Managing the severely impaired arm after stroke: a mixed-methods study with qualitative emphasis.

Purpose: There is a paucity of research into self-management strategies employed by stroke survivors outside of formal rehabilitation. This study aimed to explore stroke survivors' experiences of, and strategies for self-managing their severely impaired upper limb.Materials and methods: English-speaking stroke survivors whose upper limb had been non-functional at 3 months post-stroke took part in interviews (n = 16), a focus group (n = 6) and a survey (n = 20). Quantitative data were analysed descriptively. Qualitative data were analysed through thematic framework analysis using NVivo© software.Results: Participants' median (range) age group was 50-59 years (30-39, 70+). Median (range) time post-stroke was 39 months (4 months, 46 years). The overarching theme across the data was "choosing and expanding." Participants enacted professionally driven management strategies for their affected arm, and then chose to continue with what worked for them. Strategies were expanded through self-discovery and interaction with peers. There were sadness and frustration at the loss of arm function, but also satisfaction and self-confidence when progress was being made. Participants described an attitude of not giving up and remaining hopeful.Conclusions: These findings extend our understanding about how individuals manage their severely impaired upper limb and can be used to inform a novel stroke self-management intervention.Implications for rehabilitationStroke survivors' experiences of managing the severely affected upper limb may inform rehabilitation practice to foster self-management.Rehabilitation professionals may actively support stroke survivors in choosing from, and expanding on professionals' advice and guidance.Maintaining a positive and hopeful outlook is important to many stroke survivors. Professionals should be mindful of the potential impact of their interactions and negative predictions.Stroke survivors' experiences of managing the severely affected upper limb may inform the development of a novel tailored self-management intervention.

Starting early: integration of self-management support into an acute stroke service.

Self-management support following stroke is rare, despite emerging evidence for impact on patient outcomes. The promotion of a common approach to self-management support across a stroke pathway requires collaboration between professionals. To date, the feasibility of self-management support in acute stroke settings has not been evaluated. The Bridges stroke self-management package (SMP) is based on self-efficacy principles. It is delivered by professionals and supported by a patient-held workbook. The aim of this project was to introduce the Bridges stroke SMP to the multidisciplinary staff of a London hyperacute and acute stroke unit. The 'Plan Do Study Act' (PDSA) cycle guided iterative stages of project development, with normalisation process theory helping to embed the intervention into existing ways of working. Questionnaires explored attitudes, beliefs and experiences of the staff who were integrating self-management support into ways of working in the acute stroke setting. Self-management support training was delivered to a total of 46 multidisciplinary stroke staff. Of the staff who attended the follow-up training, 66% had implemented Bridges self-management support with patients since initial training, and 100% felt their practice had changed. Questionnaire findings demonstrated that staff attitudes and beliefs had changed following training, particularly regarding ownership and type of rehabilitation goals set, and prioritisation of self-management support within acute stroke care. Staff initiated an audit of washing and dressing practices pre- and post-training. This was designed to evaluate the number of occasions when techniques were used by staff to facilitate patients' independence and self-management. They found that the number of occasions featuring optimum practice went from 54% at baseline to 63% at three months post-training. This project demonstrated the feasibility of integrating self-management support into an acute stroke setting. Further work is required to evaluate sustainability of the Bridges stroke SMP, to understand the barriers and opportunities involved in engaging all professional groups in integrated self-management support in acute stroke settings, and to assess patient reported outcomes.