DR.

ZELIHA TULEK (Orcid ID : 0000-0001-8186-6698)

DR. INGRID POULSEN (Orcid ID : 0000-0002-0342-017X)

Accepted Article
Article type : Original Article

Nursing care for stroke patients: A survey of current

practice in eleven European countries

Zeliha Tulek, Ingrid Poulsen, Katrin Gillis and Ann-Cathrin Jönsson

Authors:

Zeliha Tulek, RN, PhD, Assistant Professor, Istanbul University Florence Nightingale Faculty

of Nursing, Istanbul, Turkey

Ingrid Poulsen, RN, PhD, Associate Professor, RUBRIC (Research Unit on Brain Injury

Rehabilitation Copenhagen), Department of Neurorehabilitation, Traumatic Brain Injury,

Rigshospitalet, Denmark

Katrin Gillis, RN, MSc, Assistant, Department of Public Health, University Centre for

Nursing and Midwifery, Ghent University / Lecturer, Odisee University College, Department

of Health Care, Sint-Niklaas, Belgium

Ann-Cathrin Jönsson, RN, PhD, Associate Professor, Department of Health Sciences, Lund

University and Department of Neurology and Rehabilitation Medicine, Skåne University

Hospital, Lund, Sweden

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.14017
This article is protected by copyright. All rights reserved.
 Correspondence:

Zeliha Tulek, RN, PhD, Assistant Professor, Istanbul Universitesi Florence Nightingale
Accepted Article
Hemsirelik Fakultesi Abidei Hurriyet Cd. 34381 Sisli, Istanbul, Turkey.

Email: tulekz@yahoo.com, ztulek@istanbul.edu.tr

Contributions

Study design: ZT, ACJ, IP, KG; data collection: ZT, ACJ, IP, KG; data analysis: ZT;

manuscript preparation: ZT, ACJ, IP, KG. All authors read and approved the final

manuscript.

Conflict of interest

The authors declare that they have no conflict of interests.

ABSTRACT

Aims and objectives. To conduct a survey of the clinical nursing practice in European

countries in accordance with the European Stroke Strategies (ESS) 2006, and to examine to

what extent the ESS have been implemented in stroke care nursing in Europe.

Background. Stroke is a leading cause of death and disability globally. Optimal organisation

of interdisciplinary stroke care is expected to ameliorate outcome after stroke. Consequently,

universal access to stroke care based on evidence-based guidelines is a priority.

Design. This study is a descriptive cross-sectional survey.

Methods. A questionnaire comprising 61 questions based on the ESS and scientific evidence

in nursing practice was distributed to representatives of the European Association of

Neuroscience Nurses, who sent the questionnaire to nurses active in stroke care. The

This article is protected by copyright. All rights reserved.

 questionnaire covered the following areas of stroke care: Organization of stroke services,

Management of acute stroke and prevention including basic care and nursing, and Secondary
Accepted Article
prevention.

Results. Ninety-two nurses in stroke care in 11 European countries participated in the survey.

Within the first 48 hours after stroke onset, 95% monitor patients regularly, 94% start

mobilization after 24 hours when patients are stable and 89% assess patients’ ability to

swallow. Change of position for immobile patients is followed by 73%, and post-void

residual urine volume is measured by 85%. Some aspects needed improvement, for example

staff education (70%), education for patients/families/carers (55%), and individual care plans

in secondary prevention (62%).

Conclusions. The participating European countries comply well with the ESS guidelines,

particularly in the acute stroke care, but not all stroke units have reached optimal

development in all aspects of stroke care nursing.

Relevance to clinical practice. Our study may provide clinical administrators and nurses in

stroke care with information that may contribute to improved compliance with the European

Stroke Strategies and evidence-based guidelines.

Key words: Stroke, nursing, clinical guidelines, survey

What does this paper contribute to in the global clinical community?

 Clinical stroke care nursing practice in accordance with evidence-based guidelines

needs to be highlighted in European countries.

 A majority of the participants in this survey reported good nursing practice, but ratio

of following guidelines was lower than expected in some nursing interventions.

This article is protected by copyright. All rights reserved.

  Evidence-based knowledge regarding clinical nursing practice in stroke care needs to

be updated regularly.
Accepted Article
INTRODUCTION

Stroke is a global health problem, even though age-standardized mortality rates of stroke

have decreased in the past two decades (Krishnamurthi et al. 2013). The number of people

who have a stroke annually and live with the consequences or die from stroke is increasing in

relation to the population growth and aging (Feigin et al. 2015). Stroke is the third leading

cause of disability-adjusted life years worldwide with a considerable increase (19%) over two

decades (Murray et al. 2012). Furthermore, stroke is an important public health issue,

because it has been shown to be a preventable and treatable disease (Jauch et al. 2013).

Consequently universal access to stroke care based on evidence-based guidelines should be a

priority.

