| Background and Objectives:Evidence-based practice showed that neurorehabilitation is an effective way to reduce the chance of disability in individuals’ recovery after a stroke.The critical time window for optimizing health should be provided rehabilitation from 1 month to 6months after stroke onset.In order to maximize the health of patients with stroke during the recovery period,it is recommended to provide scientific and standard rehabilitation therapy and training under the guidance of a multidisciplinary rehabilitation team.Besides,interventions that are integrated with rehabilitation self-management are the core strategy in the recovery period.This study aimed to investigate the rehabilitation of patients with stroke in the recovery period;clarify facilitators and barriers affecting their rehabilitation self-management;develop a nurse-led stroke rehabilitation self-management support program based on holistic rehabilitation and chronic disease self-management framework and Bandura’s self-efficacy theory;and examine the feasibility and evaluate the effectiveness of the program on stroke patients’ health-related behaviours and rehabilitation-related outcomes,including self-efficacy,self-management outcome expectations,behaviour,emotion,functions,and health-related quality of life.Methods:This study has four stages:Stage One: A retrospective study to examine the rehabilitation therapy among patients with stroke in a rehabilitation hospital.From January 2018 to December 2019,a total of 1028 cases with stroke were selected from the hospital computer systems.This study described rehabilitation therapy and nursing procedure and analyzed the effect of inpatients rehabilitation for patients with stroke.The collected data were the demographics,medical variables,and functional outcomes of the inpatients.The effect of inpatient rehabilitation were compared between inpatients with multi-dysfunction and inpatients with motor dysfunction,including the activity of daily living,upper limb,balance,cognitive,swallowing and dysarthria,as well as the adverse events.We also compared the differences of these variables between the inpatients who were only hospitalized for one time and those who were repeated hospitalized.The changes of the functional data were also analyzed among the inpatients who were repeated hospitalized.Stage Two: A prospective longitudinal study to examine a model of rehabilitation self-management behaviour for inpatients with stroke in the recovery periodA total of 204 eligible inpatients with stroke in the recovery period were recruited in the inpatient departments of the neurological rehabilitation of rehabilitation center between October 2020 and May 2021.All the participants were assessed by a questionnaire comprising the demographic characteristics and clinical-related information,the Chinese versions of the modified Barthel index,stroke self-efficacy questionnaire,stroke self-management outcome expectation scale,self-management behaviours performance scale,the stroke special quality of life scale within 3 days of admission(Time 0,t0),one or two days before discharge(Time 1,t1),and one month after discharge(Time2,t2).Latent growth curve modeling was conducted to assess the dynamic changes of these variables.Structural equation modeling(SEM)was used to test the causal relationships of these variables.Stage Three: Development of a stroke rehabilitation self-management support program for inpatients with stroke in the recovery periodFace-to-face interviews were conducted with 15 stroke patients and their caregivers,and four focus groups with 16 eligible members from multidisciplinary rehabilitation teams were also conducted.The study aims to clarify the content of rehabilitation,and the barriers and facilitators of rehabilitation self-management.Based on the findings of the retrospective study,prospective longitudinal study and qualitative study and relevant literatures(including latest international and domestic guidelines),a stroke rehabilitation support program for patients with stroke in the recovery period were developed.Stage Four: An intervention to evaluate the feasibility and effectiveness of the stroke rehabilitation self-management support program for patients with stroke in the recovery periodBased on relevant literatures and the findings of the previous studies,this study is an unrandomized,historical matched controls design.A total of 57 participants were recruited as an intervention group from the inpatient departments of neurological rehabilitation of rehabilitation center between June 2021 and February 2022.A total of60 patients with stroke who had participted in the prospective longitudinal study between January 2021 and May 2021 were matched with 1:1 as a control group.All the participants were provided standard rehabilitation therapy and management by the multidisciplinary rehabilitation team.Those in the intervention group were provided an 8-week nurse-led stroke rehabilitation self-management support program,including a stroke rehabilitation self-management booklet,eight support groups and two telephone instructions,twelve videos.The outcomes were measured at baseline and at four-week and eight-week intervention.The primary outcomes were the participants’ self-efficacy and self-management behaviours,and the secondary outcomes included their functional outcomes,self-management outcome expectation,depressive symptoms and health-related quality of life.Results:(1)Stage One: The patients with stroke were provided comprehensive rehabilitation therapy led by the multidisciplinary rehabilitation team,which covered the motor,swallowing,speech,cognitive and activities of daily living and other functional assessment and rehabilitation.Of the 1028 cases,there were 660 patients of stroke with an average age of 58.00±14.33 years and an average disease duration of4.24±9.07 months.Significant interactions between the time from baseline to post-intervention and group were found in the upper limb,cognitive function,oral intake,pressure injury and fall risk between the patients with multi-dysfunction and those with motor dysfunction(P<0.05).All the participants reported significant improvements in their balance,upper limb,swallowing,cognitive,communication and activities of daily living,and a significant decrease in the risk of pressure injury(P<0.05).There were significant time effects in activities of daily living,non-language cognitive function,oral intake,pressure injury and fall risk between the patients who were in hospitalized for only one time and those who were repeated hospitalized(P<0.05).Compared with the baseline assessment,all the patients reported significant improvements at post-intervention in these variables.The patients within 3-month after stroke onset reported significant improvements in standing balance,upper limb function,swallowing function,and cognitive function;those within 3-6 months after stroke onset were found significantly improved in standing balance,upper limb function,and cognitive function during their rehabilitation period;those over 6 months after stroke onset reported significant improvements in standing balance,swallowing function and cognitive function,as well as a decrease in upper limb function(P<0.05).