Very often, stroke patients have their own questions about their disease that they perceive as valuable and want answered. Answering such questions and educating newly diagnosed stroke patients about stroke-related information that is presumed to be important to them to learn is vital in the prevention of further illness and complications after a stroke as well as in the recovery phase. To date, however, there are no data suggesting a well-defined method for identifying learning needs among newly diagnosed stroke patients. Studying this population may assist in identifying the gap that currently exists so that optimal measures to meet the learning needs of newly diagnosed stroke patients may be practiced.
Patient education is clearly an important component of healthcare, and the literature consistently suggests dissatisfaction among patients across all facets of healthcare, including the stroke population. Stroke patients often express a lack of understanding about the nature of their illness, treatment, and recovery, and they perceive information from healthcare professionals to be inadequate and too complicated (Choi-Kwon et al., 2005). Patients often base a degree of their satisfaction on the adequacy of instruction regarding plan of care, education about diagnosis, medications, and treatments, as well as information regarding discharge planning while in the hospital. Wellwood, Dennis, and Warlow (1994) determined that patients who do not receive education relating to desired information are dissatisfied with the educational process and lack an understanding of their disease, leading to noncompliance and further medical and psychological complications. The failure of healthcare professionals to meet the learning desires of newly diagnosed stroke patients calls for a better investigation and understanding of the importance of meeting their educational needs and in preventing further unnecessary complications.
Purpose
The purpose of this study was (a) to determine if there is a change in the perceptions of what individuals newly diagnosed with stroke perceive as important to learn about stroke during different times of their stroke recovery and (b) to determine the perceived level of satisfaction among newly diagnosed stroke subjects with the stroke education provided.
Method
The study included a convenience sample of 71 newly diagnosed, first-time stroke subjects from two metropolitan hospitals in the Northeast. The hospitals are designated stroke centers approved by the American Heart Association. The power analysis was estimated at 80%. Stroke patients who presented to the emergency room of the two metropolitan hospitals were evaluated by a physician specializing in neurology. The specializing physician, known as a "neurologist," performed a complete neurological examination. Evidence of a neurological examination and evaluation for stroke was documented and found in each potential subject's chart. A pilot study preceded this study to check the feasibility and improve the design of the actual study.
Eligibility
Eligibility of stroke subjects was determined by chart reviews. Selection criteria included the following: (a) 18 years or older, (b) diagnosed with either a first-time hemorrhagic or ischemic stroke within 1 week of its onset, (c) able to speak and read English, (d) able to comprehend, (e) had access to a telephone, (f) able to hear, and (g) had a plan for discharge to either home or a rehabilitation facility. The researcher reviewed the charts of potential subjects to identify subjects that met each criterion. Further eligibility was determined by screening potential subjects for formal education. Formal education was defined as whether or not potential subjects received at least 15 minutes of stroke-related education by a healthcare professional such that subjects were able to comprehensively explain and/or demonstrate the stroke-related education in the form of verbal, visual, or handwritten material on their own. If formal education had occurred, subjects were not eligible (Falvo, 2004).
Sampling Procedure
After an introduction and explanation of the study, potential subjects were asked whether or not they wanted to participate. No potential subject refused to participate in the study. Subjects were asked to read and sign the consent. Subjects who did not have the ability to write were allowed to have a legally authorized representative sign the consent form. Five subjects were eliminated from the study secondary to early discharge and the incompletion of the initial questionnaire.
Before the distribution of the questionnaire at the time of admission and again at the time of discharge, a screening tool consisting of six questions was used to determine the subject's ability to make a reasoned decision. In addition, the screening tool assessed if each of the subjects was able to express a free choice and clearly communicated that choice. A score of less than 4 for any of the questions eliminated the subject from the study.
The initial questionnaire was completed by the subjects within 24-72 hours of their admission to the hospital, given that they were medically and neurologically stable. The time frame, 24-72 hours for the initial questionnaire, was chosen, as this is the general time frame in which peak swelling of the brain generally occurs, causing the risk of deterioration to be at its highest. Stabilization is primarily determined by the patient's mental status and level of consciousness. In some cases, stability occurred after 72 hours, and the initial questionnaire was distributed at the time of stability, preceded by the level of understanding tool to ensure eligibility.
Instrument
The questionnaire, entitled "What I want to learn about stroke," was developed by Choi-Kwon et al. (2005). The questionnaire consists of eight domains related to stroke. Each domain contains questions that reflect a topic related to stroke. The domains are as follows: (a) medical knowledge of stroke (12 topics); (b) control of risk factors of stroke (9 topics); (c) treatment of stroke with medications (6 topics); (d) treatment of stroke with surgery (5 topics); (e) treatment of stroke with herbal or alternative medicine (3 topics); (f) rehabilitation (6 topics); (g) dietary habits after stroke (7 topics); and (h) other topic areas (10 topics).