BACKGROUND

Stroke is one of the leading causes of death and disability in Europe, and the burden of the

disease is expected to increase in Europe (Kjellström et al. 2007, Bejot et al. 2016). Based on

this fact a Pan-European Consensus Meeting on Stroke Management was arranged for the

first time in 1995 in Helsingborg, Sweden, to examine the evidence-based knowledge and set

targets for 2005 in the management of stroke (Aboderin et al. 1996). In 2006, a second

Consensus Conference was arranged in Helsingborg to update the evidence in stroke care,

and to set new targets. The conference was organized by the International Society of Internal

Medicine, endorsed by the European Stroke Council and the International Stroke Society, and

co-sponsored by the WHO Regional Office for Europe. It was arranged in collaboration with

This article is protected by copyright. All rights reserved.

 the European Region of the World Confederation for Physical Therapy and the European

Association of Neuroscience Nurses (EANN) (Norrving 2007).

Accepted Article
When going through the different aspects in stroke care, the participants raised factors that

needed to be emphasized in the acute care as well as the post-discharge care. At the final

plenary session, the participants adopted the Helsingborg Declaration 2006 on European

Stroke Strategies (ESS), and the participants agreed upon the Helsingborg Declaration Goals

for 2015. The main areas of stroke management included in the declaration were organization

of stroke services, management of acute stroke, prevention, rehabilitation and evaluation of

stroke outcome and quality assessment (Kjellström et al. 2007). Attention was paid to

identify what goals were reached, what worked and what did not, and barriers for

implementation of recommended services (Norrving 2007).

The EANN emphasizes the importance of evidence-based knowledge in neuroscience nursing

including stroke care, and the need to educate clinical nurse specialists regularly in this field.

This has also been reported from studies confirming the importance of nurses in stroke care

to assess the patients’ swallowing function (Westergren 2006), nutritional screening (Smith

2016), to measure the post-void residual urine volume (Gilbert 2005), and to follow the

weight to detect malnutrition (Jönsson et al. 2008). The role of the nurse is also important in

the follow-up of recovery (Jönsson et al. 2014), risk factors and medication compliance

(Irewall et al. 2015), and to facilitate transition from hospital to community care (Condon et

al. 2016).

It is also important for nurses to consider the psychological factors that may influence the

recovery already in the acute stroke care. Post-stroke depression in the acute phase may be

related to the loss of physical abilities as well as anxiety regarding the living situation for the

This article is protected by copyright. All rights reserved.

 future (Kouwenhoven et al. 2012). Furthermore, the prevalence of pain is common after

stroke and may influence psychological factors, particularly among those with affected
Accepted Article
sensory-motor function in the upper extremity at stroke onset (Lindgren et al. 2012). In

addition, other types of pain are common after stroke (Jönsson et al. 2006) and may be an

obstacle for the physical exercise in the recovery after stroke.

The European Association of Neuroscience Nurses (EANN) has about 2500 members in

Europe covering 16 countries.The goal of the EANN is to provide a forum for collaboration

to enhance the competence in neuroscience nursing by exchange of knowledge and

experiences between national neuroscience nursing associations across Europe

(www.eann.info). In European countries where a neuroscience nursing association has not yet

been established, a neuroscience nurse is welcome as an individual member of the EANN.

Since the EANN participated in setting the Helsingborg Declaration Goals for 2015, the aim

was to conduct a survey of the clinical nursing practice in European countries in accordance

with the European Stroke Strategies (ESS) 2006, and to examine to what extent the ESS have

been implemented in stroke care nursing in Europe.

METHODS

Study Design

The study was conducted as a descriptive cross-sectional survey in 2013-2014. A

questionnaire based on the ESS and evidence-based nursing practice in stroke care was

developed by the four members of the EANN Scientific Committee including three of the

main areas of stroke management; organization of stroke services, management of acute

stroke, and prevention (Kjellström et al. 2007). The questionnaire consisted of 61 questions.

This article is protected by copyright. All rights reserved.

 Participants could choose between different options and mark “yes” or “no”. Some of the

questions included an option marked “other” where the participant could write a personal
Accepted Article
reply.

Participants

The study was presented to the representatives of the member countries at an annual EANN

board meeting and the questionnaire (in English) was distributed to the board members.

Member countries who were informed when the study was introduced were Austria, Belgium,

Croatia, Denmark, Finland, Iceland, Italy, Malta, the Netherlands, Norway, Poland, Serbia,

Sweden, Switzerland, Turkey and UK. A majority of the participating member countries used

the English version, but the questionnaire was translated from English into Dutch, French and

Turkish in the Netherlands, Belgium and Turkey to ensure that all participating nurses could

understand the questionnaire. All translated questionnaires were controlled by a consultant

with knowledge in both languages. The EANN representatives in the participating countries

sent the questionnaire to nurses in stroke care by e-mail. A description of the background and

purpose of the study was included with the questionnaire.

