Understanding Nursing on an Acute Stroke Unit

 

 J A N

 

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Understanding nursing on an acute stroke unit: perceptions of space, time and interprofessional practice Cydnee C. Seneviratne, Charles M. Mather & Karen L. Then Accepted for publication 17 April 2009

Correspondence to C.C. Seneviratne: Correspondence e-mail: [email protected] Cydnee C. Seneviratne PhD RN Post-Doctoral Post-Do ctoral Fellow and Instruc Instructor tor Faculty of Nursing University Univers ity of Calgary Calgary,, Alberta Calgary Alberta,, Canada Charles M. Mather PhD Assistant Professor Department Departm ent of Anthropo Anthropology logy University Univers ity of Calgary Alberta, Canada Karen L. Then PhD RN ACNP Professor Faculty of Nursing University Univers ity of Calgary Alberta, Canada

  Under Understand standing ing nursin nursing g on an acute stroke unit: perceptions of space, time and interprofessional practice.  Journal of Advanced Nursing  65(9),  65(9), 1872–1881. doi: 10.1111/j.1365-26 10.1111/j.1365-2648.2009.05053.x 48.2009.05053.x SENEVIRATNE C.C., MATHER C.M. & THEN K.L. (2009)

Abstract Title. Understanding nursing on an acute stroke unit: perceptions of space, time and interprofessional practice. Aim.   This paper is a report of a study conducted to uncover nurses’ perceptions of  the contexts of caring for acute stroke survivors. Background.   Nurses coordinate and organize care care and continue the rehabilitative rehabilitative role of physiotherapists, occupational therapists and social workers during evenings and at weekends. Healthcare professionals view the nursing role as essential, but are uncertain about its nature. fieldwork was carried out in 2006 on a stroke unit in CanMethod.   Ethnographic fieldwork ada. Interviews with nine healthcare professionals, including nurses, complemented observations of 20 healthcare professionals during patient care, team meetings and daily interactions. Analysis methods included ethnographic coding of field notes and interview transcripts. Findings.   Thre Threee local domains domains frame how nurse nursess unde understan rstand d challenges challenges in organizing stroke care: 1) space, 2) time and 3) interprofessional practice. Structural factors force nurses to work in exceptionally close quarters. Time constraints compel them to find novel ways of providing providing care. Moreover, Moreover, sharing of infor informatio mation n with other members of the team enhances relationships and improves ‘interprofessional collaboration’. The nurses believed that an interprofessional atmosphere is fundamental ment al for colla collaborat borative ive strok strokee pract practice, ice, despite worki working ng in a mult multiprof iprofessio essional nal environment. conceive of and respond to space, Conclusion.   Understanding how care providers conceive time and interprofessionalism has the potential to improve acute stroke care. Future research focusing on nurses and other professionals as members of interprofessional teams could help inform stroke care to enhance poststroke outcomes. Keywords:  acute stroke unit, ethnography, interprofessional practice, nursing, perceptions, space, time

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Understanding Understan ding nursing on an acute stroke unit 

Stroke can be a devastating and physically debilitating cardio/  neurovascular disease (Hickey 2003). It interrupts life, arrests previously-cherished activities, and decreases overall quality of lif lifee for sur surviv vivors ors and the their ir fam familie iliess (Ca (Canad nadian ian Str Stroke oke Network, 2007). According to the World Health Organization (2004), heart attack and stroke are leading causes of  death dea th in the wor world ld and app approx roxima imatel tely y 15 mil millio lion n peo people ple worldwide survive stroke annually. Dedicated stroke units are part of a widespread effort to ameliorate the impact of stroke. Generally, these units house comprehensive stroke programmes which include interdisciplinary plinar y teams of careg caregivers ivers including nurses, pharm pharmacist acists, s, physicians, nurse practitioners (NP), social workers, occupationall and physical therapists, tiona therapists, and spee speech ch thera therapists. pists. The ratio rat iona nale le be behi hind nd th thee pr prog ogra ramm mmes es is th that at th thee ne need edss of  individual patients require caregivers with varied expertise (Teasell   et al al..   2007). 2007). Str Stroke oke uni units ts yie yield ld cle clear ar ben benefi efits ts to patien pat ients ts (Hi (Hill ll 200 2002, 2, Str Stroke oke Uni Unitt Tri Triali alists sts’’ Col Collab labora oratio tion n al.  1991, Jorgensen et al.  1995a, (SUTC) 2007; Indredavik et Indredavik  et al. 1991, Jorgensen  et al. 1995a, 1995b, Kalra et Kalra  et al.  al.   1993, Kalra 1994). Patients who receive

