Centre for Ageing and Supportive Environments Nurses’ competence in health promotion and secondary...

Centre for Ageing and Supportive Environments

Nurses’ competence in health promotion and secondary prevention seems to be neglected

Ann-Cathrin Jönsson

Specialist Nurse

PhD Neurology

Associate Professor

Dept. of Health Sciences

Lund University, Sweden


What happens when the patient leaves the hospital?


Health promotion – essential in nursing

The international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. It has been revised several times and the latest revision was completed in 2012.

Nurses have four fundamental responsibilities:

to promote health to prevent illness to restore health and to alleviate suffering.


What about health?

…as stated by the WHO:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.


Health is broader than the WHO definition

• Having a diagnosis is not the same as being unhealthy

• Not having any diagnosis is not the same as being healthy

• The patient’s personal view is essential


Stroke– like being struck by a lightning

•Acute treatment has been developed and interdisciplinary care in a stroke unit has been found to be essential in stroke care

•What happens after the patient has been discharged from the stroke unit in a long-term perspective?

•Patient perspectives?


Lund Stroke Register started March 1, 2001

• 416 consecutive first-ever stroke patients were registered during the first year covering the catchment area of 8 municipalities with 234 505 inhabitants

• Age mean 74.3 range 18-102

• Follow-up four months after stroke (n=330), one year later (n=310)


310 persons followed up twiceResults at 16 months after stroke

•Depression, major factor influencing the level of health-related QOL measured with SF-36

•21% Moderate-severe pain (VAS 40-100) including shoulder pain

•25% Weight loss >3 kg (46% eating problems)

•19% BMI Underweight

Jönsson AC et al. (2008) Weight Loss After Stroke : A Population-Based Study From the Lund Stroke Register. Stroke;39(3):918-23. Lindgren I, Jönsson AC et al. (2007) Shoulder pain after stroke. Stroke; 38(2):343-8. Jönsson AC et al. Prevalence and intensity of pain after stroke: a population based study focusing on patients' perspectives. (2006) Journal of Neurology Neurosurg Psychiatry;77(5):590-5.Jönsson AC et al. (2005) Determinants of quality of life in stroke survivors and their informal caregivers. Stroke;36:803-808.


310 persons followed up twiceMajor Risk Factors above goal

•66% Blood Pressure ≥140/90

•70% Cholesterol levels above ≥5

•50% Diabetics (n=44) not well controlled

•42% Cardiac disease

•13% Current smokers


Secondary prevention - I• Vascular risk factors identified in clinic remained poorly addressed

6 months later.1

• Through an integrated system of education, advice and support to both patient and GP, the Integrated Care for Reduction of Secondary Stroke (ICARUSS) model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood of recurrent stroke or vascular event.2

• Nurse-led approach to the management of uncontrolled hypertension in patients with type 2 diabetes is highly effective.3

1Johnson P et al. Cerebrovascular Diseases. 2007;23:156-1612Joubert J et al. J Neurology Neurosurgery Psychiatry. 2009;80:279-2843Denver EA, et al. Diabetes Care. 2003;26:2256-2260


Secondary prevention - II

• Intervention of a stroke nurse after discharge improved patient perceptions of general health (P=0.012), reduced emotional problems (P=0.037) and social isolation (P=0.002) at 12 months.1

• Interdisciplinary project with nurse-led assessment in elderly peoples' homes resulted in reduced admissions to hospital for fractured femur, pneumonia and stroke during the period 2004 to 2006.2

• Nurses have a central role in stroke rehabilitation in the psychological care, secondary prevention and life after stroke.3

1 Burton C & Gibbon B. Journal of Advanced Nursing 2005;52:640-50.3Jenkins, P & Baker E. Nursing Older People, 2009;21(2),:34-39.3 Gibbon B et al. Nursing Times. 2012;108:47,12-15


Organizational problems?

• At discharge - the patient is referred to primary care

• In primary care the model is:

The patient will receive what he or she asks for

Why do I feel so sad and tired and dizzy? I tried to phone for an appointment with my doctor but I was just told to click at different numbers.