Ethical considerations

This study fulfilled all ethical requirements as detailed in the Declaration of Helsinki.

Information about the study was included with the questionnaire, and by replying to the

questions, the participant denoted consent. Only health professionals were involved, and it

was the nurses’ voluntary choice to participate in the study with total anonymity achieved by

returning the questionnaire in an anonymous letter to the EANN representative.

This article is protected by copyright. All rights reserved.

 Data Analysis

Data is presented by descriptive statistics including mean, standard deviation, range, number
Accepted Article
and percentage. The analysis was carried out using the SPSS 21.0 software (IBM, NY).

RESULTS

A total of 92 nurses returned the questionnaire from 11 member countries.The participants

represented Sweden (n=23), Belgium (n=15), Denmark (n=11), the United Kingdom (n=11),

Norway (n=10), Turkey (n=10), Malta (n=6), the Netherlands (n=2), Switzerland (n=2),

Iceland (n=1) and Serbia (n=1). Characteristics of the 92 participants are presented in Table

1. A majority of the participants (n=72) were working in stroke units, 12 in neurology clinic,

4 in medical clinic, 3 in neuro-intensive care, and 1 in neurosurgery clinic. Forty-two of the

participants were clinical nurse specialists, 25 head nurses, 21 bed-side nurses (RN), 2

clinical lecturers, and 1 research nurse.

Table 1: Characteristics of the Participants

Organization of Stroke Services

Organization of stroke services including basic requirements for stroke care, criteria fulfilled

for participating stroke units, and team members representing different professions trained in

stroke care are specified in Table 2. A majority (88%, n=80) reported that specialized stroke

care including rehabilitation is available for all stroke patients, and 91% (n=84) had

interdisciplinary stroke teams. Even though a majority of the participating units met the

criteria for stroke units, improvement was needed to enhance the following factors in

advanced stroke care: regular staff education in stroke care (70%, n=64), education for

patients/families/carers (55%, n=51) and individual care plans for secondary prevention

This article is protected by copyright. All rights reserved.

 (62%, n=57). The stroke team was well represented by most of the different professions

recommended to be included in the stroke team, but the number of social workers (67%,
Accepted Article
n=60), psychologists (43%, n=39) and oral hygienists (9%, n=8) was lower.

Table 2: Organization of Stroke Services

Management of Acute Stroke: Basic Care and Nursing

Clinical practice of nurses regarding management of acute stroke in stroke units or other units

with stroke care are presented in Table 3. A majority of the participants (95%, n=87) reported

that patients’ level of consciousness and physical abilities are monitored regularly within the

first 48 hours after stroke onset, and 94% (n=85) stated that patients are mobilized when they

are stable. For patients with urinary incontinence, 42% (n=39) of the nurses stated that they

use permanent catheters, and 85% (n=77) measure residual urine volume to detect urinary

problems. Bedside swallowing is assessed within 24 hours by 89% (n=75), 46% (n=38)

assessed by nurses, and 54% (n=45) in collaboration between nurses and other members in

the team. Assessment of ability to eat was performed by 98% (n=89), oral health daily by

92% (n=81), and pain assessment by 66% (n=59) of the nurses. Change of position for

immobile patients was documented by 73% (n=66). A majority of the participants stated that

written information and/or psychosocial support for patients and their families during the

acute care is provided mainly by nurses (83%, n=73).

This article is protected by copyright. All rights reserved.

 Table 3: Management of Acute Stroke

Secondary Prevention
Accepted Article
Since stroke patients usually have been prescribed new medications or had their prescriptions

changed after stroke it is important for nurses in collaboration with physicians to follow up

the results and control whether the treatment goals have been reached. A program for

secondary prevention has been established in accordance with the ESS covering follow-up of

the main risk factors, i.e. hypertension, smoking, atrial fibrillation or other cardiac diseases,

and diabetes as reported by 76-83% of the respondents (Table 3). Regarding follow-up of

nutritional status measured as weight loss (51%, n=45) and overweight (61%, n=54) the

proportion was lower and lack of physical exercise was reported by 53% (n=47). Supportive

counselling is an important factor not only in the acute stroke care, but also in the post-stroke

nursing care including risk factors such as smoking, nutritional problems, and possible

depression which is common after stroke.

DISCUSSION

To our knowledge, this is the first evaluation of stroke care nursing practice in relation to the

European Stroke Strategies. Our results show that the strategies seem to be implemented in

most countries participating in the survey. However, there is a scope for improved adherence

to guidelines in some areas of nursing practice for stroke patients. Since it has been reported

that implementation of guidelines increase quality of care and outcome after stroke including

functional recovery, survival, healthcare costs and patient satisfaction, it is important to

follow-up and if necessary improve the adherence to recommended standards by nurses

(Donnellan et al. 2013 A, Hubbard et al. 2012). Some adherence studies conducted in Europe

were carried out among neurologists or therapists (Hadely et al. 2014, Donohue et al. 2014,

This article is protected by copyright. All rights reserved.