toward a man toward manage ageria riall or und unders erstud tudy y rol rolee tha thatt coo coordi rdinat nates es rehabilitative tasks under the guidance of other professions (O’Connor 1993, 2000a). This emerging role is ‘patchy’ in that nursing ability in some areas (e.g. feeding and continence care ca re)) is ad adva vanc ncin ing g wh whil ilee ot othe herr ar area eass (e (e.g .g.. mo mobi bilit lity y an and d exercise exerc ise ther therapies apies)) are laggin lagging g behi behind nd (Per (Perry ry   et al al..   2004). Withou Wit houtt kno knowle wledge dge and ski skills lls in acu acute te str stroke oke car care, e, and acce ac cept ptin ing g re reha habi bili lita tati tion on as a no norm rmal al pa part rt of nu nurs rsin ing, g, Henderson’s vision is unattainable (Myco 1984). The role of nurses in acute stroke rehabilitation is unclear (O’Connor (O’Co nnor 1993, 2000 2000a, a, 2000 2000b, b, Forst Forster er & Youn Young g 1996 1996,, Kirkevold Kirke vold 1997, Burto Burton n 1999 1999,, 2000 2000,, Ellio Elliott tt 1999 1999,, Thorn 2000). 2000 ). Rese Researche archers rs have identified identified nurse nursess as manag managers ers or coordinators (O’Connor 1993, Burton 1999, 2000), clinical specialists (Elliott 1999), community integrators (Forster & Young You ng 199 1996) 6) and car caregi egiver verss who pe perfo rform rm int interp erpret retive ive,, consol con soling ing,, con conser servin ving g and int integr egrati ative ve tas tasks ks (Ki (Kirke rkevol vold d 1997). Kirkevold (1997) describes four unique functions in rehabilitation of stroke survivors that nurses perform but fails to operationalize these functions (O’Connor 2000a). Nurses vary in their attitudes and perceptions of their role in stroke care. In an early qualitative study, Waters and Luker

inpatient stroke care vs. care from a conve inpatient convention ntional al or gene general ral medical ward stand a better chance of surviving, and living indep ind epend endent ently ly at hom homee 1 yea yearr pos postst tstrok rokee (SU (SUTC TC 200 2007). 7). Patients on stroke units experience greater improvement in functional outcome and quality of life, and a decreased length of stay (Cifu & Stewart 1999). Researchers have proven the effectiveness of interdisciplinary stroke care (Cifu & Stewart 1999; SUTC 2007). This study looks beyond outcome measures to the daily interactions tio ns and bel belief iefss tha thatt cha charac racter terize ize com compre prehen hensiv sivee pro pro-grammes gram mes,, wit with h a par partic ticula ularr foc focus us on the role of nur nurses ses.. Nurses have long believed that they play an essential role in stroke care, but they remain uncertain about the nature of 

(1996) found that nurses thought that they were good at basic care, car e, ran rangin ging g fro from m en ensur suring ing tha thatt pat patien ients ts we were re cle clean an and dressed dresse d prior to medi medical cal assess assessment mentss to ensu ensuring ring patients weree phy wer physic sically ally rea ready dy pri prior or to the therap rapy y ses sessio sions, ns, but the considered that they had little time for rehabilitative care. Burton (2000) discovered that nurses provided care, facilitated personal recovery, and managed multidisciplinary care teams, and that these roles suggested that they could provide focused focu sed 24-h 24-hour our coor coordinat dinated ed strok strokee rehab rehabilitat ilitation. ion. Perry et al.  (2004) agreed with Burton (2000) and suggested that nursess must move beyon nurse beyond d their traditional traditional role of provi providing ding basic bas ic car caree and bec become ome act active ive par partic ticipa ipants nts in acu acute te and rehabilitative care.

their contributions contributions (Gibbon 1993, Gibb Gibbon on & Littl Littlee 1995 1995,, Waters & Luker 1996, Burton 2000). Using an ethnographic approach, we examined nurses’ perspectives on the contribution they make to the care of stroke survivors in acute settings. Part of our concern was how nurses see the social connectio conn ections ns they have with other members of the interdisciinterdisciplinary team, and what sort of values they hold toward their practice.

Observational studies of nurses in acute and rehabilitative care settings includes work by Pound and Ebrahim (2000) showing that nurses on a general medical unit and a stroke unitt pro uni provid vided ed imp impers ersona onal, l, sta standa ndardi rdize zed d car care, e, con consid sidere ered d rehabi reh abilit litati ation on sec second ondary ary to nur nursin sing g pra practi ctice ce and did not regularly consult with therapists. In contrast, nurses on an elder care unit valued and promoted patient independence, and freq frequent uently ly consu consulted lted thera therapists pists to enco encourage urage optim optimal al rehabilitat rehab ilitation. ion. The autho authors rs conc conclude luded d that optim optimal al strok strokee care requ requires ires engag engaging ing nurse nursess in rehab rehabilitat ilitation, ion, incre increasing asing traini tra ining ng in reh rehabi abilit litati ation on and com compas passio sionat natee car care. e. Boo Booth th et al. (2001) al.  (2001) compared interventions by nurses with those by occu oc cupa pati tion onal al th ther erap apis ists ts (O (OT) T) an and d fo foun und d th that at OT us used ed patient patie nt promp prompting ting and facil facilitatio itation n while nurses favou favoured red supe su perv rvis isio ion. n. Va Vari riat atio ion n in ca care re pr prac acti tice ce wa wass be beca caus usee of 

Introduction

Background Henderson (1980) offered a vision of nurses with a leading role in acute care and rehabilitation, including working with patients to relearn activities, movement, and continence and nutritional care. In contrast to this vision, nurses are moving   2009

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differ ferent ent int interv ervent ention ion and ass assess essmen mentt sty styles les and lac lack k of  dif preparation and education in stroke rehabilitation on the par of the nurses. According to Bukowski et Bukowski  et al. (1986), al.  (1986), neuroscience nurses could coul d imple implement ment rehab rehabilita ilitation tion thera therapy py over the 24 hour period, support treatments recommended by physiotherapists (PT), (PT ), and ens ensure ure tha thatt pat patien ients ts and fam familie iliess lea learn rn the therap rapy y techniques to continue rehabilitation at home. Nurses play an essential role in acute and rehabilitative stroke care (Gibbon 1993, Gibbon & Little 1995, Waters & Luker 1996, Burton 2000) but the broader social construction of stroke rehabilitation and care providers’ perceptions toward this construction remains unclear.

