Nursing’s Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community

Abstract

Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing’s impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing’s influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.

Observation of the Effect of TTM-Based Health Information Behavior Combined with Continuous Nursing on Cognitive and Motor Function, Living Ability, and the Quality of Life of Cerebral Stroke Patients

“…With the continuous progress of medical technology, the mortality of patients with CS has decreased, but a variety of complications of patients after discharge is still inevitable. Without timely rehabilitation guidance, patients may miss the best opportunity for rehabilitation, which will seriously affect patients' cognitive function, motor function, living ability, and quality of life and eventually lead to patients cannot adapt to society [8,9]. erefore, CS patients still need continuous medical and health services for a period of time after discharge.…”

Nursing’s Contributions to Stroke Care During COVID-19

“…While nurse staffing and budgets are always tight, having a nurse leader functioning in a liaison/care manager role to oversee care transitions makes good sense and saves dollars, not to mention that better care will be administered, leading to higher satisfaction among both survivors and families. 7 A major challenge is getting hospital administrators to see the value of this role and understand the overall benefits both to their institutions and the communities they serve.…”

“…Transitioning across multiple care settings is commonplace for stroke survivors and their families, but these transitions are often challenging, frequently leading to anxiety, frustration, and confusion. Camicia et al 7 provide an interesting and useful perspective in their article Nursing's Role in Successful Stroke Care Across the Continuum. They present evidence supporting the essential roles nurses perform in facilitating safe, effective, and efficient care transitions from the acute, postacute, and back into the community.…”

Access, Utilization, and Implementation of Research Among Rehabilitation Nurses: A Qualitative Study

“…Despite the recent increase in randomized controlled trials in clinical rehabilitation research, rigorous study designs may be less prevalent, leaving nurses with a smaller pool of literature from which to draw evidence for clinical practice ( Honkanen et al, 2019 ; Morris et al, 2020 ). With regard to content, studies that address issues most germane to rehabilitation, such as long-term functioning, complex social needs, return to independence, and vocational outcomes, are fewer in number, as are studies that include nursing home residents and participants with cognitive or functional impairments ( Camicia et al, 2021 ; Gerber et al, 2020 ; Rose et al, 2017 ; Sheehan et al, 2019 ). These and other qualities specific to the rehabilitation setting suggest that a better understanding of the research barriers experienced by rehabilitation nurses is warranted.…”

“…Current literature on nurses’ use of research information is often dated, based outside the United States, limited to the hospital setting, and based on nurses in general as opposed to those working in rehabilitation specialties ( Akerjordet et al, 2012 ; Breimaier et al, 2011 ; Brown et al, 2009 , 2010 ; Chen et al, 2013 ; Fink et al, 2005 ; Leasure et al, 2008 ; McMaster et al, 2013 ; Patterson et al, 2017 ; Roxburgh, 2006 ; Saunders & Vehviläinen-Julkunen, 2016 ). Although some barriers may transcend country lines and nursing specialties, the use of research information and the unique challenges of evidence-based practice in rehabilitation nursing are not well understood.…”