 Otterman et al. 2012), or focused only one aspect of stroke care, and there seems to be a lack

of studies including interventions in nursing care. From an interview study with stakeholders
Accepted Article
and interdisciplinary team members it was found that, barriers to adherence to guidelines

were lack of resources, and insufficient training and education (Donnellan et al. 2013 B). It

has also been raised that it is vital that nurses maintain compliance with practice guidelines,

research and skills, and social media has been found to have a potential in terms of

educational benefits (Moorley et al. 2015).

Our study was carried out in eleven European countries, but our sample was not homogenous

in terms of education and nurse specialist competence. Despite agreed standards for nursing

education in the Bologna declaration signed by 29 European countries already in 1999

(Lahtinen et al. 2013), there were differences in education level of nurses. However a large

majority of the respondents had a Bachelor (n=53) or Master (n=22) degree, and only 17 of

the nurses had high school education. Those who had their basic education in nursing on high

school level, i.e. no Bachelor or Master level, had probably studied before the Bologna

declaration had been agreed upon by the European countries. Nurse specialist education is

important in stroke care and and the number of specialist nurses is low in several of the

participating countries as confirmed in this study. This indicates a need to further develop the

availability of education in this field as described in a Polish study (Slusarz et al. 2012).

The European Stroke Strategies include several interdisciplinary areas related to stroke care,

but in our study the focus was mainly on nursing care components of the ESS, e.g. the nurses’

assessment and management of common health problems in stroke care. Careful monitoring

of patients’ neurological impairments and level of consciousness is a vital issue in the acute

stroke care and it creates a rationale for establishment of stroke units (Kjellström et al. 2007,

This article is protected by copyright. All rights reserved.

 Jauch et al. 2013). As described in our results, a large majority of the participants reported

that the acute care nursing practice within the first 48 hours after stroke onset was well in
Accepted Article
accordance with the evidence-based guidelines and the ESS.

A common problem after stroke is urinary incontinence, which may last long-term (Pizzi et

al. 2014). However, although many participants for assessment of this problem followed the

guidelines, the case was not the same for management of the problem. Most of the nurses

(85%) reported that they measure postvoid residual volume of urine, which is positive.

However, as many as 42% of the nurses stated that they used permanent (indwelling) catheter

for patients, which indeed is not recommended (Jauch et al. 2013). One explanation for that

could be that they may not have a formal urinary incontinence assessment plan in their units

as concluded from a survey of 41 stroke units (Jordan et al. 2011). Another explanation could

be that they may not have enough time to implement post-void residual volume measurement

and optimal interventions when needed due to shortage of staff. A British study estimated

that time not only for therapy, but also for nursing care was inadequate, because stroke

patients received low levels of care by registered nurses and almost half of the nurses

providing care were assistant nurses (Rudd et al. 2009). An audit in Ireland confirmed these

results reporting inadequate staff resources and significant variability in the availability of

specialist staff (Horgan et al. 2011). Other reasons for lack of good practice regarding urinary

incontinence might be the fact that promotion of urinary continence is not a priority area of

stroke rehabilitation for nurses (Booth et al. 2009).

Only 83 of the participants replied yes to the question concerning standard assessment of

swallowing; only 38 were done by nurses, and 45 by other team members. However, a study

has shown good agreement between assessments of swallowing done by nurses and speech

This article is protected by copyright. All rights reserved.

 therapists (Weinhardt et al. 2008). Ability to eat and oral health were assessed by most of the

participating nurses, but assessment of pain (66%) and documentation of position change for
Accepted Article
immobile patients (73%) were conducted to a lower degree. Already in 1992, it was reported

that immobility after stroke might cause pain related to pressure on the skin and

musculoskeletal deconditioning. Consequently, frequent body repositioning was emphasized

when the patient is immobile in bed (Coletta et al. 1992). Our survey showed that

information and/or psychosocial support to patients and their families was mainly given by

nurses. Since supportive counselling is important in the acute as well as the post-acute

nursing care, it is disappointing that 13% of the patients could not receive any information

and support, which is particularly important for survivors affected by this severe disease.

Our survey indicates that secondary prevention after stroke is not optimal in all represented

units. The need to optimize secondary prevention has been confirmed by an international

multi-disciplinary group of stroke experts, including World Stroke Organization leaders

through the development of a Post Stroke Checklist to improve long-term stroke management

(Ward et al. 2014). The ICARUSS model (Integrated Care for the Reduction of Secondary

Stroke) including early prescription of medications by the medical staff, and promotion of

lifestyle changes by a nurse coordinator has been reported to reduce the risk for recurrent

stroke (Joubert et al. 2009). Development of a nurse-led post acute stroke clinic has also been

found effective to facilitate recovery by early intervention in management of modifiable risk

factors, including cognitive and psychological difficulties (Crowe 2009). Another good

example of improved health promotion is a nursing intervention program in a Swedish study

aiming at lifestyle changes that resulted in reduced blood pressure, increased physical

activity, and motivating patients to adhere to treatment (Drevenhorn et al. 2012). The nurses’

role in secondary prevention after stroke by assessing and advising on risk factors and

This article is protected by copyright. All rights reserved.

 ensuring adherence to medication regimens has also been emphasized in a British study

(Gibbon et al. 2012). Although the nurses’ interventions in the acute stroke care is the most
Accepted Article
dominant part in our survey, these studies confirm the importance of the nurse’s role in health

promotion and secondary prevention also in the post-acute stroke care.