The study Aim The aim of the study was to uncover nurses’ perceptions of  the contexts of caring for acute stroke survivors.

Methodology Ethnography Ethnograp hy is a quali qualitative tative research approach (Spradley (Spradley 1979, 197 9, 198 1980). 0). In ant anthro hropol pology ogy,, eth ethnog nograp raphy hy is a too tooll for describing desc ribing cultures, and the chie chieff meth methods ods ethn ethnograp ographers hers employ empl oy are obse observatio rvation n and inte interview rviewing. ing. Ethn Ethnograp ographers hers record their observations and interviews in field notes and other media, including audio and visual formats. Postfieldwork wo rk,, re rese sear arch cher erss an anal alyse yse an and d in inte terp rpre rett th thee re reco cord rdss to uncover dominant themes or understandings among members of the culture (Spradley 1979, 1980, Aamodt 1991). In this study, stu dy, eth ethnog nograp raphy hy pro provid vided ed a mea means ns of exp explor loring ing how stroke unit nurses organized and coordinated care.

purposive sampling (Morse & Field 1995, Hammersley & Atkinson 2007) to locate participants, and excluded individuals who could not read, write, or speak English. In total, we followed ten RN, two LPN, one PCA, one NP, two PT, a PT and three physicians physicians (n   = 20), nine of whom we formally interview inte rviewed. ed. Participants Participants ranged in age from 24 to 52 years, 15 were female and five were male. Nurses were the study focus but we also interviewed four other professionals to help contextualize interprofessional perspectives.

Data collection Fieldwork took place from February to November of 2006. Observations averaged 2–3 hours on 3 days/week. The fieldworke wo rkerr (CS (CS)) mad madee obs observ ervati ations ons dur during ing eve every ry typ typee of shi shift. ft. The fieldwork began with 3 months of general observation on the unitt wit uni with h the fiel fieldw dwork orker er wat watchi ching ng at the cha charti rting ng des desk, k, nursing station and walking in the hall. Notes from observations were transcribed via computer. The fieldworker clarified gaps in field notes by returning to the field site and making moree foc mor focuse used d obs observ ervati ations ons dri driven ven by inf inform ormant ant com commen ments. ts. To explore work practices, we interviewed participants (Emerson et al.   1995) using ‘grand tour’ questions such as ‘Can you walk me through your typical day?’ and asking for examples of nursing practice vs. that of other professions.

Ethical considerations The loc The local al hea healthresea lthresearch rch eth ethics ics boa board rd gra grante nted d eth ethica icall app approv roval al forr th fo thee st stud udy. y. We us used ed se seve vera rall in info form rmat atio ion n se sess ssio ions ns to introduce the study to members of the stroke unit. During thesee sessio thes sessions ns and inte interview rviewss we infor informed med strok strokee unit memb members ers about patient confidentiality. We sought written consent only from observation and interview participants and verbal assent from patients when participants were providing direct care.

Participants and setting The study took place on an18-bed acute stroke unit located in a large tertiary medical centre in Canada. As part of a greater health region, the stroke unit provided specialized interventions, management and investigative care during acute and sub-acute stroke phases. It had 18 beds, two located beside a nursing station and 16 in four-bed rooms with connecting corridors leading to a nursing station. Located on a different floorr fro floo from m the neu neuros roscie cience ncess dep depart artmen ment, t, the str stroke oke uni unitt shared space with another general neurological unit. Staff on the unit included registered nurses (RN), licensed practical nurses (LPN), patient care attendants (PCA), NP, PT, OT, speech therapists and physicians. The staffing ratio wass on wa onee RN or LP LPN N to ev ever ery y fo four ur pa pati tien ents ts.. We us used ed 1874

 

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Data analysis Analysis of field notes focused on identifying central domains, specific spec ific domai domain n comp componen onents ts and relat related ed work typologies typologies (Spradley 1979, 1980, Hammersley & Atkinson 2007). We discovered three main themes (domains) and further identified theme components (componential analysis). Finally, we broke work activities into types on the basis of relationships between nurses, and between nurses and other professionals (typological analysis). Through an ongoing process of reading field notes, transcripts and then returning to the field setting for further observations, we crosschecked our findings and were we re ass assure ured d tha thatt our stu study dy dom domain ains, s, com compon ponent entss and related subcategories were culturally salient. The Authors. Journal compilation    2009 Blackwell Publishing Ltd

 

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Reflexivity Ethnographers change in the process of conducting research and spending an extensive period learning cultural domains and categories, and from building relationships with study participants (Davies 1999, Hammersley & Atkinson 2007). Indeed, if an ethnographer’s ideas, beliefs and values did not changee it might indicate chang indicate that she failed in unde understand rstanding ing the cult cu ltur uree sh shee wa wass st stud udyi ying ng.. To ke keep ep tr trac ack k of th thee so sort rtss of  changes they undergo and the impact of these changes on their fieldwork, ethnographers employ ‘reflexive’ techniques. In this study, the fieldworker used ‘asides’, integrative memos and research journals (Spradley 1979, 1980, Emerson  et al. 1995) 199 5) to mak makee exp explic licit it her pre presup suppos positi itions ons and ins inside iderr rela re lati tion onsh ship ips, s, an and d to ma main inta tain in aw aware arene ness ss of he herr so soci cial al position within the culture. Some staff knew the researcher as a nursing instructor or a previous employee. Asides and journaling helped her denote prior relationships, and highlight instances when she might have had ‘built-in’ biases or made priori judgments. Reflexive techniques helped control for potential biases from having an insider perspective, which we did not want to lose because it was essential for gaining access to the study setting, building rapport and building and maintaining trust with staff.

