Second Edition
Edited by
JANE WILLIAMS
Southern Health Foundation Trust
Southampton, UK
LIN PERRY
University of Technology Sydney
Northern Hospitals Network South Eastern
Sydney Local Health District
Sydney, NSW, Australia
CAROLINE WATKINS
University of Central Lancashire
Preston, UK
This edition first published 2020
© 2020 by John Wiley & Sons Ltd
Edition History [1e, 2010]
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Library of Congress Cataloging‐in‐Publication Data
Names: Williams, Jane (Jane E.), editor. | Perry, Lin, editor. | Watkins, Caroline, editor.
Title: Stroke nursing / edited by Jane Williams, Lin Perry, Caroline Watkins.
Other titles: Acute stroke nursing
Description: Second edition. | Hoboken, NJ : Wiley‐Blackwell, 2019. | Preceded by: Acute stroke nursing / edited by Jane Williams, Lin Perry, Caroline Watkins. 2010. | Includes bibliographical references and index. | Identifiers: LCCN 2018054706 (print) | LCCN 2018057605 (ebook) | ISBN 9781119111467 (AdobePDF) | ISBN 9781119111474 (ePub) | ISBN 9781119111450 (pbk.)
Subjects: | MESH: Stroke–nursing | Evidence‐Based Nursing
Classification: LCC RC388.5 (ebook) | LCC RC388.5 (print) | NLM WY 152.5 | DDC 616.8/10231–dc23
LC record available at https://lccn.loc.gov/2018054706
Cover Design: Wiley
Cover Image: © KTSDESIGN/SCIENCE PHOTO LIBRARY/Getty Images
Dr. Jane Williams
Jane Williams is Director for Transformation, Director of Transformation for physical health services based in Southern Health NHS Foundation Trust, Southampton, UK. She spent 20 years, until 2014, developing the stroke service in Portsmouth. During this time, Jane was involved in many national working parties, including the National Stroke Strategy, UK Forum for Stroke Training, and UK Stroke Forum. Jane has been a member of The Stroke Association research awards committee. A founder member of the National Stroke Nursing Forum, Jane undertook a term of office as chair.
Jane's current role is based in a large community health organisation which provides services across physical, mental health, and learning disabilities both in people's own homes and in bed‐based services. The current foci of her work include development of new models for community health services, integration of intermediate care services, and how clinicians can use activation to support their own practice whilst supporting patients with health behaviour change techniques.
Professor Lin Perry
Lin Perry is Professor of Nursing Research and Practice Development, University of Technology Sydney and the Northern Hospitals Network, South Eastern Sydney Local Health District, Sydney, NSW, Australia. She has a specialist interest in chronic conditions, practice, and service development, particularly in relation to knowledge translation and change management for frontline staff. A past member of the Intercollegiate Stroke Working Party in the UK and current member of the Stroke Foundation Guidelines Working Party and Stroke Network, New South Wales Agency for Clinical Innovation in Australia, she has extensive experience with national guideline development, benchmarking, service review, and evaluation.
Professor Dame Caroline Watkins
Dame Caroline Watkins is Professor of Stroke and Older People's Care, Director of Research and Innovation, Faculty of Health & Wellbeing, University of Central Lancashire, Director of Lancashire Clinical Trials Unit, and Director of Lancashire research Institute For global health and wellbeing (LIFE), Preston, UK. She is Chair of the UK Stroke Forum. Her multidisciplinary team of researchers have a large portfolio of clinically relevant stroke research and contribute to stroke service development locally, nationally and internationally. Caroline's Services to Nursing and Older People's Care were recognised with the award of the DBE in the New Year Honours 2017.