LIMITATIONS

A number of limitations should be considered when results of this survey are interpreted. A

considerable limitation is that in some countries there were several participants and in some

of the countries very few, sometimes only one. The generalizability of the findings all over

Europe is limited because several European countries have not joined the European

Association of Neuroscience Nurses, and five of the member countries could not participate

because they could not arrange the translation of the questionnaire, or had no member active

in stroke care. Another factor that may have had a considerable impact on the results is the

fact that a quarter of the participants were Swedish nurses. Taking these limitations into

account, this is the first study to give an impression of the evidence-based competence in

nursing practice in stroke care in several European countries.

CONCLUSIONS

The results of this study show a picture of eleven European countries regarding adherence to

standards in stroke care with a particular focus on nursing. Our survey demonstrates that the

European Stroke Strategies and evidence-based nursing practice seem to be well

implemented in most of the measures as reported by nurses participating in the survey.

However there is a variability of standards in some aspects of stroke care nursing and

consequently there is a scope for improvement.

This article is protected by copyright. All rights reserved.

 RELEVANCE TO CLINICAL PRACTICE
Accepted Article
To optimize the organization of stroke care in Europe it is important to update clinical

nursing practice in relation to evidence-based guidelines. The results of this survey may

provide administrators and clinical nurses with valuable information of nursing practice in

stroke care. Although clinical nursing practice for stroke patients has followed the guidelines

as reported by a majority of the participating nurses, there is still room for improvement in

some aspects. Future studies with a more representative sample would be beneficial.

Acknowledgements

We would like to express our thanks to the European Association of Neuroscience Nurses

(EANN) for their support and also to the nurses who voluntarily participated in this study.

References

Aboderin I & Venables G (1996) Stroke Management in Europe. Pan European Consensus
Meeting on Stroke Management. Journal of Internal Medicine 240, 173-80.

Bejot Y, Bailly H, Durier J & Giroud M (2016) Epidemiology of stroke in Europe and trends
for the 21st century. La Presse Medicale 45(12 Pt 2), e391-e398.

Booth J, Kumlien S, Zang Y, Gustafsson B & Tolson D (2009) Rehabilitation nurses

practices in relation to urinary incontinence following stroke: a cross-cultural comparison.
Journal of Clinical Nursing 18(7), 1049-58.

Coletta EM, Murphy JB (1992) The complications of immobility in the elderly stroke
patients. The Journal of the American board of family practice (5), 389-97.

Condon C, Lycan S, Duncan P & Bushnell C (2016) Reducing readmissions after stroke with
a structured nurse practitioner/registered nurse transtional stroke program. Stroke 47(6),
1599-604.

Crowe C (2009) Development and implementation of a 'nurse run' post acute stroke clinic.
Australian nursing journal 16(8), 28-31.

Donnellan C, Sweetman S & Shelley E (2013 A) Health professionals' adherence to stroke

clinical guidelines: a review of the literature. Health Policy 111(3), 245-63.

This article is protected by copyright. All rights reserved.

 Donnellan C, Sweetman S & Shelley E (2013 B) Implementing clinical guidelines in stroke:
a qualitative study of perceived facilitators and barriers. Health Policy 111(3), 234-44.
Accepted Article
Donohue A, McLaughlin C, Crowe M & Horgan F (2014) Clinical guideline adherence by
physiotherapists working in acute stroke care. Irish Medical Journal 107(9), 287-9.

Drevenhorn E, Bengtson A, Nilsson PM, Nyberg P, Kjellgren KI (2012) Consultation

training of nurses for cardiovascular prevention – A randomized study of 2 years duration.
Blood Pressure 21:5, 293-299.

European Association of Neuroscience Nurses (EANN) (2017) www.eann.info/ (Accessed

March, 7, 2017)

Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, Barker-
Collo S, Moran AE, Sacco RL, Truelsen T, Davis S, Pandian JD, Naghavi M, Forouzanfar
MH, Nguyen G, Johnson CO, Vos T, Meretoja A, Murray CJ, Roth GA; GBD 2013 Writing
Group; GBD 2013 Stroke Panel Experts Group (2015) Update on the Global Burden of
Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology
45(3), 161-76.