Randomised Controlled Study stratified for age and gender at Skåne University Hospital, Malmö

Follow-up after 3 months (intervention group) and 1 year both groups

•Secondary prevention

•Assessments

•Supportive counselling

•Referral if needed to physician, nurse, physiotherapist, occupational therapist or other professionals


219 persons followed up after 3 months (194 survivors after one year)391 persons followed up one year after stroke (197 controls)

Cerebral Infarction 88%

Intracerebral Haemorrhage 12%

Women 51%

Age mean/median years 72.8/75

No significant differences in baseline characteristics between the two randomised groups


Examples of health problems at both follow-ups

• Fatigue, depression, sleeping problems

• Medication compliance /side effects

• Pain

• Need assistance training

• Ability to drive not assessed

• Problem with vision

• Oedema, leg ulcer, urinary infection?

• Blood pressure above goal

• Cholesterol values above goal

• Undiagn or not controlled diabetes

• Malnutrition

• Cardiac arrythmia

• Cognitive dysfunction

• Dizziness, imbalance risk of fall

• Need for psychosocial support including counselling smoke cessation


Recipients of the referrals sent by the specialist nurse after one year for both groups

• Referral to the neurologist on call concerning acute health problems 4 %

- Referral by Neurologist to patient’s GP 2 %

• Referral by Specialist Nurse to GP 53 %

• Referral to the GP responsible for

medical care at the nursing home 9 %


Number of interventions needed among 194 patients at 3 months and after 1 year

After 3 months

79 % needed intervention

36 % 1 intervention

30 % 2 interventions

10 % 3 ”

3 % 4 ”

P = <0.001

After one year


35 % 1 intervention


9 % 3 ”

1 % 4 ”


197 control group


38 % 1 intervention


10 % 3 ”

2 % 4 ”

194 intervention group

P = 0.03


35 % 1 intervention


9 % 3 ”

1 % 4 ”

Comparison after one year between the control group and the intervention group


Effect of supportive counselling?

EQ-5D question on anxiety/depression – patient’s view:

•I am not anxious or depressed

•I am moderately anxious or depressed

•I am extremely anxious or depressed

After one year 60% in the intervention group experienced no anxiety/depression compared with 48% in the control group. (p=0.042)


Conclusion

Follow-up by a specialist nurse referring most health problems to primary care was not optimal

Some benefitsSome improvement of patients’ health Improved routines for the primary care as reported by

several GPsCould be expected to reduce the need for

rehospitalisation as reported in the study by Jenkins et al.


The follow-up program may be further

enhanced by co-operation between the

specialist nurse and a stroke clinician to

optimize medication and health problems

before referring the patients to the primary

care with a specified care plan.

Jönsson AC et al. 2014. Secondary prevention and health promotion after stroke: Can it be enhanced? Journal of Stroke and Cerebrovascular Diseases; 23(9):2287-95


• About 20% of first-ever stroke patients survive 10 years after stroke - Perth, Australia (Hardie et al. 2003)

• A more recent report showed that 24% had survived ten years after stroke – South London Stroke Register (Wolfe et al. 2011)

• In my 10-year follow-up 35% (n=145) of all persons with a first-ever stroke had survived

Only few long-term studies on outcome after stroke


Ten-year follow-up assessments

• Functional status Barthel Index (0-100) • Patients’ self-reports using EQ5D

including ADL, pain/discomfort, anxiety/depression and also own report on health and physical activities

• 73% at the outpatient clinic, 8% in special housing, 6% at the hospital, 12% by telephone call combined with home visit


Comparison baseline vs after ten years

416 baseline 145 after ten years

Cerebral Infarction 86% 87%

Intracerebral Haemorrhage 9% 7%

SAH 3% 5.5%

Undefined 2% 0.5%

Age median years 76.5 78.1

- age range 18-102 28-97

Men/Women 56%/44% 59%/41%


Conclusions ten years after stroke

• >70% independent in ADL.

• Almost 50% were physically active daily before stroke as well as ten years later

• A large majority of survivors had a positive view on their own health

• Still...several of them had risk factors not optimally followed up

Functional status and patient-reported outcome 10 years after stroke: the Lund Stroke Register. Jönsson AC, et al. 2014. Stroke;45(6):1784-90.


Further conclusionsIn the group of 165 persons who

died before ten years - 55% were

living alone already at 16 months

47% could not manage daily life without home care

These persons as well as the ten year survivors could benefit from secondary prevention and health promotion from experienced neuroscience nurses


Thank you

Date post:	20-Jan-2016
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