Professor Anne W. Alexandrov, Professor and Program Director for NET SMART at the Health Outcomes Institute, Fountain Hills, AZ, USA; a Professor of Nursing and a Professor of Neurology at the University of Tennessee Health Science Center at Memphis, Memphis, TN, USA; and the Chief Nurse Practitioner of the University of Tennessee – Memphis Mobile Stroke Unit, Memphis, TN, USA
Dr. Munirah Bangee, Research Associate, Faculty of Health & Wellbeing, University of Central Lancashire, Preston, UK
Dr. Elizabeth Boaden, Senior Research Fellow, School of Nursing, University of Central Lancashire, Preston, UK
Professor Dominique Cadilhac, Head of Translational Public Health and Evaluation Division in Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, VIC, Australia and Head of Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
Dr. Madeline Cruice, Reader/Associate Professor, School of Health Sciences, City, University of London, London, UK
Professor Kathryn Getliffe, Previously Professor of Nursing, School of Nursing and Midwifery, University of Southampton, Southampton, UK (now retired)
Dr. Josephine Gibson, Reader in Health Services Research, School of Nursing, University of Central Lancashire, Preston, UK
Clare Gordon, Consultant Nurse, Stroke Services, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
Kirsty Harrison, Senior Lecturer, School of Health Sciences, City, University of London, London, UK
Professor Katerina Hilari, Professor of Acquired Communication Disorders, School of Health Sciences, City, University of London, London, UK
Dr. Stephanie Jones, Senior Research Fellow, School of Nursing, University of Central Lancashire, Preston, UK
Vicky Kean, Advanced Nurse Practitioner, George Eliot Hospital NHS Trust, Nuneaton, UK
Dr. Cherry Kilbride, Senior Lecturer in Physiotherapy, Brunel University London, London, UK and Lead Therapist, Research and Practice Development, Royal Free London NHS Foundation Trust, London, UK
Dr. Peter Knapp, Senior Lecturer in Evidence‐based Decision Making, Department of Health Sciences & the Hull York Medical School, University of York, York, UK
Dr. Rosie Kneafsey, Head of School for Nursing, Midwifery and Health, Coventry University, Coventry, UK
Professor Diana Lee, Professor of Nursing, The Nethersole School of Nursing; Director of the Y.K. Pao Foundation Centre for Nursing Excellence in Chronic Illness Care; and Deputy Director of the CUHK Jockey Club Institute of Ageing at the The Chinese University of Hong Kong
Dr. Elizabeth Lightbody, Reader in Health Services Research, Faculty of Health & Wellbeing, University of Central Lancashire, Preston, UK
Mary Lyons, Senior Lecturer in Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; and Senior Research Fellow, University of Central Lancashire, Preston, UK
Professor Jane Marshall, Professor, Division of Language and Communication Science, School of Health Sciences, City, University of London, London, UK
Professor Sandy Middleton, Professor of Nursing and Director of the Nursing Research Institute, a joint collaboration between St Vincent's Health Australia (Sydney) and Australian Catholic University, Syndey, NSW, Australia
Dr. Elaine Pierce, Independent Lecturer and Researcher
Associate Professor Julie Pryor, Nursing Research & Development Leader, Royal Rehab, Sydney, NSW, Australia and Clinical Associate Professor, University of Sydney, Sydney, NSW, Australia
Dr. Judith Redfern†, Senior Research Fellow, School of Nursing, University of Central Lancashire, Preston, UK
Dr. Clare Thetford, Senior Research Fellow, Faculty of Health & Wellbeing, University of Central Lancashire, Preston, UK
Dr. Lois Thomas, Reader in Health Services Research, School of Health Sciences, University of Central Lancashire, Preston, UK
Stroke has become a recognised nursing specialty worldwide, supported by practice standards that blend nursing knowledge and clinical skills in both neurovascular and cardiovascular physiology [1]. The challenge and responsibility that we accept when caring for stroke patients requires acknowledgment of their highly vulnerable physiological and psychological states, for we provide care at a most fearful time in patients' lives. The disruption to family dynamics and their social, economic and spiritual needs are substantial.