Findings Space Participants described ‘space’ as a challenge to patient care. Thre Th reee th them emes es pr pred edom omin inat ated ed in th thee da data ta:: ‘n ‘nur ursin sing g in a submar sub marine ine’,’ ’,’ nur nursin sing g too close’ close’ and ‘nursing ‘nursing in a sta state te of  code burgundy’. Nursing in a submarine Staff used the term ‘submarine’ to refer to the unit. Command centres are located near the front of submarines, with missile rooms at the rear. The nursing station was located near the entrance of the unit, while the majority of four-bed rooms were located at the middle and far end. According to one nurse: Our submarine…it’s just a more condensed unit. But the thing that

Understanding Understan ding nursing on an acute stroke unit  I’m too claustrophobic on this unit. It’s like I am closed in …if you look down the hall from the nursing station you feel like the walls and curtai curtains ns ar aree cl closi osing ng in ar aroun ound d yo you. u. It is so nar narrow row.. I fe feel el constricted because I cannot do my work in cramped space. I bump into other people all the time.

Nursing too close Nursing Limited space made it difficult to move, to use and relocate equipment equip ment,, trans transfer fer patie patients, nts, docu document ment nursing care and interact with colleagues. Limited space required alternative work strategies to ensure that one did not get in the way of  one’s colleagues. For example, nurses unlocked the wheels on beds in rooms near the nursing station, wheeled them to an open space, and then transferred patients to stretchers. One nurse said: This unit is not set up for us to nurse or do rehab. It is designed so that we are constantly bumping bums, literally  bum to bum …when we transfer patients. We are bashing into one another when we feed patients and when we provide any kind of nursing care.

The layout of the unit caused nurses to bump into each other, and put patients in situations where staff could not ensure appropriate care, privacy or confidentiality. Nursing under a state of ‘code burgundy’ A ‘code burgundy’ signals a lack of beds. The unit included an over-capacity bed in a shared hall. Caring for patients in hallways hallw ays comp compound ounded ed havin having g to work ‘too close close’. ’. Nurse Nursess disapprove disap proved d of nursing under a state of code burgundy: burgundy: [We] feel badly for the lack of privacy for that patient in the hallway. I mea mean n eve even n I had to per perform form an inti intimat matee proc procedu edure, re, a uri urinary nary catheter insertion in the hall, and I hated doing it.

Ironically, despite disapp Ironically, disapprovin roving g of these conditions, conditions, nurse nursess often oft en fac faced ed cri critic ticism ism fro from m pat patien ients’ ts’ fam famili ilies es for the con condit dition ions: s: I think it really stressed [us] out, because [we] were taking the brunt of family complaints. You try telling the patient that you are just following procedure. This is a region issue and we are obligated to do what the region tells us, but we don’t agree.

A state of code burgundy means increased means  increased workloads and the ethical challenge of ‘hallway care’.

most bothers me is it’s not centred. If you have patients in the last room…at the other end you are not in close proximity proximity to anything or anybody – you’re alone. That drives me crazy because the nursing station is so far away.

Participants connected their feelings of claustrophobia on the unit with being on a submarine. The unit lacked work space

Time Participants’ talked about time in three major ways: ‘lack of  time’, ‘preserving time’ and ‘time with and without space’. Each concept denotes limitations and challenges to providing care.

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Lack of time Participants complained that care errors, missed therapy or treatm tre atment ent app appoin ointme tments nts,, and awk awkwar ward d pat patien ientt tra transf nsfers ers occurred because of lack of time to plan. Lack of time also compro com promis mised ed nur nurses ses’’ we wellb llbein eing. g. The They y ass associ ociate ated d wo workrkrelated injuries to the pressures of needing to work quickly to complete all the work before the end of a shift:

Time with and without space Time and space were evolving and interconnected concepts. As result of a lack of space, patients received physiotherapy and occupational therapy in the main therapy department. A PT commented:

We are always injuring ourselves because we rush around. There is

much of a space conflict on the unit that it’s really hard sometimes to

just no just nott en enou ough gh ti time me fo forr us to do th thin ings gs pr prop oper erly ly wi with th ou ourr patients…So if things get missed so be it.

set things up optimally, so we would rather work with patients down in the gym without the nurses.