Gibbon B, Gibson J, Lightbody CE, Radford K, Watkins C (2012) Promoting rehabilitation

for stroke survivors. Nursing Times 108(47),12-5.

Gilbert R (2005) Using Essence of Care benchmarking to develop clinical practice. Nursing
Times 101(2), 54-5, 57, 59.
Hadely KA, Power E & O'Halloran R (2014) Speech pathologists' experiences with stroke
clinical practice guidelines and the barriers and facilitators influencing their use: a national
descriptive study. BMC Health Services Research 14, 110.

Horgan F, McGee H, Hickey A, Whitford DL, Murphy S, Royston M, Cowman S, Shelley E,

Conroy RM, Wiley M & O'Neill D (2011) From prevention to nursing home care: a
comprehensive national audit of stroke care. Cerebrovascular Disease 32(4), 385-92.

Hubbard IJ, Harris D, Kilkenny MF, Faux SG, Pollack MR & Cadilhac DA (2012)
Adherence to clinical guidelines improves patient outcomes in Australian audit
of stroke rehabilitation practice. Archives of Physical Medicine and Rehabilitation 93(6),
965-71.

Irewall AL, Ögren J, Bergström L, Laurell K, Söderström L & Mooe T (2015) Nurse-Led,
Telephone-Based, Secondary Preventive Follow-Up after Stroke or Transient Ischemic
Attack Improves Blood Pressure and LDL Cholesterol: Results from the First 12 Months of
the Randomized, Controlled NAILED Stroke Risk Factor Trial. PLoS One 10(10), e0139997.

Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P,
McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark
M & Yonas H; on behalf of the American Heart Association Stroke Council, Council on
Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical
Cardiology (2013) Guidelines for the early management of patients with acute ischemic

This article is protected by copyright. All rights reserved.

 stroke: a guideline for healthcare professionals from the American Heart Association/
American Stroke Association. Stroke 44, 870–947.

Jordan LA, Mackey E, Coughlan K, Wyer M, Allnutt N, Middleton S (2011) Continence

Accepted Article
management in acute stroke: A survey of current practices in Australia. Journal of Advanced
Nursing 67(1), 94-104.

Joubert J, Reid C, Barton D, Cumming T, McLean A, Joubert L, Barlow J, Ames D, Davis S

(2009) Integrated care improves risk-factor modification after stroke: initial results of the
Integrated Care for the Reduction of Secondary Stroke model. Journal of Neurology
Neurosurgery & Psychiatry 80(3), 279-84.

Jönsson AC, Höglund P, Brizzi M & Pessah-Rasmussen H (2014) Secondary prevention and
health promotion after stroke: Can it be enhanced? Journal of stroke and cerebrovascular
diseases 23(9), 2287-2295.

Jönsson AC, Lindgren I, Norrving B & Lindgren A (2008). Weight loss after stroke: A
population-based study from the Lund stroke register. Stroke 39, 918-923.

Jönsson AC, Lindgren I, Hallström B, Norrving N & Lindgren A (2006) Prevalence and
intensity of pain after stroke: a population based study focusing on patients’ perspectives.
Journal of Neurology, Neurosurgery and Psychiatry 77(5), 590-5.

Kjellström T, Norrving B & Shatchkute A (2007) Helsingborg Declaration 2006 on European

stroke strategies. Cerebrovascular Diseases 23(2-3), 231-41.

Kouwenhoven SE, Kirkevold M, Engedal K & Kim HS (2012) Living a life in shades of
grey': experiencing depressive symptoms in the acute phase after stroke. Journal of Advanced
Nursing 68(8), 1726-37.

Krishnamurthi RV, Feigin VL, Forouzanfar MH, Mensah GA, Connor M, Bennett DA,
Moran AE, Sacco RL, Anderson LM, Truelsen T, O’Donnell M, Venketasubramanian N,
Barker-Collo S, Lawes CM, Wang W, Shinohara Y, Witt E, Ezzati M, Naghavi M, Murray C;
Global Burden of Diseases, Injuries, Risk Factors Study 2010 (GBD 2010); GBD Stroke
Experts Group (2013) Global and regional burden of first-ever ischaemic and
haemorrhagic stroke during 1990-2010: findings from the Global Burden of Disease Study
2010. Lancet Global Health 1(5), e259-81.

Lahtinen P, Leino-Kilpi H & Salminen L (2014) Nursing education in the European higher
education area - variations in implementation. Nurse Education Today Jun 34(6), 1040-7.

Lindgren I, Lexell J, Jönsson AC, Brogardh C (2012) Lef-sided hemiparesis, pain frequency,
and decreased passive shoulder range of abduction are predictors of long-lasting post-stroke
shoulder pain. Physical Medicine & Rehabilitation 4(8), 561-8.

Moorley C1, Chinn T (2015) Using social media for continuous professional development. J
Adv Nurs. Apr;71(4), 713-7.

Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, et al (2012)
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-

This article is protected by copyright. All rights reserved.