There is much we can offer patients for primary prevention, rapid diagnosis, treatment, complication avoidance, rehabilitation, and secondary prevention. However, many factors limit provision of ‘state of the science’ stroke care. System and economic factors limit availability of stroke resources in some centres, including: lack of access to sophisticated imaging techniques to diagnose stroke and determine pathogenic mechanism, or inability to provide timely reperfusion treatment. Workforce factors may mean nursing, physician, and therapy specialists best equipped to diagnose, treat and prevent stroke are not available. Political and geospatial factors may result in stroke patients being taken to the nearest, rather than best, comprehensive facility. Finally, human factors may limit patients' and families' understanding and acceptance of risk factors, preventative medicine, and early notification of emergency personnel.
As nurses, we try to understand how these factors affect our ability to offer patients high‐quality evidence‐based care. Discomfort with our programs' limitations motivates us to generate powerful advocacy strategies to increase awareness and build consensus in support of program improvement. As exciting advancements in nursing and healthcare emerge, we must use our dissatisfaction when particular evidence‐supported methods are unavailable in our workplaces, cities, or countries, and ask, ‘Why not?’
This text will prepare nurses new to stroke practice and further the knowledge and skills of current stroke nurses. Readers will learn evidence‐based nursing and medical care supported by research generated across the world. As you read, I encourage you to perform a self‐inventory of content that you have yet to master, and consider the gaps in the stroke systems of care (diagnosis, treatment, prevention, and rehabilitation) at your facility. Consider what you can do to improve your own care and that of your interdisciplinary peers, and actively work towards achievement of best practice.
To accept the role of ‘stroke nurse’ is an honour and a privilege. We are the most trusted health professions by patients and families [2, 3], the most numerous of all healthcare providers, and well‐positioned as key drivers of healthcare quality. I hope that you will accept this responsibility and use this text to support your stroke nursing journey.
In Australia, as elsewhere globally, stroke is a leading cause of death and disability [1] and optimal management is imperative. Provision of care for stroke patients in dedicated units by a coordinated multidisciplinary team is a pivotal strategy for improving patient outcomes [2]. This evidence has underpinned health reforms for hospitalised stroke patients worldwide. Data from the 2017 Stroke Foundation national audit showed 89% of Australian hospitals (with ≥75 people with acute stroke admitted annually) have a stroke unit (Kevin Hill, pers. comm., 18 April 2018) [3]. However, access to stroke unit care is not guaranteed; only 69% of stroke patients admitted to audited hospitals with a stroke unit received treatment on that unit [3]. The national thrombolysis rate is low (13%), but some hospitals achieve thrombolysis rates of up to 23% [3]. This demonstrates a major challenge for Australia – provision of equitable access to care. Australian stroke units are primarily (92%) in urban locations rather than rural settings, potentially disadvantaging non‐metropolitan inhabitants [4]. However, ‘hub and spoke’ models, where larger stroke services provide coordinated care across a defined geographic region [5], are promising as support strategies for smaller rural hospitals.
Nationally, initiatives are informing and supporting improvements in the quality and planning of Australia's acute stroke services. The Stroke Foundation has developed a National Acute Stroke Services Framework [5], providing recommendations and definitions for general hospital and stroke specialist services. This is informed and supported by Australian Clinical Guidelines for Stroke Management [6]. In 2015, the Australian Commission on Safety and Quality in Health Care launched the Acute Stroke Clinical Care Standard [7]. Developed in consultation with consumers, clinicians, researchers, and health organisations, and consisting of seven quality statements and measurable indicators, the standard aims to improve early assessment and management of stroke, including initiation of an individualised rehabilitation plan. Collection of data for the stroke standard is not currently mandatory, but data for these key stroke processes of care could drive practice change.