Lack of time hindered working on patie patient nt rehab rehabilitat ilitation. ion. Participants knew that correct positioning and transferring of  patients assists in stroke rehabilitation, but they believed that they the y lac lacked ked the tim timee for patients patients to mov movee and position position independently:

One nurse said it was hard to do rehabilitation on the unit because of limited time and space:

It is easier to take over for patients, dressing them or brushing their

and all of those things…that would be great, but it doesn’t happen.

teet te eth h ra rathe therr tha than n he help lpin ing g th them em do th thee ta tasks sks.. It is a mat matte terr of 

I know that it is much easier for [physiotherapists] to do transfers in the main therapy department because the setup is ideal. There is so

Ther Th eree ar aree li limi mitat tatio ions ns on wh what at we ca can n do in thetimeand spa space ce al allo lott tted. ed. To be able to come in and have the time to do all of those extra things…like assist patients in their room with feeding or mobilization

Nurses organized their time according to what they believed

Time wit Time with h and wit with h out ade adequa quate te spa space ce aff affect ected ed nur nurses ses’’ participation in bedside rounds. Unit policy stated that nurses should attend and review patients’ neurological status, vital sign si gnss an and d ch chan ange gess in co cond ndit itio ion. n. Ro Roun unds ds oc occu curr rred ed at

they were physi physically cally capable of acco accomplish mplishing ing durin during g the work wo rk day day.. Wh When en pat patien ientt acu acuity ity was high the there re we were re tim timee constraints and rehabilitation was not a priority:

09.00 hours, when nurses were preparing patients for therapy appointments and tests, and/or were providing acute medical care. For nurses attendance at rounds was not a priority:

The patients need time for us to let them do what they can and…for

Then there is the issue of doing rounds on the unit with the docs. I

themselves. But, that requires a whole lot of time and effort, which

really do not like the idea because your time is so compressed. You

thee nur th nurse sess don don’t ’t hav have. e. So I am su sure re so some me of [t [the he pat patie ient nts] s] are

have so much going on during the day and to just repeat what the

frustrated because they realize that and they aren’t able to do as much

[charge nurse] already knows is…well, just repetit repetitive. ive.

accomplishing what is required for patients in a specific window of  time.

as they would like to do…Some days you just can’t wait, you have to get it done and move on.

Preserving time To preserve time nurses coordinated their work and cared for patients as a team. They met and identified tasks they could do more efficiently working together. Alternately, individuals who had fewe fewerr patie patients nts volun volunteer teered ed to ‘pick ‘pick-up’ -up’ patients from fro m col collea league guess who had a hea heavie vierr pat patien ientt loa load. d. A mor moree implicit approach to preserving time developed as a consequence of familiarity. As one nurse related: For me team nursing is knowing who you work with. I don’t know whether it’s the people I normally work with, but we just know each others rhythms. rhythms. It is a matter of not talking about what we should do but just knowing each other.

Participa Partic ipants nts org organi anize zed d the their ir wor work k to mee meett tim timeli elines nes and prescr pre scribe ibed d sch schedu edules les.. The They y pre prepou poured red med medica icatio tions, ns, and arrived early to complete stroke assessments, vital signs and

One reason to miss bedside rounds was a lack of space in the four-bed rooms. Field observations revealed that the stroke neurologist, stroke residents, one or both NP and the charge nurse nur se att attend ended ed bed bedsid sidee rou rounds nds.. Gat Gather hered ed aro around und eac each h be bed, d, the group discussed patient status. According to the nurses there was‘never eno was‘never enoughroom ughroom any way way’, ’, andatten andattendan dance ce did notgive them new patient information and was thus ‘a waste of time’.

Interprofessional practice Participant descriptions of interprofessional practice included two main components: ‘relationships between stroke professionals’ and ‘communication/co ‘communication/collaboration’. llaboration’. Each component highlights highl ights how partic participant ipantss unde understoo rstood d inte interactio ractions ns on the stroke unit and interprofessional practice more generally. Relationships between stroke professionals Nurses Nur ses’’ und unders erstan tandin ding g of str stroke oke car caree dif differ fered ed fro from m oth other er profes pro fessio sional nalss and thi thiss aff affect ected ed how the they y dev develo eloped ped and

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maintained relationships on the stroke team in three major ways. First, working together and sharing experiences were the cornerstones of relationships between nurses. Second, relationships between nurses and therapists developed ope d aro around und per percep ceptio tions ns of how best to add addres resss pat patien ientt needs. Nurses felt that therapists’ failure to recognize and acknowledge the role of nurses in rehabilitation can lead to resentment and half hearted attempts at rehabilitation. One nurse lamented: We ar aree not recogn recogniz ized ed fo forr the mobili mobility ty things things we do or in an any y concerns we have about our patients. So, sometimes we don’t work hard at it. The physios are only concerned that we get the patients ready for their rehab times in the gym. So we do that for them and then concentrate on our patients’ medical needs.

Nurses felt tha Nurses thatt the therap rapist istss had a nar narrow row view of nur nursin sing g practi pra ctice. ce. In the co cours ursee of the their ir pro profes fessio sional nal int intera eracti ctions ons,, nursess were responsible nurse responsible for patie patients’ nts’ medical needs while therapists were responsible for rehabilitation. Third, nurses saw their relationships with stroke physicians and NP in terms of interprofessionalism. Participants claimed that in its original state the stroke team was a matter of  interprofessiona interprofe ssionall prac practice. tice. Nurse Nursess and physic physicians ians candi candidly dly discus dis cussed sed pat patien ients ts and co collab llabora orated ted.. One of the str stroke oke physicians summarized his view of the situation: It should be interprofessional, ideally. In general, stroke units are interdisciplinary. Only a small part of stroke unit care is the physician roles. So during most of stroke care, beyond the acute phase, when you have somebody settled, the physician’s role is relatively minor. It’s all about excellent nursing care and rehabilitation. So the team,

Understanding Understan ding nursing on an acute stroke unit  Having both NP has helped as sort of go between to advocate to the doctors for the things that we need. The NP are more available to come see the patient in an emergent or urgent situation. That helps because you can get the ball rolling for whatever procedures that need to be done.