(2)Stage Two: The average age of patients with stroke was 57.33±14.75 years.The results of latent growth curve modeling demonstrated that the levels of self-efficacy,self-management outcome expectation,self-management behaviour,balance function,and health-related quality of life remained an increasing trend(P<0.001).The intercept,slope,quadratic term of self-management outcome expectation,self-management behaviour,activities of daily living and balance function showed significant differences,indicating these variables varying across individuals(P<0.001);self-efficacy and health-related quality of life illustrated significant effects on intercept and slope factor(P<0.001).The final SEM model revealed an adequate fitness to the current data.The result showed that all the variables explained 90% of the variance in self-management behaviour at t2 and 68% of the variance in health-related quality of life at t2 after controlling age.Self-efficacy and self-management outcome expectation predicted self-management behaviour at the following stage.Self-efficacy and self-management outcome expectation at t1 had direct effects on prediction of ADL at t1.However,self-efficacy and self-management outcome expectation did not have significant effect on ADL at t2.Self-efficacy,self-management outcome expectation and activities of daily living at t1,and self-management behaviour at t1 and t2 had direct effects on the quality of life at t2.(3)Stage Three: Three themes and eleven categories emerged from the qualitatived data of the multidisciplinary rehabilitation team,patients with stroke and their caregivers.The contents of rehabilitation self-management included the knowledge and skills related to rehabilitation,rehabilitation goal-setting and planning,medical management and emotion management.Facilitators to rehabilitation self-management comprised positive outcome expectation in rehabilitation training,active coping,multifaceted support,and a good physical rehabilitation environment.Barriers to rehabilitation self-management werephysical impairment,negative emotions and stress,and lack of home-based rehabilitation self-management support.The contents of the stroke rehabilitation self-management support program for patients with stroke in the recovery period include intervention goal,participants,providers,duration of the program,intervention strategies,intervention types,outcomes and outcome measures.It is a nurse-led,doctor and therapist participation program.The goal of the program is to improve rehabilitation self-management of patients with stroke in the recovery period.The core content of the program includes disease management,emotion management,daily life and role management.The type of the intervention include fact-to-face and group instruction,telephone instruction,booklet and video;in the early intervention period,the intervention strategy is to improve self-efficacy,and in the later period,the main strategy is to improve self-efficacy and outcome expectations.The duration of the intervention is 8 weeks.The primary outcomes were self-efficacy and self-management behavior,and the secondary outcomes were self-management outcome expectations,function,depression,and health-related quality of life.(4)Stage Four,a total of 117 participants completed the intervention and 3participants in the intervention group dropped out.The age of the participants was18～84 years,and the average age of the intervention group and control group were53.72±13.82 years and 57.03±14.45 years.Significant interactions between time from baseline to post-intervention and group were found in the total and sub-scale scores of self-efficacy,the total score of self-management behaviour and scores of three domains(emotion management,role management and core self-management skills)(P<0.01).All the participants demonstrated significant improvements at post-intervention in self-efficacy and self-management behaviour,and the improvements among those in the intervention group were higher than those in the control group(P<0.01).There were significant interactions between time from baseline to post-intervention and group in self-management outcome expectation,negative emotion and health-related quality of life(P<0.01).All the participants demonstrated significant improvements at post-intervention in self-management outcome expectation and health-related quality of life,and the improvements among those in the intervention group were higher than the participants in the control group(P<0.01).All the participants illustrated a significant decrease at post-intervention in depression,and the risk of depression in the intervention group was only 0.243 of that in the control group(P<0.01).Significant interactions between time from baseline to post-intervention and group were found in the activities of daily living,upper limb function and swallowing function.There was a significant time effect and group effect in the balance function.There was only a significant time effect in cognitive(non-aphasia patients)and communication function;and there was a significant group effect in cognitive(aphasia patients)function.All the participants demonstrated a significant improvement at post-intervention in their function,and the improvements in activities of daily living,balance function and upper limb function among those in the intervention group were higher than those in the control group(P<0.05).Conclusions:The stroke rehabilitation self-management support program for patients with stroke in the recovery period was effective in improving their self-efficacy,self-management outcome expectation and self-management behaviour,decreasing the risk of depressive symptoms,and improving quality of life.The support program also showed a potential effect on patients’ function,including their activities of daily living and balance,cognitive,swallowing,and communication functions.The findings also indicated the feasibility of the program for patients with stroke in the recovery period. |
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