Collection of reliable, nationally comparable data is imperative to drive clinical practice change. The Stroke Foundation organises alternate‐year clinical audits which enable benchmarking across states for key stroke processes of care. In 2015, the Australian Stroke Coalition launched the Australian Stroke Data Tool (AuSDAT), underpinned by a national stroke data dictionary. AuSDaT is an online data collection tool for stroke clinical performance monitoring and improvement and is the method of data collection for the Australian Stroke Clinical Registry (AuSCR). Established in 2009, AuSCR is a collaborative national stroke registry collecting prospective stroke data, using a minimum data set of four key stroke indicators (eight in Queensland), to monitor, promote, and improve the quality of acute stroke care nationally. Importantly, AuSCR collects follow‐up data at 90–180 days post‐stroke and is linked with the National Death Index, providing mortality data and patient outcomes [8]. Data from the Stroke Foundation audit and AuSCR have been used to improve the quality of Australian stroke care [9].
Australian nurses play a pivotal role in the delivery of high‐quality acute stroke care [10]. Education and research are two important factors in the delivery of evidence‐based care. The Acute Stroke Nursing Education Network (established in 2013) facilitates the delivery of evidence‐based acute stroke care by providing educational networking opportunities for stroke clinicians. This network runs regular webinars on clinically relevant topics for acute stroke nurses [11]. Australia has a thriving multidisciplinary stroke research community. Many stroke units throughout the country are involved in multi‐centre, national and international clinical trials and research projects aimed at improving stroke services. Importantly for nurses, since publication of the first edition of this book, results from the Quality in Acute Stroke Care (QASC) Trial have been published. This landmark trial demonstrated the key role of nurse‐led management of fever, hyperglycaemia, and swallowing difficulties and the consequent significant reduction of death and dependency when nurses do these ‘simple’ things well [12–14].
Excitingly for stroke nursing, in recent years several stroke nurse practitioners have graduated in Australia. ‘Nurse practitioner’ is a protected title in Australia and only available to those with an approved nurse practitioner qualification at Masters degree level who demonstrate advanced nursing practice in a clinical leadership role in a particular area of practice. These senior clinical nurses will have a pivotal role in shaping future stroke services, including new models of nurse‐led care.
Australia has well‐developed support for stroke survivors in the form of local state‐based organisations and networks and the Stroke Foundation, working together to improve stroke care. This book sets out in detail what excellence in stroke nursing looks like. It makes a unique and essential contribution to dissemination of evidence‐based practice and promotes improvements to stroke nursing care internationally.
In Hong Kong, stroke is the fourth commonest cause of death [1], with at least 20,000 people becoming paralysed or losing their functional abilities as a result each year [2]. Death and disability from stroke will increase as the population rapidly ages in the coming decades.
Over 90% of Hong Kong stroke patients are managed in public hospitals. As elsewhere, acute stroke management depends largely on effective intervention within hospitals where organised care is provided by stroke units, using standardised stroke orders and integrated stroke pathways managed by multidisciplinary professionals. Stroke units are effective in reducing stroke mortality, increasing the proportion of patients returning home at six weeks, and reducing the need for institutional care [3]. Since 2016, 15 acute stroke units (260 beds) have been set up in acute public hospitals, which enhance acute stroke management so that patients benefit from early intervention [4]. However, access to these units is not always assured, as these 260 beds are serving over 90% of Hong Kong's 7.3 million population. Three acute stroke units have been provided with upgraded facilities to become referral centres for acute stroke patients from across Hong Kong.
The use of thrombolytic treatment in managing acute ischaemic stroke was conservative until the early 2010s [5]. This was due to a reported higher rate of intracranial haemorrhage from thrombolysis because of racial differences [6] and a lack of resources in our public health system. To facilitate neurologists' remote thrombolysis assessment during non‐working hours, a Security‐Enhanced Mobile Imaging Distribution System (SEMIDS) was introduced in 2012. Based on this telestroke system, 24‐hour thrombolytic services have been implemented in most hospitals, resulting in a threefold increase in stroke patients receiving thrombolysis. SEMIDS thrombolytic service relieves the local shortage of neurologists and has greatly improved healthcare for acute stroke patients [7]. Prompt recognition of stroke and rapid access to appropriate treatment are critical in improving stroke outcomes. Fast‐track Transient Ischaemic Attack (TIA) Priority Clinics have also been set up to provide timely treatment for mild stroke patients and reduce the risk of neurological events through multidisciplinary collaboration.
