Stroke is a leading cause of adult disability and the third leading cause of death worldwide. It is a formidable health challenge for patients, their carers and health services. 

Approximately 7,000 people are admitted to hospital in the Republic of Ireland each year following a stroke, of whom approximately 20% die per year as inpatients.¹ It is estimated that over 30,000 people in Ireland are survivors of stroke, many of whom have significant residual disability including hemiparesis, the inability to walk, need for help with activities of daily living, clinical depression and cognitive impairment.²

Many strokes are preventable, and research has shown that fast and effective treatment and acute stroke management can ‘rescue’ brain tissue, significantly reducing further damage and preventing death and disability. However, until recently stroke has been relatively neglected by health service planners. 

Audit of stroke services

The first ever National Audit of Stroke Services was undertaken in 2008.² The report of the first audit made for sobering reading and demonstrated that care given to patients who had suffered a stroke was sub-optimal and grossly inadequate. 

Improved outcomes for patients were then made a policy priority for the HSE, as evidenced by the implementation of the National Stroke Programme in 2010. The Programme aimed to improve stroke care in Ireland by provision of funding, development of infrastructure and specialist posts nationally, specifically the development of a national programme for thrombolysis therapy, the creation of designated stroke units and the recruitment of medical, nursing and health and social care professionals with specialist knowledge in stroke. 

In 2015 a repeat audit was undertaken³ to assess how much progress had been made against both national and international standards, bringing attention to areas that have improved significantly and identifying areas of weakness, providing the next building block for the National Stroke Programme. 

Access to specialist nursing support

Notably, one area of considerable development was access to specialist nursing support for stroke patients; in 2015 at least one clinical nurse specialist was in post in 85% of hospitals compared to 14% in 2008. 

As a result of the National Stroke Programme, Tallaght hospital obtained a second stroke clinical nurse specialist post. The clinical nurse specialist in stroke in Tallaght Hospital plays a pivotal role in the assessment, planning, implementation and evaluation of care provided to stroke patients, while also ensuring continuous service progression. 

The scope of the role allows the stroke clinical nurse specialist to provide education and training for patients and staff while also auditing current practice and continually evaluating the quality of patient care. 

Specialist input throughout patient journey

In Tallaght Hospital, the specialist stroke nursing service delivers care to both inpatients and outpatients ensuring specialist input throughout the patient journey. Key areas of clinical nurse specialist input include provision of direct and indirect patient care, patient advocate role, educational role to both patients, families and staff, audit role and consultative role. 

To maintain high standards of expert nursing care delivery in Tallaght Hospital, the stroke clinical nurse specialist continually evaluates the service provided to identify areas of possible development. In 2015, one such development was the introduction of the stroke clinical nurse specialist ward round. 

Ward rounds

Traditionally, ward rounds are medically-led and while the importance of the nurses’ presence has been identified,³ time constraints and staffing shortages often create barriers to the nurses’ attendance on the ward round.  Ward rounds are an established core activity of inpatient care during which decisions are made and tasks allocated. The multidisciplinary team approach is an essential element to effective stroke care. 

Nurses are an integral part of the multidisciplinary team, providing 24/7 stroke care, from planning and implementing care to the evaluation of the patient’s condition. 

To improve the way nurses managed stroke patients in an acute setting, a stroke clinical nurse specialist ward round was initiated at Tallaght Hospital to look at essential nursing care on the acute stroke unit and step-down beds.

Aims of specialist ward

The aims of the stroke clinical nurse specialist ward round are:

• To assist nurses to integrate best practice, local stroke policies and guidelines into the clinical environment

• To improve patient care and safety through early detection and prevention of stroke complications

• To guide and support nurses providing care for stroke patients with complex nursing needs

• To continue specialist nurse input following initial clinical nurse specialist assessment of the patient on admission

• To improve clinical communication between nurses and patients

• To identify areas of nursing practice that require development

• To provide ward-based education to both nurses and patients.

Smooth integration

To facilitate smooth integration of the nurse-led ward round into the clinical area a number of measures were taken:

• A revised Guideline on the Nursing Management of a patient with stroke under the care of the acute stroke service was developed in conjunction with the Nurse Practice and Development Unit in Tallaght hospital. This guideline provided direction on nursing management of patients on admission for the first 24 hours, after 24 hours and ongoing. This guideline is placed in the front of the nursing notes of patients on admission when the clinical nurse specialist is conducting an initial patient assessment

• The clinical nurse managers and nursing staff in the clinical area were consulted via face-to-face meetings and also by questionnaires to ascertain their expectations of the nurse-led ward round

• The stroke clinical nurse specialist developed a nursing care review document, which focused on specific nursing care areas to be examined on a weekly basis.

 The nurse-led ward round commenced in June 2015 and after six months an audit of 187 patient care reviews was undertaken. As a result of these 187 reviews, 158 recommendations were made to enhance patient care and outcomes. 

Recommendations

Recommendations were made in relation to the following specific nursing care areas: 

• Approximately one-third (31%) of recommendations were made in relation to elimination (eg. bladder/bowel function). These recommendations included advice pertaining to the assessment and management of urinary and faecal incontinence and urinary catheter care and constipation

• 17% of recommendations were made in the area of falls prevention, which included falls risk assessment and implementation of preventative strategies. 

• Nutrition and swallowing are two potential areas of concern following a stroke. In 19% of patient care reviews on the ward round, advice in relation to swallow screening, dietary modifications, oral hygiene, positioning and mealtime assistance was required. 

• Direction on pain assessment and management was given in 6% of care reviews 

• In 8% of reviews guidance was provided in relation to the monitoring of physiological parameters. 

• A key nursing responsibility is the management of skin integrity – the clinical nurse specialist made recommendations in 5% of cases focusing specifically on preventative measures in liaison with the multidisciplinary team. 

• Further guidance was required in 14% of patient reviews concerning medications, functional outcomes, mood assessment and deep vein thrombosis prevention. 

It is important to acknowledge that all patient care reviews on the clinical nurse specialist ward round involved collaboration with the primary RGN to ensure implementation and evaluation of the recommendations made. 

Potential benefits

It is difficult at this stage to measure the impact of clinical nurse specialist-led nursing rounds on the quality of nursing care; however this does not diminish the potential benefits. The nursing care areas where recommendations were made are critical areas of post-stroke care, which when not managed effectively can lead to poorer patient outcomes and longer hospitalisation. 

In addition, nursing rounds enhance the effectiveness of education and practice improvement strategies by guiding staff in applying knowledge in practical situations.⁵  Nurse-led rounds encourage staff  nurses to question their practice and to evaluate the care they are providing to stroke patients in collaboration with the clinical nurse specialist in stroke to provide patients with a high standard of evidence-based care.

This article is based on a presentation to the 19th Annual Stroke Conference, organised by the Irish Heart Foundation.

References

1. Towards earlier discharge, better outcomes, lower cost: stroke rehabilitation in Ireland Irish Heart Foundation/RCSI/ESRI 2014. Available to download from www.esri.ie 
2. Irish Heart Foundation National Audit of Stroke Care April 2008
3. Irish Heart Foundation/HSE National Stroke Audit December 2015
4. Ward Rounds in Medicine, Principles for Best Practice.  A joint publication of the Royal College of Physicians and Royal College of Nursing October 2012 
5. Mahanes, D. Quatrara, BD. Dale Shaw, K. (2013)  APN-led nursing rounds: An emphasis on evidence-based nursing care. Intensive and Critical care Nursing Vol 29 Issue 5