The questionnaire, initially written in Korean, was translated into English by two unrelated Korean natives, one is a nurse in the field of neurology and is familiar with the medical terms used in the questionnaire. Content validity was established. Internal consistency for the questionnaire was determined using Cronbach's alpha. Cronbach's alpha ranged from .90 to .95 (Choi-Kwon et al., 2005). For this study, a principal axis factor analysis with varimax rotation was conducted to assess the underlying questions for the domains of the questionnaire. No assumptions were violated. The reading level was estimated to be at the sixth grade level. Table 1 presents the content within the questionnaire.
Results
Table 2 is a summary of the data analysis for demographic data for the study. The mean age of the total sample (N = 71) was 57.35 years. 52.9% were men and 47.1% were women. 91.4% were White and 8.6% were Black. 4.3% of subjects had an education below high school level and 95.7% had an education at or above high school level. Most subjects lived with someone (74.6%). 31.3% of subjects received an annual income below $20,000. Most subjects were discharged to home (67.6%).
Is there a change in the perceptions of what individuals newly diagnosed with a stroke think is important for them to learn about stroke during hospitalization and postdischarge?
Repeated measures of ANOVA were conducted for the 32 subjects who completed the questionnaire on admission (Time 1), upon discharge from the hospital (Time 2), and after discharge from the hospital (Time 3). t Tests were conducted for the 39 subjects who did not complete the questionnaire after discharge.
Results showed that there was no change in the level of importance for six of the eight domains, suggesting that the domains were consistently perceived as important for patients to learn. Table 3 provides the mean level of importance for subjects who completed the questionnaire in entirety and those who did not. Table 4 summarizes the findings.
Within-subjects repeated measures ANOVA was used to test whether there was a significant difference in the level of importance among individual questions within each domain. Results determined that the level of importance increased over time for the questions "how important is it for you to learn about high cholesterol and stroke?" and "how important is it for you to learn about exercise and stroke?" Table 5 summarizes the findings.
How satisfied are patients with their understanding of the information they were taught about stroke during hospitalization and postdischarge?
Repeated measures of ANOVA were conducted for the 32 subjects who completed all three questionnaires. t Tests were conducted for the 39 subjects who did not complete the questionnaire after discharge to home or the rehabilitation facility. Results showed some increase in the level of satisfaction over time; however, the level of satisfaction never reached a level of 4 (satisfied) on the Likert scale. Overall, patients were not satisfied with any of the patient education in the eight domains on the questionnaire. Table 6 provides the mean level of satisfaction for subjects who completed the questionnaire all three times and those who did not. Table 7 summarizes the findings.
Discussion
Level of Perceived Importance
The data analysis for this study are consistent with prior studies suggesting that stroke patients perceive stroke education to be important (Choi-Kwon et al., 2005; Clark et al., 2005).
Medical Knowledge of Stroke
Overall, the means for the subjects who completed the study in its entirety (n = 32) and those who did not (n = 39) were similar in that the range for all groups was between important and very important. The perceived level of importance as important and very important to learn medical information about stroke suggest that subjects who are diagnosed with a new stroke want to acquire medical information about stroke perhaps to facilitate recovery and prevent further strokes and complications in the future (Watchters-Kaufman, Schuling, The, & Jong 2005). Although medical information comprises only one domain related to stroke, subjects have identified this topic as important.
Control of Risk Factors of Stroke
All of the subjects identified a level of importance of learning about control of risk factors for stroke. However, subjects who completed the study in its entirety also identified "neutral" as a level of importance for learning about control of risk factors for stroke. The subjects who chose "neutral" may not have had identifiable risk factors for their stroke or they were aware and knowledgeable about their risk factors and therefore did not perceive it as important to learn about this domain. The individual questions "how important is it for you to learn about high cholesterol and stroke?" and "how important is it for you to learn about exercise and stroke?" were particularly perceived as important for patients to learn.
Treatment of Stroke With Medications
The findings for this study and domain suggest that subjects are consistent in their perceptions that it is important to very important for them to learn about the treatment of stroke with medications over time.
Treatment of Stroke With Surgery
The means for the perceived level of "importance" to learn about the treatment of stroke with surgery ranged from neutral and important to important over time among subjects who either completed the study in entirety or not. An explanation for this difference across time may be that some patients may not have felt it was as important to learn about treatment of stroke with surgery because they were being discharged to home; however, once they were home, perhaps anxiety levels increased or their symptoms did not improve or perhaps symptoms worsened and the topic of surgery and stroke became more important. Or some patients may have found the topic of surgery and stroke important after discharge because they were out of the acute phase and therefore had more time to absorb the effects of the stroke and the implications of preventing strokes in the future.
Treatment of Stroke With Herbal or Alternative Medicine
Using repeated measures ANOVA, this study suggests that patients did not perceive the topic, "Treatment of Stroke With Herbal or Alternative Medicine" as desirable to learn during hospitalization and after discharge. The intake of herbal or alternative medicine among newly diagnosed stroke patients was not a part of this study. Possible reasons for the findings in this study related to the level of importance to learn about "Treatment of Stroke With Herbal or Alternative Medicine" may be that newly diagnosed stroke patients may simply not be interested in learning about this topic or because they already feel sufficiently knowledgeable about this topic. The findings may also suggest that patients are already aware of the limited data that exist related to the interactions and adverse effects of herbal or alternative medication, despite the increased usage of herbal or alternative medications (Grant, 2000). The findings from the study "The Educational Needs of Newly Diagnosed Stroke Patients" may also be explained by studies that suggest that patients who consume herbal medications often do not inform their primary healthcare professional (Lin et al., 2010). One particular reason is that patients are often aware of the limited data pertaining to herbal medication or alternative medications and do not want to be either judged or discouraged by their primary healthcare professional to not take them (Lin et al., 2010).
