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Mohapatra, Sushmita (2019) Rehabilitation for survivors of severe stroke. PhD thesis, University of Nottingham.

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Abstract

Providing appropriate rehabilitation for stroke survivors with severe disabilities can be challenging. This is due to the magnitude of neurological impairment early after stroke as well as the complexity of delivering long-term care post-hospital discharge. Severe stroke survivors have limited access to rehabilitation as a likely result of uncertainty related to their potential for functional gains. They are also likely to require greater health and social care resources for long-term care with significant cost implications. Rehabilitation following stroke has been proven beneficial after a severe stroke; however, recovery remains ambiguous. Several clinical and non-clinical factors are evidenced to influence the provision of rehabilitation interventions. However, it is not known how the decisions are made in practice for service provision, what service they receive and how they relate to the stroke survivors’ recovery and rehabilitation.

Aims

This thesis aimed to explore the recovery and rehabilitation of severe stroke survivors by investigating the decision-making process for determining rehabilitation and service provided as a result. The study also evaluated the functional recovery made by severe stroke survivors in the first six months and investigated their caregivers’ perspectives on rehabilitation services they received.

Methods

A prospective design with a fixed convergent mixed method approach was chosen to investigate the research questions. Three independent studies were conducted concurrently in two distinctive phases with independent sets of results.

A qualitative approach was taken in the first phase to explore the decision-making process using semi-structured interviews with 22 hospital staff responsible for determining rehabilitation for severe stroke survivors. Functional recovery was investigated in the second phase using an observational cohort study. Patient outcomes were longitudinal measured using validated tools in 52 severe stroke survivors (NIHSS ≥ 10 and mRS ≥4 at admission). Information was also obtained on rehabilitation services accessed post-hospital discharge in the first six months post-stroke. The second part of the study also used semi-structured interviews with 18 caregivers to investigate their experience of the rehabilitation received post-stroke.

All data were collected from a single hospital site, covering a selected region in the East Midlands. The data were analysed separately and integrated using a structured triangulation method in the interpretation stage complement, validate and strengthen the overall findings.

Results

Results established a complex, dynamic, temporal process of decision-making for post-stroke rehabilitation of people with severe functional disability. This required multiple stages of corroborations amongst key decision makers to evaluate the impacts of several social and external factors, additional to severity of stroke. Severity of stroke was defined for rehabilitation purposes and a clinically meaningful change in functional abilities was evidenced in 69% of stroke survivors with severe disabilities with no causal relationship with the initial severity. A noticeable involvement of healthcare professionals during this period suggested the possible contribution of rehabilitation in the early phase post stroke. Rehabilitation was valued for recovery; however, an integrated, client-centred approach was identified as lacking for managing severe disabilities after stroke. This, along with limited shared-planning for rehabilitation led to a low confidence of caregivers in the current healthcare system.

Conclusions

The overall findings of the thesis established a complex, dynamic, cognitive process of clinical reasoning amongst hospital staff for deciding rehabilitation of severe stroke survivors. The study quantified the recovery made in the first six months and suggested that a significant functional improvement is possible in the severely disabled patients that could influence their rehabilitation plan. Thesis findings also highlighted the potential inadequacies in rehabilitation services provided and emphasized the need for incorporating the service users’ expert knowledge in shaping future models of care for severe stroke survivors and their caregivers.

Item Type:	Thesis (University of Nottingham only) (PhD)
Supervisors:	Fisher, Rebecca Walker, Marion
Keywords:	Severe stroke; Rehabilitation
Subjects:	W Medicine and related subjects (NLM Classification) > WL Nervous system
Faculties/Schools:	UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID:	56449
Depositing User:	Mohapatra, Sushmita
Date Deposited:	21 Aug 2019 14:25
Last Modified:	07 May 2020 10:16
URI:	https://eprints.nottingham.ac.uk/id/eprint/56449

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