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An Exploration of the Nursing Role in a Telehealth Based Stroke Secondary Prevention Program

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NURSE – LED TELEHEALTH STROKE PREVENTION 1 An Exploration of the Nursing Role in a Telehealth Based Stroke Secondary Prevention Program. Submitted in total fulfilment of the requirements of the degree of Master of Philosophy. April 2015 David A. G. Jackson. Department of Medicine and Health Sciences. School of Nursing. The University of Melbourne. Correspondence concerning this work should be addressed to David Jackson, Department of Neurology, The Royal Melbourne Hospital, Grattan St Parkville, Victoria 3050. Produced on archival quality paper NURSE – LED TELEHEALTH STROKE PREVENTION 2 Abstract This research study set out to explore a specialist nursing role in the field of Telehealth for chronic disease management. This study aimed to explore the role of the nurse through measurement of nursing activity during the one-year period of participant follow-up. The study aimed to effect long-term secondary prevention of stroke through an evidence based approach to the management of modifiable cardiovascular risk factors and post stroke depression in the community setting. Research suggests that up to 80% reduction of risk of successive stroke can be achieved if recommendations from evidence-based guidelines are implemented. Notwithstanding these findings a gap exists in the implementation of preventative strategies for stroke survivors in the community. Results from previous research indicate that Telehealth is cost effective and potentially may significantly reduce socioeconomic burden and the probability of successive stroke. A small number of studies have highlighted potential mechanisms through which Telehealth can benefit the stroke survivor, carers, families and health professionals. Researchers have recommended more research into Telehealth in order to develop and to define effective interventions. A pilot randomised controlled trial (RCT) conducted at two metropolitan hospitals showed positive results in risk factor and depression outcomes. Integral to this model of care was the role of the nurse. In the current nurse-led, nested multicentre RCT, study nurses gained increased telephone access, to follow-up and support stroke survivors and their General Practitioners. There were 93 participants (43 intervention) recruited from four metropolitan hospitals over a period of two years. Nursing staff were integrated with the multidisciplinary team in designated stroke centres and General Practitioners in the community. Specialists were available to NURSE – LED TELEHEALTH STROKE PREVENTION 3 participate in shared care. Telephone follow-up was initially attenuated by risk for second stroke, with high-risk individuals receiving a greater frequency of follow-up. The results indicated that nurses engaged in both fundamental nursing process and advanced activities to assist stroke survivors through transitions across the health landscape after stroke. Case management, assessment and care planning were frequent fundamental activities and occupied a relatively large percentage of the nurse’s time. The mean difference in outcome systolic blood pressure was significantly improved in the intervention group. The mean difference in post stroke depression screening score was significantly better for the intervention group. Lifestyle modification in particular physical activity was better in the intervention group. The results add support to the place of nursing in the ongoing care of stroke survivors in the community setting. NURSE – LED TELEHEALTH STROKE PREVENTION 4 Declaration This thesis comprises only my original work towards the Master of Philosophy except where indicated in the text. Due acknowledgement has been made in the text to all of the other material used. The thesis is less than 40,000 words in length, exclusive of tables, figures, bibliographies and appendices. Signed: Date: NURSE – LED TELEHEALTH STROKE PREVENTION 5 Acknowledgements There were many kind people to whom I would thank for their efforts in providing support during the course of this thesis. I am especially grateful to Associate Professor Stephen Elsom for his generosity with time, counsel, clarity of thought, unflinching courage and unwavering support. Excellent support was provided from the School of Nursing, Melbourne School of Graduate Research, the Office for Research Ethics and Integrity and the Melbourne Health Research Directorate. In this respect I am grateful to Associate Professor Marie Gerdtz, Associate Professor Bridget Hamilton, Professor Elizabeth Patterson, Professor Ian Van Driel, Dr Angela Watt, and Professor Ingrid Winship. Ms Debra O’Connor, Professor David Ames and Mr Dallas Ware provided critical support during pivotal moments. I was fortunate to commence in research under the directorship and guidance of Professor Stephen Davis. Professor Davis has supported my role within the Department of Neurology and provided all necessary resources to complete this project and make this nursing-led study a reality. I am similarly grateful to the group of renowned investigators for their acceptance of this nursing study and access to their respective stroke units. In another scheme, this research would not have been at all possible if not for the support from the Health Care Fund (HCF) Research Foundation. My phenomenal colleagues; Melissa Ugalde, Louise Weir, Anne Claxton, Andrea Moore, Karen Bartholomeusz and Adrianna Cartwright provided volumes of expert knowledge and counsel and all worked with particular enthusiasm and focus to integrate this novel role. This group of dedicated senior nurses were of ultimate importance in the completion of this work. In the background, Associate Professor Peter Hand, doctors’ Hans Tu, and Bruce Campbell, maintained an ongoing interest in this study and provided unrestricted access to stroke unit patients in this highly competitive research arena. NURSE – LED TELEHEALTH STROKE PREVENTION 6 I thank Roshani Prematunga, Zewdu Wobalem and importantly Lucy Busija for the expert assistance provided in developing an understanding of the beauty of, and challenges within, statistical analysis, including an appreciation of the sometimes-serendipitous nature of the discovery process. My family Bronwyn, Levi and Ari, have been most patient and tremendously understanding throughout the development and implementation of this research project and further along the long - sometimes unbelievably steep, twisted, rutted - road of the thesis. Together we hurtled along and my dear family made many sacrifices. I offer them always my deeply heartfelt thanks. I have my loving parents Kathleen and Samuel to thank for the spirit of enquiry they quietly encouraged, their grounding in the principles of honesty and integrity and for the excellent opportunity in education that they worked so very hard to grant. NURSE – LED TELEHEALTH STROKE PREVENTION 7 Table of Contents Abstract ..................................................................................................................................... 2 Declaration ................................................................................................................................ 4 Acknowledgements .................................................................................................................. 5 Table of Contents ..................................................................................................................... 7 Introduction ............................................................................................................................ 10 Background to this Study .............................................................................................................. 10 The Primary Care, Evidence-Practice Gap. Nursing, Social Work and Medicine Integrated with Telehealth ................................................................................................................................ 10 Literature Review .................................................................................................................. 17 Stroke Epidemiology in the Developed World ............................................................................. 17 Incidence. ..................................................................................................................................... 17 Mortality. ...................................................................................................................................... 17 Survival. ....................................................................................................................................... 19 Recurrence. ................................................................................................................................... 19 Stroke in Developing Countries .................................................................................................... 19 Rural and Remote Areas ................................................................................................................ 20 Economic Considerations: Cost and Burden of Disease. ............................................................ 21 Acute Stroke Management ............................................................................................................ 22 Thrombolysis. ............................................................................................................................... 23 Stroke Care Units. .........................................................................................................................
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