The organisational context of nursing care in stroke units: A case study approach

3.1. Data collection 

Before each visit, sites were sent a visit plan detailing planned activities and project requirements. Either a research nurse or Advanced Nurse Practitioner from each site liaised with the local research ethics committee to determine if ethical review was required for the study, provided an approved study information sheet to potential participants, and constructed a schedule for interviews with those indicating a willingness to take part.

Interviews with the lead clinical nurses, members of the nursing team, and other professional staff from the stroke service were completed by Burton et al., 2008 to identify and explore strategic issues that relate to the organisation and delivery of stroke nursing care. The responsibilities of posts rather than titles were used to identify relevant individuals. A semi-structured interview schedule was constructed and used flexibly to determine interviewees’ perceptions of the purpose of stroke unit nursing care, and how this was supported in the local context. Nurses were asked to identify those factors that help them provide effective care and rehabilitation within the stroke unit. Interviews with therapy staff focused on perceptions of the purpose of stroke unit nursing care, and its relationship with therapy. Additional questions to all participants related to stroke unit action and business plans, organisational development initiatives, links with stakeholder organisations (patient groups, practice, education and research), and workforce issues (including professional and personal development strategies).

Copies of relevant documentation to include nursing induction packs, professional development strategies, clinical guidelines and protocols, core care plans were requested. In addition, a study diary was maintained throughout to record informal conversations, participation in activities such as journal clubs, meetings and presentations, and personal reflections on opportunities for observation of clinical practice.

3.2. Sample 

An overview of the formal interviews undertaken in the two sites, including the interviewee's professional background and service role, is presented in Table 2. Participants were drawn from all professional groups working on the stroke units, or others from management or education who worked with the units. As stroke unit care is a multidisciplinary enterprise, it was felt inappropriate to solely focus on the views of nurses. There were no major differences in the role profile and professional background of respondents across the participating sites. Twenty formal (digitally recorded) interviews were completed. The mean length of interviews was 39min, with a range of 28–71min. The total recorded interview time amounted to 773min, 482min of which were with participants from nursing.

Table 2. Overview of interviews completed during the study

	Role	Profession	Participants
	Strategic roles influencing whole stroke service
	Stroke program director	Medicine	1
	Regional stroke program manager	Nursing	1
	Regional stroke education coordinator	Nursing	1
	Stroke unit roles
	Clinical manager	Nursing	2
	Advanced Practice Nurse	Nursing	1
	Stroke specialist nurse	Nursing	2
	Registered nurse	Nursing	1
	Nurse educator	Nursing	1
	Occupational therapist	Occupational therapy	2
	Speech therapist	Speech therapy	1
	Physiotherapist	Physiotherapy	3
	Social worker	Social work	1
	Other roles
	Nurse researcher	Nursing	1
	Nurse director (hospital role)	Nursing	1
	Neurology liaison nurse	Nursing	1

3.3. Analysis 

The analysis focused on exploring nursing practice within the three care domains identified earlier, and organisational context in which they are developed and delivered. All interviews were fully transcribed. Using the Framework Approach (Ritchie and Spencer, 1993), an initial list of themes was generated from multiple readings of the interview transcripts. These were then indexed using Atlas Ti software to enable all relevant quotations to be linked to relevant themes. Memos were added where necessary to emphasise the context of particular quotations.

The synthesis of data from each site was supported by cross-case analysis (Miles and Huberman, 1994, Yin, 2003). This approach has the potential to preserve the context of the data derived from each study site visited, whilst creating a ‘bigger picture’ or patterns for specific issues, in this case the emerging themes, across those sites (Mays et al., 2005). In practice, the themes and their associated quotations were explored individually and then across the two sites through the construction of a text tables. An extract of a word table relating to the ‘teamwork’ theme is provided in Table 3. This enabled the identification of differences in theme relevance and context across the two study sites. Due to financial and other constraints it was not possible to return to individual participants to check the interpretation of data. As this approach relies on ‘argumentative interpretation’ (Yin, 2003; p. 137), the complete tables of themes was sent to the study liaison nurses to comment on interpretation, parsimony and relevance.