Communication and collaboration Participants claimed that communication and collaboration were critical to the success of the unit. Regular communication ensured everyone understood how other members envision si oned ed pa pati tien entt ca care re.. We Week ekly ly st stro roke ke ro roun unds ds pr prov ovid ided ed opportuni oppo rtunities ties to discu discuss ss patie patients, nts, collaborate collaborate on care and share sha re alt altern ernate ate pla plans ns or pos possib sibili ilitie ties. s. Att Attend endanc ancee did not guarantee guaran tee parti participat cipation, ion, and inclu inclusion sion in discu discussion ssionss was predic pre dicate ated d on who led rou rounds nds.. One stroke stroke tea team m mem member ber commented: When I lead rounds I like to spend more time on the functional and the social end of things than the medical. I want to make sure the team feels like they’re involved and valued.

This individual thought that it was important to include all team members, and was concerned that some did not feel valued or believe that they were influencing progression and discharge plans for their patients. Nurses were the only team members who did not regularly attend stroke unit rounds because ‘[they] did not have enough time to leave [their required duties] and attend an hour-long stro st roke ke ro roun und’ d’.. On Onee of th thee ph physi ysici cian anss cl clai aime med d th that at th thee atte at tend ndan ance ce of nu nurs rses es at th thee st stro roke ke ro roun unds ds wo woul uld d ha have ve provided more information for both doctors and nurses:

by accident of history and hierarchy, is led by a physician but we have

I think that maybe if we could arrange the time for once a week in the

a NP, all the nurses, the physiotherapist, and social work...Everybody

[stroke unit] rounds for the nurses to attend. I think that might be

is involved in care including home care planning, etc.

beneficial in the long run for all the staff because we can learn so

Another participant commented: We needed something different on our stroke unit. Our unit was not desig des igned ned to be exc exclus lusio iona nary ry in any way. It was intend intended ed to be interprofessional.

The stroke unit was supposed to be an interdisciplinary place where staff felt comfortable sharing information. It would work wor k in a non non-hi -hiera erarch rchica icall way way,, wit with h eac each h pro profes fessio sional nal’s ’s opin op inio ion n be bein ing g va valu lued ed an and d fo form rmin ing g pa part rt of th thee pl plan an fo forr medical and rehabilitative care. Stroke nurses thought that collaboration was important, and that it involved open communication with physicians and NP. They felt that they had positive relationships with the two NP because these professionals were approachable and accessible acces sible during acute and nonnon-acute acute situations. situations. One nurse asserted:   2009

much from each other especially about stuff we don’t have time to find out.

The at The atte tend ndan ance ce of nu nurse rsess at st stro roke ke ro roun unds ds wo woul uld d ha have ve reinforced the notion that the unit was interprofessional.

Discussion Study limitations Ethnography is not a science of generalization. Ethnographic findings come from certain individuals, situations or single case ca sess fr from om a pa part rtic icul ular ar co cont ntex extt an and d a pa part rtic icul ular ar ti time me (Ham (H amme mers rsle ley y & At Atki kins nson on 20 2007 07). ). Ou Ourr fin findi ding ngss ar aree no nott necessaril nece ssarily y indic indicative ative of what happens happens on all strok strokee units and thus the study is not about how stroke units are, but rather about how a stroke unit can be. Although we accept

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limitation ationss wher wheree repre representa sentativen tiveness ess is conc concerne erned, d, we also limit believe that we have found common issues in stroke care in particular, and medical care more broadly.

Space limitations and time constraints are the backdrop of  clinical clini cal care throu throughout ghout North Ameri America. ca. Wein Weinberg berg (2003 (2003))

Hearn & Mich Michelson elson 2006, Patmo Patmore re 2006 2006). ). Thro Thromboly mbolysis sis made stroke an acute event, and thereby helped radically alter the practice of stroke care. Armed with a novel intervention, stroke teams had to work within the boundaries of a narrow therapeut ther apeutic ic wind window. ow. Both the ackn acknowle owledgmen dgmentt that organized niz ed str stroke oke uni units ts imp improv roves es out outcom comes es and the tem tempor poral al demands of thrombolysis motivated the adoption of coordinated nat ed int interp erprof rofess ession ional al car caree tea teams ms and uni units ts suc such h as the

not notes esplete that tha nurses nur have long lon faced fac edeff aective lack lac kly,of int resour res ource s to comple com te tdai daily lyses tasks tas ks saf safely elyg and effect ively, intera eract ctces with wit h patients, patie nts, or atten attend d in-se in-service rvice educ education ation sessio sessions. ns. Notw Notwithithstanding the apparent universality of these problems, in our view it is not advisable to dismiss or devalue the concerns of  those who work in caregiving environments. Our investigation presented an opportunity to re-open dialogue about the import imp ortanc ancee of ins instit tituti utiona onall org organi anizat zation ion and str struct ucture ure regarding appropriate space and use of time related to stroke care (Peszczynski et (Peszczynski  et al. 1972, al.  1972, Ulrich et Ulrich  et al. 2004). al.  2004). A su subs bsta tant ntia iall bo body dy of li lite tera ratu ture re su supp ppor orts ts th thee vi view ew that organized organized strok strokee unit care impro improves ves strok strokee outc outcomes omes (Indredavik   et al al..   1991, 1991, Kalra   et al al..   1993, 1993, Kal Kalra ra 199 1994, 4,  Jorgensen et  Jorgensen  et al. 1995a, al.  1995a, 1995b, Hill 2002, SUTC 2007). What

