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Identifying priorities for strengthening and developing the nursing contribution in a field of practice: A case study in stroke care
Abstract
Building on earlier work, this paper describes a coordinated and systematic method for identifying priorities for nursing development within a field of practice. The nursing contribution in stroke care serves as a case study, the primary aim of which was to establish priorities for research and development in stroke care from a nursing perspective. The initiative was a partnership between the Royal College of Nursing and the Stroke Association, supported by the Royal College of Physicians.
... The research councils could learn much from some health-related charities, who have developed excellent partnerships that have successfully shaped strategies to ensure that the priorities of end users -as well as career researchers -are considered. For example, see the work of the James Lind Alliance (http://www.lindalliance.org/), and the Stroke Association's new research strategy (http://www.stroke.org.uk/research/stroke-associationresearch-strategy) and previous work undertaken with this charity demonstrating a strong alignment between the priorities identified by services users and cares and nurses (McMahon et al., 2003). ...
In recent years stroke has been recognised as a national clinical, research and policy priority. Stroke nurses and stroke nursing are important contributors, but previous studies have highlighted lack of clarity and contradictions in the nursing role. A stroke nursing conference in 2002 offered the opportunity to explore nurses' vision for the future through a series of focus group meetings. Many examples of good practice were identified, for example, nursing contributions to risk factor management and secondary prevention, service co-ordination and development, follow-up and support of stroke patients and their families. However, areas for further development include realigning services to a patient focus and ensuring equitable access, integrating services, supporting development of the nursing research evidence base and providing career and educational frameworks for nurses in stroke care. Nurses set out a vision for stroke nursing in which current strengths and developments are consolidated and disseminated in a dynamic, multiprofessional, integrated patient-focused service.
Objectives:
To define the characteristics and determine the effectiveness of organised inpatient (stroke unit) care compared with conventional care in reducing death, dependency, and the requirement for long term institutional care after stroke.
Design:
Systematic review of all randomised trials which compared organised inpatient stroke care with the contemporary conventional care. Specialist stroke unit interventions were defined as either a ward or team exclusively managing stroke (dedicated stroke unit) or a ward or team specialising in the management of disabling illnesses, which include stroke (mixed assessment/rehabilitation unit). Conventional care was usually provided in a general medical ward.
Setting:
19 trials (of which three had two treatment arms). 12 trials randomised a total of 2060 patients to a dedicated stroke unit or a general medical ward, six trials (647 patients) compared a mixed assessment/rehabilitation unit with a general medical ward, and four trials (542 patients) compared a dedicated stroke unit with a mixed assessment/rehabilitation unit.
Main outcome measures:
Death, institutionalisation, and dependency.
Results:
Organised inpatient (stroke unit) care, when compared with conventional care, was best characterised by coordinated multidisciplinary rehabilitation, programmes of education and training in stroke, and specialisation of medical and nursing staff. The stroke unit care was usually housed in a geographically discrete ward. Stroke unit care was associated with a long term (median one year follow up) reduction of death (odds ratio 0.83, 95% confidence interval 0.69 to 0.98; P < 0.05) and of the combined poor outcomes of death or dependency (0.69, 0.59 to 0.82; P < 0.0001) and death or institutionalisation (0.75, 0.65 to 0.87; P < 0.0001). Beneficial effects were independent of patients' age, sex, or stroke severity and of variations in stroke unit organisation. Length of stay in a hospital or institution was reduced by 8% (95% confidence interval 3% to 13%) compared with conventional care but there was considerable heterogeneity of results.
Conclusions:
Organised stroke unit care resulted in long term reductions in death, dependency, and the need for institutional care. The observed benefits were not restricted to any particular subgroup of patients or model of stroke unit care. No systematic increase in the use of resources (in terms of length of stay) was apparent.
The nursing professions' R&D priority-setting Initiative was established to increase the involvement of nurses, midwives and health visitors in research and development activities in the UK. A first phase of work explored the feasibility of establishing a systematic and coordinated process for identifying priorities for R&D for the nursing professions.
The second phase aims to build on the collaboration and cooperation achieved in phase one to establish a process and structure to promote a united professional voice for nursing on R&D (Scott et al., 1999). To this end, proposals were developed to establish a strategic alliance of the professional interests which would be known as the Strategic Alliance for Research in Nursing, Midwifery and Health Visiting. Part of the role of this alliance would be to lobby for funding for research activity in nursing.
This paper sets out to investigate the involvement of nurses with the nursing research charities and looks at ways nurses could improve their chances of obtaining funding from such sources.
This paper describes a national initiative to establish a co-ordinated and systematic method for identifying priorities for research and development, jointly set up by the Royal College of Nursing and the Centre for Policy in Nursing Research. It uses an explicit policy-making model described by Lomas1 to outline the stages of the project. This model is also used to consider how nursing is influencing the current national clinical effectiveness and research and development agendas. Consideration is given as to whether the priority- setting exercise could make a difference to this wider policy agenda.
The aim of this paper is to provide a report of the progress made in the first phase of the national initiative established to identify priorities for R&D for the nursing professions, which was reported earlier in this journal (Kitson et al., 1997). Here we describe how the methods were used, discuss the primary and secondary results achieved in the first phase of the initiative and present an outline of how it is proposed to take these results forward in a second and more strategic phase. The aim of the first phase was to explore the feasibility of establishing a national systematic process for identifying priorities for R&D in the nursing professions*. It is now proposed to establish a strategic alliance for research in nursing, midwifery and health visiting and these proposals are summarised at the end of the paper.
Little appears to have been written about how district nurses perceive their role in relation to the care and management of stroke patients in the community despite the high number of stroke patients on their case loads A qualitative study using a semi-structured interview was undertaken with a convenience sample of 30 district nurses representing each locality in one health district in England Findings suggest that district nurses do not have a major role in the rehabilitation of stroke patients in the community and generally become involved in their care once the patient's chromcity has reached the point of inability to meet self-care demand, or the carer is unable to cope
Management of stroke patients in specialist stroke units hastens recovery but is not believed to influence mortality. We did a statistical overview of randomised controlled trials reported between 1962 and 1993 in which the management of stroke patients in a specialist unit was compared with that in general wards. We identified 10 trials, 8 of which used a strict randomisation procedure. 1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards. The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months. The findings were not significantly altered if the analysis was limited to studies that used a formal randomisation procedure. We conclude that management of stroke patients in a stroke unit is associated with a sustained reduction in mortality.
This article, the second of two considering the nurse's role in stroke rehabilitation, focuses on potential nursing contributions in a number of areas. There is scope, particularly in the community, to develop a far greater nursing role in both the acute and the postacute phases of rehabilitation. However, nurses often have ambivalent attitudes towards rehabilitation--seeing acute care as more prestigious and important. Such attitudes are developed and reinforced in basic training which gives relatively little emphasis to chronic illness.
- Rudd, A.