Table 3. Example of coding for teamwork theme and synthesis across case study sites

	Case study site A	Case study site B	Interpretation
	Evidence of a strong team ethic, enhanced by co-location of patients. “It's tons, tons of dialogue between them and I think that's been the best part of our unit” Interview 3(498:499)	Evidence of a strong team ethic, which enhanced staff recruitment “when I recruit people are very happy here. The stroke team's here” Interview 13 (1036:1051)	Importance of a strong team ethic which values the contribution of nursing
	Different professional and organisational perspectives on therapeutic transfer caused some tension between therapy and nursing “transfers was the thorniest issue for us between us and nursing” Interview 1 (904:909)	Some overlap between nursing and therapy “Would a nurse and therapist ever agree together a goal for a patient? Sometimes” Interview 19 (1308:1317)	Clarity in the type and practice of role overlap between therapy and nursing is required
	Facilitated by workplace systems and processes, access to specific nursing roles for liaison, and opportunistic collaboration “the interaction between therapists and nurses seems to be quite opportunistic really” Interview 1(53:54)	Communication facilitated by formal structures and processes “Thursdays we have the big rounds where the nurses are definitely there and it's a more in-depth round” Interview 16(344:344)	Team communication facilitated by formal structures and mechanisms and opportunistic working
		Effective team working was viewed to depend on the development of good interpersonal relationships between staff members “If I see someone well positioned in bed, I will say, wow this person was well positioned there” Interview 21 (316:317)	Good team work may depend on the ability to develop productive interpersonal relationships between team members
		Continuity challenged by rotation of medical staff “So you’re having to sort of change and adapt as the neurologists rotate round the unit” Interview 10 (707:735)	Team work may be challenged by rotation of staff

3.4. Ethical issues 

Whilst no significant ethical issues were anticipated for the study, a request was made to lead contacts to facilitate opinions from the relevant ethics committees. Ethical review to conduct the study was required by both sites, and obtained. The table of participants (Table 2) does not identify which of the two sites interviewees were from. Given the specificity of some service role titles, doing so would threaten their anonymity, a pre-requisite for their involvement. All participants received a study information sheet, and were asked to sign a consent form which highlighted the voluntary nature of their participation.

4.1. Stroke service base 

Both stroke services studied appeared to be heavily underpinned by a neurological service model. This had clearly produced significant benefits in driving the development of acute stroke care through prompt access to hospital, and developing diagnostic imaging techniques and thrombolysis. It appeared that the specialist service model adopted on the stroke units had benefits for the development of nursing staff knowledge and expertise:

… your knowledge advances so much quicker because you see (strokes) more often (Interview 18, 434:435).

The neurological service model had driven some developments in stroke nursing which tended to relate to medical developments such as intensive monitoring during and after the administration of thrombolysis. Some aspects of stroke nursing care, such as stroke prevention and psycho-social care, were linked to developments in other disease groups, for example “on the back of developments in general cardiovascular services” (Interview 8, 3:4).

4.2. Management 

A demarcation between management of the whole stroke service and of constituent clinical settings was evident in both sites. Members of the multidisciplinary team, and some senior nursing roles, worked across the stroke service in a number of clinical settings. Clinical nursing staff were generally located in specific settings, some of which provided services for a range of patient groups, mostly within the neurosciences. This posed a significant challenge for nursing management who were tasked with maintaining the operational delivery of nursing care and ensuring compliance with the strategic agendas of the stroke and other neuroscience programs. Senior nurse managers reported a role in ensuring that their setting was viewed as integral to the delivery of the stroke program: “we tried to integrate this stroke program … but as an in-patient manager I have neuro science and the stroke beds” (Interview 4, 475:488).