stroke unit in this study. Although the ideal acute stroke care team includes a focus on re reha habi bili lita tati tion on,, th thee nu nurs rses es in th this is st stud udy y ch chos osee no nott to consistently spend time walking with their patients or taking timee to ass tim assist ist wit with h dre dressin ssing g and gro groomi oming ng (al (alll imp import ortant ant rehabilitation activities). They believed that if they had the time, they would perform rehabilitative care. A recent study  et al.  2008) showed that nurses who incorpo(Va ha kangas et  ¨ ¨ha  ¨ kangas rated rehabilitation into their daily care increased the amount of time ‘working with’ patients to maximize patient independence. The question is whether our stroke unit nurses were aware that a re-evaluation of their time from focusing on nursing tasks to facilitating rehabilitation might increase or ‘preserve’’   time spe ‘preserve spent nt wit with h the their ir pat patien ients. ts. Org Organi anizin zing g and

the literature fails to address is the importance of adequate work wo rk spa space ce for pro provid viding ing thi thiss car care. e. Our par partic ticipa ipants nts per per-ceived lack of space as a constant challenge to providing care. Rather Rat her tha than n des descri cribe be wh what at the they y did reg regard arding ing str stroke oke and rehabilitative care, nurses talked about what they were forced to do because of inade inadequate quate spaces and insuf insufficien ficientt time time.. They did not take the time to assist patients to wash, dress and pract practise ise mobil mobilizati ization. on. They complained complained abou aboutt inade inade-quatee physi quat physical cal space for medic medication ation delivery, delivery, chart charting ing and interactio inte ractions ns with patients. These comm comments ents are conc concernin erning g because they show that nurses did not (and probably cannot) make rehabilitation rehabilitation and patie patient nt auton autonomy omy (Burt (Burton on 1999 1999,, 2000) priorities in their acute stroke care.

implement implem enting ing an edu educat cation ion ses sessio sion n for the str stroke oke nur nurses ses abo about ut facilit fac ilitati ation on of car care, e, as est establ ablish ished ed by Boo Booth th et al al.. (200 (2005), 5), coul could d increase their use of facilitative interventions in rehabilitation. They could have advocated for change by documenting their lack of time concerns time  concerns and by requesting more staff through evaluation of patient acuity levels. A recent American study (Neatherlin & Prater 2003) illustrates that nurses are wellpositioned posit ioned to assist in the development development and evalu evaluation ation of  appropriat appro priatee staffi staffing ng level levelss on rehab rehabilita ilitation tion units through documentation of how they spend their time at work.

How conceptions of time affect work practices in stroke care have not been explored in the literature. In the past, stroke str oke phy physic sician ianss ado adopte pted d ‘wa ‘watch tchful ful wai waitin ting’ g’ for pat patien ientt recovery. Thrombolytic therapy changed stroke care in the 1980s, providing a means of treating a class of acute cases of  ischaemic stroke. The window of opportunity for thrombolysiss is thr ysi three ee hou hours rs aft after er sym sympto ptom m ons onset. et. Members Members of the stroke team now use phrases such as ‘time is brain’ as a reminder that the longer it takes for intervention, the greater the resulting neurological deficit (Barber et (Barber  et al.  2005). Team members have a second term, ‘door to needle time’, which refers to the time between a patient’s arrival at the hospital and the sta start rt of thr thromb omboly olytic tic the therap rapy y (Hi (Hill ll   et al al..   2000). Temporal metaphors denote boundaries and different dimensions sio ns wit within hin the wor work k spa space ce (Ge (Gell ll 199 1996, 6, Blu Bluedo edorn rn 200 2002, 2,

The nur The nurses ses in our study study dis discu cusse ssed d how their their rol rolee in the interprofessional team developed out of day-to-day working relationsh relat ionships. ips. The strok strokee team is multi multidisci disciplina plinary ry beca because use each team member works independently and reports assessments and interventions mainly in team meetings. Nevertheless, participants used the term interprofessional to refer to the stroke team. This suggests a lack of clarity about the type of work relationships and team interactions that exist on the unit.. In mult unit multidisci idisciplina plinary ry team teamss indivi individuals duals work separ separately ately and come together to share information, while interdisciplinary ar y te team amss me memb mber erss co colla llabo bora rate te to cr crea eate te ca care re pl plan anss as they th ey jo join intl tly y as asse sess ss an and d tr trea eatt pa pati tien ents ts (O (Ovr vret etve veit it 19 1997 97,, Sorrel Sor rellsls-Jon Jones es 199 1997, 7, Pay Payne ne 200 2000, 0, Pol Pollard lard   et al.   2005). Heal He alth thca care re pr prof ofes essi sion onal alss co comm mmon only ly us usee th thee te term rmss synony syn onymou mously sly,, alt althou hough gh in the cas casee of acu acute te str stroke oke car care, e,

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What is already known about this topic •

•

  Stroke Stroke is a dev devast astati ating ng ne neuro urovas vascul cular ar dis diseas easee tha thatt affects over 15 million people worldwide annually.   Organized stroke units decrease overall mortality and average length of stay, improve quality of life, independen pen dence ce and lik likeli elihoo hood d of liv living ing at hom homee 1 yea yearr poststroke.

