Transitioning home from the acute stroke unit: A mental well being perspective Organization: McMaster University and Hamilton Health Sciences
Summary
This fellowship took place at the Hamilton General Hospital (HGH) within the integrated stroke program through collaboration between McMaster University and Hamilton Health Sciences (HHS). HHS is a regional stroke center that provides acute, rehabilitation and prevention services across the stroke continuum through its integrated stroke model. This fellowship focused on the band 6 pathway that includes patients from the acute stroke unit who do not require inpatient rehabilitation, and are able to be safely discharged home with community services as needed as determined by an interdisciplinary team.
Upon discharge from the acute stroke unit band 6 patients receive a two-week telephone follow up with the Nurse Practitioner (NP) and a 3 month in person follow up with the Stroke Prevention Clinic nurse and Stroke Neurologist. If applicable the patient may also be seen through outpatient rehabilitation services and/or the stroke research program. The fellowship utilized a research perspective to assess the mental well being of band 6 patients during hospitalization and the first month after discharge home to inform improvements to the existing care pathway. Through collaboration of research and clinical staff we developed a study protocol, obtained ethics approval and conducted a small mixed methods research study entitled mental well-being and experience of minor ischemic and hemorrhagic stroke patients recently discharged home after a brief stay in an urban acute stroke unit: A mixed methods approach (ICARE). The key findings of this study and a review of the current literature was used to inform development of a standardized documentation tool and enhanced communication strategy for the 2-week NP telephone follow up. Education, key findings and positive participant feedback was presented to staff on the acute stroke unit to promote openness, awareness and facilitate communication about mental well being after stroke.
My overall learning goal was to enhance my leadership skills through obtaining knowledge, skill and expertise in the area of nursing led stroke research as it relates to post stroke mental health, patient engagement and enhancing patient care. Through attending the McMaster University School of Nursing Qualitative Health Research Bootcamp, I gained basic skills and knowledge in designing applied qualitative research studies. Through designing the mixed methods research protocol with input from my mentor, mentorship team and McMaster School of Nursing faculty, I was able to apply my knowledge in a real-world context. My attendance at the Canadian Stroke Congress enabled me to better understand the current landscape of research on stroke care transitions, mental health and rehabilitation. I applied this knowledge to our research study and knowledge translation strategy. My participation in a health research and evaluation graduate course encouraged me to think about the design and scientific rigor of future quantitative studies in this population. In the final paper for this course, I developed a research proposal that could build upon the work conducted through the fellowship. My attendance at the Masterclass on patient-oriented research prompted me to consider strategies for engaging patients in research and health services design. Although we were unable directly involve a patient representative due our short timeline, we employed a qualitative research strategy to gather patient perspectives and utilized those perspectives to inform practice. My experience at the Applied Suicide Intervention Skills Training (ASIST) enabled me to feel more comfortable talking to patients about mental health and address suicide risk if it was identified during follow up. My attendance at the HHS knowledge translation series highlighted that knowledge translation is much more than presenting information. It is important to consider the local context and how new knowledge can be integrated and assessed within current processes. Through working closely with the nurse practitioner on the acute stroke unit, I was able to see firsthand the role of nurses in leadership and influencing change. Overall, the fellowship provided me with a variety of experiences to better support my ability to promote nursing research.