4.3. Team working 

The importance of a team approach to the delivery of the stroke services was recognised by nursing staff, which appeared to have improved with the co-location of stroke patients in a specific clinical area. A variety of structures that facilitated team working were identified, although these related mainly to “multidisciplinary rounds … once a week where we all sit and that's the allied help, the pharmacist, doctors, nurses” (Interview 10, 240:245). These provided the opportunity for discussion across multidisciplinary expertise. It was evident that different professional groups maintained their own individual patient records. However, opportunities for documenting assessments, interventions and rehabilitation plans that emerged from these rounds and other multidisciplinary discussions were available, for example “in the integrated progress notes” (Interview 22, 223:229).

A key challenge to team working was the rotation of medical staff to different parts of the stroke and neurology service, as “not every neurologist will think the same way or have the same cast on stuff so that's hard for the staff” (Interview 19, 536:552).

A range of issues was identified as representative of the nursing contribution to multidisciplinary care. These included providing a family perspective, advocacy for the patient, assessment, and discrete clinical or functional elements such as swallowing, continence and mobility. Three clinical issues in which nurses and therapists collaborated provided good examples of differences in the nature of multidisciplinary working: dressing practice, nutrition, and patient moving and handling. Dressing practice was viewed by therapists as being a “definite area of overlap” (Interview 1, 880:888). At times the relationship between the contributions of therapy staff and nurses was vague. Nurses ‘continued’ therapists’ interventions, but more detailed questions that explored how this operated in practice drew little information.

Multidisciplinary working was also able to broaden the context of nursing interventions. In site A, occupational therapists worked along side nurses providing nutritional support, combining a functional and cognitive role, addressing the wider, social context of patient eating and drinking:

OTs are also involved in feeding … You’ve got four bedrooms … That's about as distracting an environment as you can ask for so even that can be affecting it so there; this then overlaps a little bit with swallowing. Interview 1 (996:1006)

The third example refers to the issue of ‘therapeutic transfer’ where there was a degree of tension in the collaboration in site A. The purpose of a therapeutic transfer was to maximise the potential for patient involvement in the transfer, requiring “the patient to do absolutely the maximum amount of work … that they can safely do which means it's inherently a little less safe … but it's more therapeutic” (Interview 1, 913:919). By implication therefore there was more potential for accidents. Therapy staffs were more comfortable with the notion of risk-taking within patient moving and handling. This contrasted with a safety-driven approach from nursing where “anything beyond a easy mini-assist they (nurses) won’t do. So patients get no chance to practice the therapeutic transfers” (Interview 1, 941:943).

Therapists described a range of communication strategies to ensure that nurses were aware of their recommendations about aspects of patients’ rehabilitation. These strategies included the use of medical records and bedside notices for issues such as dysphagia, mobility and communication. As the use of notices has the potential to break patient confidentiality, it was evident that staff approached their use with sensitivity, and sought the views of patients. In addition, therapists were able to communicate their recommendations to nurses through the individual patients concerned.

Despite the use of formal mechanisms for sharing professional expertise and knowledge, it was strikingly evident in the data that “the interaction between therapists and nurses seems to be quite opportunistic really” (Interview 1, 53:54). Team working also depended on the personal relationships that developed between staff.

Nurses will grab me in the hall and say … this patient seems like they’re doing really well, they’re really hungry can you re-assess … So from that perspective I have a great rapport with the nurses … Interview 14 (526:533)

The development of these personal relationships depended on the visible presence of therapy staff in clinical areas, and, interestingly, on the identification and discussion of good practice.

4.4. Nursing approach 

Discussions about the content of nursing care revealed a strong similarity with the domains of care outlined in the theoretical framework. Nurses had a key role to play in the provision of fundamental aspects of caring, although this was usually delegated to ‘nursing support’ roles such as “a health carer. We give her six of the heavy baths … But otherwise you’re responsible for everything whether it be brushing her dentures or putting a central line” (Interview 13, 955:969). Generally, this aspect of nursing care was limited to the provision of supportive care, and was not viewed as a contribution to patients’ rehabilitation. Support roles had been particularly important in enabling nurses to meet the increasing demands of their workload.