Understanding Understan ding nursing on an acute stroke unit 

which physi which physicians cians were prese present. nt. Ultima Ultimately, tely, nurses stopp stopped ed attending atten ding beca because use of time constraints constraints and their perception perception that the charge nurse could provide requisite information on their behalf.

Conclusion Nurses Nur ses are an und underv ervalu alued ed and und underu erutil tilize ized d res resour ource ce in

•

  Nurses Nurses are important and essential essential members members of interprofessional stroke teams as they work with and care for patients 24 hours a day.

What this paper adds •

•

•

  Limi Limite ted d wo work rk sp spac acee an and d la lack ck of ti time me to care for patients are important issues for neuroscience nurses.   Inte Interprof rprofessio essional nal practice practice is a key fact factor or that requires re-evaluation in acute stroke care.   Nurse Nursess should assume a leadership leadership role as rehab rehabilitailitation practitioners who promote ‘working with’ rather than ‘doing for’ their patients.

Implications Implic ations for pract practice ice and/o and/orr policy •

•

  Providing Providing education education sessions for stroke nurses about facilitati facil itation on of care could increase nursing use of facilitative interventions in rehabilitation.   Nur Nurses ses ought to bec become ome advocate advocatess for change change by docume doc umenti nting ng the their ir spa space ce and tim timee con conce cerns rns and by requestin requ esting g work workspace spacess and temp temporal oral envir environme onments nts appropriate for stroke survivors.

inter interprofe professiona ssionall and inte interdisci rdisciplina plinary ry teams are the gold standa sta ndard rd (Ca (Canad nadian ian Str Stroke oke Net Networ work k and the Hea Heart rt and Stroke Fou Stroke Founda ndatio tion n of Can Canada ada:: Can Canadi adian an Str Stroke oke Str Strate ategy gy 2006; SUTC, 2007; Teasell et Teasell  et al. 2007). al.  2007). Despite Desp ite desiri desiring ng to work inte interprof rprofession essionally, ally, team memb members ers found it diffic difficult ult to comm communica unicate te and colla collaborat boratee consi consistent stently. ly. Participants explained explained that only some nurses wanted to attend rounds and perceived that only some members of the stroke team valued nursing attendance. These findings are consistent with literature exploring team members’ perceptions of nurse attend att endanc ancee at uni unitt rou rounds nds or tea team m mee meetin tings gs (Co (Cott tt 199 1998, 8,  et al. 1999). al. 1999). According to Cott (1998), nurses do not Milligan et Milligan regularly attend team meetings except through a representative such as a charge nurse. The exclusion of nurses may be as a result of lack of interest in attending team meetings or to how a culture typically organizes team meetings. In our study, nurses nur ses sai said d tha thatt wh wheth ether er or not the they y fel feltt we welco lcome me dep depend ended ed on   2009

rehabilitation. Our study shows that in ting some cases nurses hold hol d the themse mselve lves s bac back k fro from m inc incorp orpora oratin g reh rehabi abilit litati ation on principles, and that they believe this occurs because of ‘real world’’ struc world structural tural and temp temporal oral work issue issues. s. An embe embedded dded cultural belief exists that nurses only have time for basic care and that rehabilitative care requires expert knowledge usually held he ld by PT an and d OT OT.. Ho Howe weve ver, r, nu nurs rses es do no nott wo work rk in isolation and have the capacity to work with other professionals outside traditional boundaries. Stroke Str oke nur nurses ses wor world ld wid widee mus mustt emb embrac racee pro profes fessio sional nal developme deve lopment nt and atte attend nd educ education ation sessions regarding the use of facilitative interventions in rehabilitation. We see no reas re ason on th that at nu nurs rses es ca cann nnot ot ta take ke on a le lead ader ersh ship ip ro role le as rehabilitat rehab ilitation ion pract practition itioners ers who prom promote ote ‘work ‘working ing with with’’ rather than ‘doing for’ their stroke survivors. Furthermore, nurses nur ses oug ought ht to bec become ome adv advoca ocates tes for wor work k spa space cess and temporal environments appropriate for patients admitted to acute stroke units.

Acknowledgement Many tha Many thanks nks go to Dr Kat Kathry hryn n Kin King g for assistanc assistancee wit with h manuscript preparation and to the late Dr Marlene Reimer, mentor and colleague.

Funding Dr Cydn Cydnee ee Sene Seneviratn viratnee recei received ved funding for this doctoral research resea rch from the Canad Canadian ian Assoc Associatio iation n of Neur Neuroscie oscience nce Nurses research fund and from the FUTURE Program for Cardiovascular Nurse Scientists, a CIHR Strategic Training Fellowship.

Conflict of interest No conflict of interest has been declared by the authors.

Author contributions CS, SM and KLT wer weree res respon ponsib sible le for the stu study dy con concep cep-tion and design; CS performed the data collection; CS, CM and KLT per perfor formed med the dat data a ana analys lysis; is; CS and CM wer weree

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responsible for the drafting of the manuscript; CS and CM made critical revisions to the paper for important intellectual content; CS and KLT obtained funding; CS provided administrative, technical or material support; KLT supervised the study.

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