Outcomes
As acute stroke treatment advances, mortality and hospital length of stay are decreasing, allowing increasing numbers of minor stroke patients to be discharged home after only a brief acute care hospitalization. Previous research suggests mood is an unmet need after discharge home from an acute stroke unit (Crow, 2018). Terrill and colleagues (2018) report 29-40% of minor stroke patients experience post stroke depression. Post stroke anxiety (PSA) is less studied, however in a recent metanalysis, the frequency of PSA in the general stroke population was highest at 0-2 weeks post stroke (36.7%) and decreased slightly over time: 24.1% at 2weeks-3months (Rafsten et al., 2018). The ICARE study completed through our fellowship qualitatively and quantitatively assessed prospectively the mental well-being experience of 14 minor stroke patients during hospitalization, 2 weeks and 4 weeks after discharge from acute care. Our qualitative findings suggest that returning home was viewed positively among patients and this was supported by reduced PHQ9 (depression screening tool) and HADS-A (Anxiety screening tool) scores quantitatively. In our sample, anxiety scores (HADS-A) appeared higher than depression scores (HADS-D) throughout the 4 week follow up and we felt that this was supported by the qualitative data. Quantitative data displayed visually as scatter and box and whisker plots suggest in our sample HADS-A scores appeared higher among patients employed full time at baseline or < 65 or >80 years old. It is important to note, however that our sample size was very
small and these visual trends require assessment in larger samples before conclusions could be made. Qualitatively some participants did report psychosocial challenges post stroke but noted perceived protective factors to prevent negative consequences on mood. Analysis of qualitative participant responses identified positive and trusting social relationships, finding use and keeping busy, communication and a positive perspective as perceived protective factors. Clinically, we utilized these findings to include a standard mental well-being assessment in the 2-week NP call. We also improved the clinical communication strategy to promote continuity of care. An in-service with the results of the fellowship was conducted to promote awareness and discussion of mental well-being stroke recovery.
The fellowship provided the opportunity for clinical and research staff to collaborate on a nursing led research study from design to analysis and develop skills to conduct future nursing led research. This collaboration was highlighted as part of a research meeting with the stroke accreditation auditor who was visiting Hamilton Health Sciences as part of stroke Distinction. We are hopeful to present the findings of the ICARE study as an oral or poster presentation at an upcoming conference. The study results offer suggestions for future research related to early supportive discharge, care transitions, psychosocial recovery and promotion of positive mental well being in minor stroke patients. The fellowship also highlighted some of the great work and processes that already exist at our institution. These findings were shared with management and staff on the acute stroke unit and NP clinic to congratulate them on the work they are doing. Additionally, the fellowship highlighted patient feedback related to perceived protective factors and this information was shared with staff to promote ease of conversation regarding post stroke mental well being in the minor stroke population. The largest impact of the fellowship was on the NP 2-week telephone clinic. This clinic provides the primary point of contact with the stroke team after discharge home from the acute stroke unit. As part of the fellowship a standardized documentation tool was developed to document assessments and findings identified at the two week follow up including a component to assess mental well being (PHQ2 with PHQ9 as needed, questions 8-13 of the Heart and Stroke post stroke checklist, overall clinical assessment). During this time a band 6 mood assessment pathway was also documented to better define the communication and assessment strategy utilized. Additionally, changes were made to allow information obtained at the 2-week NP follow up call to be relayed to family physicians and stroke prevention clinic staff to promote communication and continuity of care. Through creating standard workflow that incorporates mental well being, it will now be possible to begin to quantitatively measure mental well being and impact of interventions on a larger scale.
Overall experience
Overall, my fellowship experience was very positive and I am thankful to RNAO for providing nurses the opportunity to enhance their knowledge, skill and expertise through a self-directed learning plan while addressing a need or gap in service. As an RN in the Leadership-Research stream, the fellowship provided an opportunity to engage with clinicians, researchers and administrative staff in a more collaborative manner on a project directly relevant to local patient care. The timeline of the fellowship encouraged us to work quickly to design a research study, obtain ethics approval, conduct the study and implement changes based on our results and experience. The benefit of research in this field is apparent through our discussions with patients and our review of the literature. We wish we had more time to enroll additional patients and speak to them about their stroke recovery experience. Through the fellowship I have become more comfortable talking with patients about their mental well-being and psychosocial challenges associated with stroke. In my nursing practice, I feel better prepared to support patients with this aspect of recovery. During the conduct of our study, we learned that patients appreciate staff talking with them about the psychosocial aspects of stroke recovery even though it may be difficult to discuss. We also learned about some of the challenges conducting research on mental well being and through this experience, we are better prepared for future research in this field. The fellowship experience has highlighted that communication, continuity of care and support after discharge home from the hospital are important considerations in promoting positive psychosocial well being after a minor stroke. In health contexts, engaging in qualitative research provides tools for nurses to answer research questions that are difficult to answer using quantitative methods. This new knowledge has contributed to my development as a novice researcher and a foundation upon which I can develop advanced research skills.