Some aspects of therapeutic nursing outlined in the theoretical framework were identified in the data. For example, therapists recognised the value of a family oriented approach to nursing care, and in particular the knowledge of family systems and relationships that nurses gained, in informing rehabilitation plans:

Asking nurses about … the evening when the family shows up. How did they seem to you? How are they dealing with this? … or if there's conflict within the family. I need to get a nurse's first hand take on like who are the players here. Interview 1 (1053:1055)

The benefits that an holistic, therapeutic approach to care nurses brought to multidisciplinary practice were clearly articulated, as nurses were “aware of more than just the medical nuts and bolts” (Interview 2, 585:608). Relationships that nurses built with patients were perceived to provide important knowledge about individual circumstances that moulded the interventions of therapists.

The incorporation of formal therapist-initiated activities into fundamental aspects of nursing practice did not however appear to be fully realised. Possibly due to this lack of engagement in therapist-initiated activities by nurses, some therapists doubted that “many of the nurses would actually consider what they do rehab-nursing” (Interview 8, 1607:1612).

Nurses appeared to have a key role in care management, as the nurse was “the 24/7 person is the one that really can co-ordinate that team” (Interview 20, 614:616).

4.5. Nurse staffing 

The fact that inpatient stroke beds were co-located with different neurological services in site A meant that clinical nursing staff tended to rotate through the neurology unit. Co-location meant that clinical nursing staff were available to rotate through the service, although this meant “it is very difficult to develop … working relationships” (Interview 2, 55:66), in this case, therapists and nurses.

Ward-based clinical nursing staff were supported by a more senior Nurse Clinician who worked collaboratively with physicians about the care of individual patients. Both advanced and specialist nursing roles were evident within the stroke service. The specialist nursing role was generally associated with higher levels of clinical practice in aspects of the stroke service model. For example, the following excerpt outlines the role of a stroke prevention specialist nurse who co-ordinated the care of patients with Transient Ischaemic Attack:

… I act as a link for them and as a liaison between the tests, specialists referral. And then there's the risk factor (reduction), which is probably 75% of when I am due a visit with them. Interview 9 (210:229)

Advanced Practice Nurses on the other hand adopted a more strategic role across the whole stroke service model, and incorporated a variety of role domains “50% of it should be clinical, umm, some leadership, some research, some education” (Interview 9, 44:45). In addition, this role initiated the care process and collaborates with other health care professionals in the delivery of complex and comprehensive care (Donnelly, 2003). Role incumbents had a high degree of autonomy, and had developed a high level of clinical expertise in aspects of stroke care, for example as “an entry point down in Emerge for the stroke team” (Interview 7, 15:60). This was expertise was used to support the delivery of medical care in collaboration with, and the support of, the stroke physicians.

A key purpose of these roles was the provision of an overarching consistency in care, reflecting the nature of role funding: the stroke program provided the service model which was applied across the various components of the institution. From a professional perspective, although some advanced practitioners were involved in the provision of interventions delegated from the medical role, there was a strong recognition that the role was also concerned with the development of nursing … rather than nurses taking on more of what were considered to be previously doctor's roles” (Interview 11, 213:217).

4.6. Clinical leadership 

Nursing management reported a clear role in the maintenance and development of the general workplace culture which supported the delivery of high quality nursing care. They viewed an emerging role for senior ward-based nursing staff, and in particular the Nurse Clinicians (equivalent to a nursing team leader), in providing “more of a leadership focus on the unit for the (registered nurses)” (Interview 4, 736:764).

