants and in some
of the countries very few, sometimes only one. The generalizability of the findings all over
Europe is limited because several European countries have not joined the European
Association of Neuroscience Nurses, and five of the member countries could not participate
because they could not arrange the translation of the questionnaire, or had no member active
in stroke care. Another factor that may have had a considerable impact on the results is the
fact that a quarter of the participants were Swedish nurses. Taking these limitations into
account, this is the first study to give an impression of the evidence-based competence in
CONCLUSIONS
The results of this study show a picture of eleven European countries regarding adherence to
standards in stroke care with a particular focus on nursing. Our survey demonstrates that the
However there is a variability of standards in some aspects of stroke care nursing and
nursing practice in relation to evidence-based guidelines. The results of this survey may
provide administrators and clinical nurses with valuable information of nursing practice in
stroke care. Although clinical nursing practice for stroke patients has followed the guidelines
as reported by a majority of the participating nurses, there is still room for improvement in
some aspects. Future studies with a more representative sample would be beneficial.
Acknowledgements
We would like to express our thanks to the European Association of Neuroscience Nurses
(EANN) for their support and also to the nurses who voluntarily participated in this study.
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Secondary Prevention
• Is there a structured program for control of secondary 90 77 (86)
prevention?
• Are the following factors included in the program? * 89
- Hypertension 73 (82)
- Smoking 71 (80)
- Lack of physical exercise 47 (53)
- Atrial fibrillation / other cardiac diseases 68 (76)
- Diabetes 74 (83)
- Overweight / Obesity 54 (61)
- Underweight / Weight loss 45 (51)
* More than one option has been marked
† Other team members: OT-Occupational therapist, SLT-Speech language therapist, PT-Physiotherapist,
NA-Nurse
Assistant