 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859),
2197-223.

Norrving B; International Society of Internal Medicine; European Stroke Council;

Accepted Article
International Stroke Society; WHO Regional Office for Europe (2007) The
2006 Helsingborg Consensus Conference on European Stroke Strategies: Summary of
conference proceedings and background to the 2nd Helsingborg Declaration. International
Journal of Stroke 2(2), 139-43.

Otterman NM, van der Wees PJ, Bernhardt J & Kwakkel G (2012) Physical therapists'
guideline adherence on early mobilization and intensity of practice at dutch acute stroke
units: a country-wide survey. Stroke 43(9), 2395-401.

Pizzi A, Falsini C, Martini M, Rossetti MA, Verdesca S & Tosto A (2014)

Urinary incontinence after ischemic stroke: clinical and urodynamic studies. Neurourology
and Urodynamics 33(4), 420-5.

Rudd AG, Jenkinson D, Grant RL & Hoffman A (2009) Staffing levels and patient
dependence in English stroke units. Clinical Medicine (Lond) 9(2), 110-5.

Slusarz R, Ireland S & Green T (2012) Specialist nursing training in Poland: applications
for neuroscience nursing. Canadian Journal of Neuroscience Nursing 34(3), 12-7.

Smith S, Westergren A, Saunders J & Hagell P (2016) Nutritional screening: a user-friendly

tool adapted from Sweden. British Journal of Nursing 25(4), 208-11.

Ward AB, Chen C, Norrving B, Gillard P, Walker MF, Blackburn S, Holloway L, Brainin M,
Philp I; Global Stroke Community Advisory Panel (GSCAP) (2014) Evaluation of the Post
Stroke Checklist: a pilot study in the United Kingdom and Singapore. International Journal
of Stroke 9 Suppl A100, 76-84.

Weinhardt J, Hazelett S, Barrett D, Lada R, Enos T & Keleman R (2008) Accuracy of

a bedside dysphagia screening: a comparison of registered nurses and speech therapists.
Rehabilitation Nursing 33(6), 247-52.

Westergren A (2006) Detection of eating difficulties after stroke: a systematic review.

International Nursing Review 53(2), 143-9.

This article is protected by copyright. All rights reserved.

ccepted Articl Table 1: Characteristics of the participants
Years in
Country (n=11) Educational background Position † Clinic stroke care
High Bachelor Master Nurse Head Bedside Clinical Stroke Neurology Medicine Neuro- Mean ±SD
School degree degree specialist nurse nurse lecturer unit clinic clinic intensive* (Range)
Sweden (n=23) 8 12 3 19 1 3 - 23 - - - 11.9 ±6.6 (4-25)
Belgium (n=15) 1 10 4 - 8 7 - 13 1 1 - 11.8 ±9.7 (1-31)
Denmark (n=11) 4 6 1 7 2 1 - 9 1 - 1 12.5 ±6.3 (1-26)
UK (n=11) - 5 6 8 - 1 1 9 1 - 1 11.0 ±9.1 (1-28)
Norway (n=10) - 10 - 6 1 3 - 10 - - - 10.3 ±4.7 (5-20)
Turkey (n=10) - 7 3 - 8 2 - 3 5 - 2 8.8 ±6.6 (2-23)
Malta (n=6) 4 1 1 - 3 3 - 2 2 2 - 15.2 ±9.1 (1-25)
Netherlands (n=2) - 1 1 - 1 1 - 2 - - - 3.0 ±2.8 (1-5)
Switzerland (n=2) - - 2 1 - - 1 - 1 1 - 10.0 ±9.9 (3-17)
Iceland (n=1) - - 1 1 - - - 1 - - - 17.0
Serbia (n=1) - 1 - - 1 - - - 1 - - 19.0
Total (n=92) 17 53 22 42 25 21 2 72 12 4 4
* 3 Neurointensive care (Denmark and Turkey) + 1 Neurosurgery clinic (UK)
† 1 nurse in Denmark had the position research nurse and one in UK had not stated position

This article is protected by copyright. All rights reserved.

 Table 2: Organization of Stroke Services
Response Reply yes
total (n) n (%)
Accepted Article
Basic requirements
• Regular education for all health care professionals about signs and 91 67 (74)
symptoms of stroke and how to act when symptoms occur?
• Regular information in the society about signs and symptoms of 92 66 (72)
stroke and how to act when symptoms occur?
• If yes, does information include that patients must arrive at the 66 60 (91)
hospital as soon as possible to start thrombolysis within 4.5 hours?
• National information that it is possible to prevent stroke before a 88 47 (53)
first /recurrent stroke by awareness of risk factors?
• Acute hospital care available for all stroke patients? 92 91 (99)
• Specialist stroke care and rehabilitation for all stroke patients? 91 80 (88)
• Evidence-based guidelines for stroke care in your country? 90 71 (79)
• Do all wards with stroke care in your hospital follow guidelines? 91 73 (80)
• Stroke care clinic responsible for regular education of health care 91 73 (80)
personnel in stroke care?
• Evaluation of quality of stroke care by following national quality 91 68 (75)
indicators as described in national guidelines?
• Collaboration between emergency call centre and stroke unit? 91 65 (71)
• Do pre-hospital services call the hospital before arriving? 91 78 (86)