Leadership appeared to be crucially important in driving developments in stroke care, and came from a variety of sources including and senior nursing staff within the stroke program. Leadership related both to driving stroke services forward, and raising the profile of stroke across the institution as a whole:

you need to be out there and just … promote what it's all about, what's (stroke) prevention and how easy it is really. Interview 9 (739:743)

This was particularly important as effective delivery of the stroke program required the commitment of a wide range of hospital services and settings.

4.7. Developing stroke practice through research 

Medical research appears to have been the strongest driver of stroke service development at service A. Initially this had focused on the development of thrombolysis as an effective treatment for acute stroke, requiring the re-design of pre-hospital care and acute care facilities. Whilst acute stroke care remained a high priority for the stroke program, it appeared that a ‘research-led service’ culture influenced all components of the stroke service.

Links between members of the stroke service and higher education were maintained principally through teaching and project work. However, these links were not always viewed as a reciprocal, where “there can be more take from the university than there is give” (Interview 11, 758:759).

A range of professional nursing organisations, some with a specialist neurology focus, were however viewed as playing an important role in supporting the development of nursing practice. Despite the availability of opportunities for networking and learning, it appeared that their uptake was “Very limited” (Interview 8, 136:162).

It appeared that education and training focused primarily on the clinical aspects of the nursing role, with few opportunities for research capability building. The quantity of nursing research in stroke was generally accepted to be limited. Whilst there was clear support for the expansion of nursing research amongst medical staff, it was evident that there were few funding opportunities specifically targeted at nurses.

4.8. Education and training 

A comprehensive education and training strategy was identified in both sites, driven by clearly defined expectations of the role in clinical practice in terms of “core competencies for working with stroke survivors” (Interview 20, 127:132). As clinical nurses were recruited to work in neurosciences rather than stroke per se, induction for newly appointed staff addressed the range of disease related groups within this specialty. Senior nursing staff from the stroke program, in this case an Advanced Practice Nurse was able to provide specialist stroke input into the induction. The delivery of continued bedside education provided by the stroke program was believed to be indicative of a learning culture.

Education and training of nurses was supported by the Canadian Nursing Association which provided accredited opportunities for learning. A clear strategy to support nursing staff who wished to access these opportunities was evident, including funding for “50% for their classes … and the rest when they pass” (Interview 4, 315:325) and peer support for learning. In addition, support was available to enable nurses to attend key international learning and networking opportunities.

4.9. Clinical supervision and performance review 

Nursing staff employed by the institution rather than the stroke program undertook a yearly evaluation with the senior nurse manager for their clinical area. These focused “on the … understanding of the care of the patient, understanding of the patient themselves … the anatomy, physiology, what the patient's gone through” (Interview 13, 441:457). Professional development and learning needs were also identified, for example in “a learning plan … and your goals for the next year and … What opportunities would you like to pursue and what can I do to facilitate that?” (Interview 4, 900:916).

Whilst the senior nurse manager had formal responsibility for performance review, informal feedback on the individual performance of registered nurses was available on the inpatient stroke wards:

… providing feedback to staff on their general quality of care … would be … a relationship from you through to the nurse clinicians through to an RN for example. Most likely it would be from the nurse clinicians to the RN or the LPN … Interview 4 (831:856)

Nurse clinicians were supported in this activity by members of the stroke program, principally the Advanced Practice Nurses who provided a key role in the mentorship of clinical nursing staff. Here, their expert clinical knowledge was used to promote an understanding of the science behind aspects of stroke management. Those nurses working at this advanced level highlighted the importance of conferences for networking and peer support, and their networks evidently extended beyond nursing.

Interestingly, there was also some evidence of cross-professional performance review, where nursing management participated in the review of individual therapists, albeit that this contribution related to issues relating to operational management of the clinical area:

… when it comes to performance appraisals the chief (therapist) will say … X's up for a performance appraisal. I go and listen but I’m right up front with them. I said … It's not my background. … they look to be doing fine. The patients are doing well. They show up for work. I’m happy they go for conferences … Interview 13 (661:665)