Reliable, comparable, and up‐to‐date data are imperative to improving practice and the quality of stroke care. While a Hong Kong city‐wide stroke data bank is not yet available, the Hospital Authority (HA), which manages all of Hong Kong's public hospitals, has maintained a computerised ‘Clinical Management System’ (CMS) for clinical management since 1999. As over 90% of all hospital stroke admissions are to hospitals run by the HA, the clinical data for these patients are captured in the CMS database. A territory‐wide ‘Electronic Health Record’ (eHR) has also been developed (2009) by the HA to enhance access to and sharing of participating patients' health data by authorised healthcare providers in the public and private sectors. This has enhanced our endeavours to continuously improve service quality and safety for stroke care.
Nurses in Hong Kong play a critical role in all phases of stroke care. Nurse‐led TIA clinics, stroke clinics, and transition care programmes for discharged stroke survivors provide stroke care and management from initial evaluation and diagnostic workup through to rehabilitation. When nurse consultants were established in the HA (2009), stroke nurse consultants were also appointed. Whilst these consultants have a clinical leadership role to promote nurse‐led stroke care, the development is in its infancy, as only a few have been appointed since 2009.
In Hong Kong, and other Asian regions (e.g. China, Korea, and Japan), improvement in stroke care has paradoxically increased the number of stroke survivors. Most stroke survivors need long‐term preventive medicine, intense rehabilitation, and caregiver support. In Hong Kong, there is active participation of public institutions, charity funds, non‐government organisations, and professional organisations in promoting public awareness and improving local stroke services and rehabilitation. The Hong Kong Neurological Society and the Hong Kong Stroke Society, for example, have developed guidelines and protocols on many aspects of the general management of stroke patients from admission to rehabilitation. These guidelines are used by professionals in both public and private hospitals. A wide range of innovative rehabilitation services (i.e. use of video games, music therapy, and robots) have been piloted by different professional stroke organisations and non‐government organisations.
One salient feature of Hong Kong's stroke care is the integration of Chinese and Western medicine in stroke treatment and rehabilitation. Local research has found that the use of integrative medicine, which includes the basic treatment of Western medicine and routine rehabilitation in conjunction with acupuncture and Chinese medicine, improves stroke patient outcomes [8]. Since 2014, the HA has developed the Integrated Chinese‐Western Medicine (ICWM) programme for three disease areas, including stroke rehabilitation. With this programme, Chinese medicinal treatment options, including acupuncture, cupping therapy, tui na, and herbal medicine, have been introduced at an earlier stage for stroke patients in public hospitals.
As in other developed cities, one‐third of the stroke sufferers in Hong Kong are less than 65 years old, and numbers are increasing in younger people [1]. Primary prevention by promoting healthy lifestyle changes and screening individuals for known risk factors will continue to be a key mechanism for reducing the burden of stroke in the wider Hong Kong community. However, Hong Kong is yet to develop a well‐established policy or territory‐wide primary care network or programme capable of effectively achieving these aims.
This book, a unique stroke nursing text, provides a stimulus for nurses to anchor stroke care in the reality of life in the acute stroke wards and in the community of the stroke survivors and caregivers. This work is significant, not only because it recognises the complexity and delicacy of stroke care, but also because it makes explicit the depth of knowledge and understanding necessary for such care provision. The precepts of this excellent book could both illuminate and ultimately change stroke care practice. It is essential reading for all nurses, not just for stroke care nurse specialists.
We would like to acknowledge the chapter authors of the previous edition, Michael Leathley, Chris Burton, Wendy Brooks, Aeron Ginnelly, Sheila Payne, Peter Humphrey, Louise Brereton, Jill Manthorpe, and Graham Williamson, who were no longer involved in this edition.
The editors would also like to acknowledge the editorial support team: Kerry Hanna, Alison Doherty, Naoimh McMahon, and Kateryna McDonald.