Rehabilitation
Subjects who completed the study in entirety may represent a population of patients who did not require to be discharged to a more intensive rehabilitation center. However, they may have required outpatient or home services for physical therapy, occupational therapy, and/or speech therapy, which may explain why the perceived level of importance of learning about rehabilitation ranged between neutral and important. Lastly, subjects who did not complete the study in its entirety may represent patients who were discharged to a rehabilitation center and, therefore, perceived this topic as important to learn. In addition, this may also explain why these subjects did not complete the study in its entirety; their strokes may have been too severe so that it was too difficult to complete and there was no one to assist with the questionnaire, or once discharged to the rehabilitation center, subjects may have neglected to complete the questionnaire at Time 3 for various reasons.
Dietary Habits After Stroke
All subjects who participated in this study showed a perceived level of importance for learning about dietary habits over time that ranged from between neutral and important. Overall, this domain was rated as one of the least important topics for patients to learn despite the means. One might assume that "neutral" was chosen as the level of importance because of the lack of awareness patients have related to their risk factors for stroke. Many patients are not aware of having high blood pressure, high cholesterol, or diabetes; nor are they aware of how their diet affects such risk factors. The choice of "neutral" may also reflect that patients think they are already knowledgeable about dietary habits related to stroke and do not feel they require additional information about this topic. Subjects who responded with "important" may have seen the need to improve their diet, given the role of diet as a risk factor for stroke.
Other Topics
The increased perceived level of importance among subjects who did not complete the questionnaire in its entirety compared with subjects who did complete the questionnaire in its entirety may be attributed to the severity of stroke. One might assume that subjects with more severe strokes and symptoms perceived this domain to be more important to learn about because many of the topics within this domain pertain to the physical abilities of the subjects after a stroke. An assumption might also be made that those subjects with more severe strokes did not complete the questionnaire in its entirety because of the physical and psychological effects of the stroke. An explanation for the significant increase over time for perceived level of importance of learning about "what other people will think" may be attributed to this being a sensitive topic for patients who may have thought that their stroke symptoms would disappear completely before discharge from the hospital. The findings may represent a population of patients who become increasingly concerned about others' perception of them with their stroke deficits.
Level of Perceived Satisfaction
The level of satisfaction never reached a level of 4 (satisfied) on the Likert scale for any of the eight domains. Despite the findings that two domains were perceived as not important for patients to learn (treatment of stroke with herbal or alternative medication and dietary habits after stroke), patient perceptions of learning about these topics were rated below a level of satisfaction, suggesting that they were either not taught about the topic area or perceived the content of teaching as unsatisfactory.
Implications for Future Research
The findings for this study suggest that healthcare professionals need to be aware of the significance in meeting the educational needs of newly diagnosed stroke patients perceived as important for them to learn. Although it is important for healthcare professionals to not withhold information related to stroke and to educate patients about all aspects of stroke, knowing what is perceived to be important for them to learn may mean spending more time on those topics. It is important for healthcare professionals to educate patients about the individual questions that indicated a level of significance and to use additional methods to disseminate information and educate this population by utilizing videos, handbooks, and selected Web sites.
This study did not address the preferred method of stroke education. Future studies are required to address the preferred method by which stroke education is taught as perceived by newly diagnosed stroke patients as well as time spent on patient education. This study was limited to newly diagnosed stroke patients and their perception of stroke education during hospitalization and 2 weeks postdischarge. Future studies are required to address the need for follow-up stroke education beyond 2 weeks postdischarge and the effectiveness of the education as well to evaluate the efficacy of treatment adherence.
Implications for this study include (a) replicating this study using an experimental approach, (b) individual patient assessment by nurses to determine patient perceptions related to their stroke, (c) developing a hospital protocol requiring nurses to utilize a screening assessment tool similar to the content on the questionnaire used for this study to identify what patients want to learn about stroke, (d) developing a uniform method by which stroke education is taught in acute care settings, (e) designing and developing a stroke educator role within the acute care setting, (f) designing and developing a stroke education model, (g) designing and developing a continued stroke education plan for the outpatient setting, and (h) future studies that include the families and primary caregivers of stroke patients.
Limitations of This Study
The primary researcher was the only person involved in obtaining participants, thus restricting availability to recruit all potential subjects. Some subjects were unable to complete the second questionnaire due to early discharge. Subjects were limited to two designated stroke centers. The study was self-reporting. The format of the questionnaire caused some subjects to miss questions. The number of subjects for the study could be larger. The study utilized a descriptive design.
References