Stroke units or other units with stroke care

Criteria fulfilled in your ward /stroke unit *
• Dedicated beds for stroke patients 92 73 (79)
• Interdisciplinary team 92 84 (91)
• 24-hour availability immediate imaging (CT or MRI) service 92 85 (92)
• Availability of protocols and guidelines for acute treatment 92 85 (92)
• Availability of protocols/guidelines for prevention of complications 92 75 (82)
• Mobilization as soon as vital functions are stabilized 92 86 (94)
• Weekly interdisciplinary team meetings 92 79 (86)
• Continuous staff education in stroke care 92 64 (70)
• Education for patients/families/carers 92 51 (55)
• Individual care plans for secondary prevention 92 57 (62)
Team members trained in stroke care in participating units *
• Physician 92 83 (90)
• Nurse 92 89 (97)
• Physiotherapist 92 90 (98)
• Occupational therapist 92 71 (77)
• Speech therapist 92 80 (87)
• Psychologist 91 39 (43)
• Social worker 90 60 (67)
• Dietician 91 68 (75)
• Oral hygienist 91 8 (9)
* More than one option has been marked

This article is protected by copyright. All rights reserved.

 Table 3: Management of Acute Stroke and Prevention
Response Reply yes
total (n) n (%)
Accepted Article
Basic Care and Nursing
• Monitoring neurological impairments and consciousness 92 87 (95)
regularly within the first 48 h after stroke onset
 * 92
Tool used for monitoring level of consciousness
- Glasgow Coma Scale 67 (73)
- NIH Stroke Scale 53 (58)
- FOUR Scale 2 (2)
- RLS Scale 15 (16)
- No specific scale 1 (1)
• Mobilization as soon as the patient is stable, usually after 24 90 85 (94)
hours
• Prevention of deep venous thrombosis for immobilized 92
* 41 (45)
patients
- Elastic compression stockings 12 (13)
- Mechanical compression 76 (83)
- Low molecular Heparin
 * 92
Assistance used for patients with urinary incontinence
- Diapers 84 (91)
- Permanent catheter 39 (42)
- Intermittent catheter 45 (49)
• Method used to measure post-void residual urine volume 91 77 (85)
- Intermittent catheter 8 (10)
- Bladder scan 69 (90)
• Noting defecation in the patient record daily 91 86 (95)
• Assessment of swallowing to identify dysphagia within 24 84 75 (89)
hours
• Bed-side method to assess swallowing function 83
- Standardized Swallowing Assesment (SSA) 41 (49)
- Gugging Swallowing Screen (GUSS) 7 (8)
- Facial-Oral Tract Therapy (FOTT) 3 (4)
- Other strategy: (More than one option, water test, etc) 32 (39)
• Team member assessing swallowing function 83
- Registered nurse (RN) 38 (46)
- RN and other team member † (OT, SLT, PT, NA, 45 (54)
neurologist)
• If the patient is unable to swallow, how does he/she receive 91
nutrition, water or other liquid?
- Nasogastric tube 86 (95)
- Percutaneous endoscopic gastrostomy 2 (2)
- Total parenteral nutrition 1 (1)
- Intravenous fluids 2 (2)
• Method used in assessment of the patient’s ability to eat * 91 89 (98)
- Self-report 14 (16)
- Observation 77 (87)
- Tool/questionnaire 17 (19)
• Recording time for position change for immobilized patients in 91 66 (73)
bed

Evaluation of pain by using a structured tool/questionnaire 90 59 (66)
• Assessment of patient’s oral health daily 88 81 (92)
• Are all stroke patients with aphasia assessed and treated by 92 79 (86)

This article is protected by copyright. All rights reserved.

 SLT †?
• Assessment of cognitive function 91 80 (88)
• Team members who assess cognitive function †: 78
- Registered nurse (RN) 8 (10)
Accepted Article
- OT (n=41), Neurologist (n=15), Neuropsychologist (n=8), 70 (90)
PT/SLT (n=6)

Providing written information and/or psychosocial support * 88
- By the nurse 73 (83)
- By the social worker 30 (34)
- No 11 (13)
• Taking part in goal-planning with the team before discharge 89
- Patient 4 (5)
- Family 5 (6)
- Both 65 (73)
- None of them 15 (17)
• Are rehabilitation services available for all stroke patients, if 90 79 (88)
needed?
• After discharge from acute care, where can a stroke patient 90
have access to rehabilitation when needed?
- Chronic care institutions 3 (3)
- Rehabilitation hospitals 11 (12)
- Outpatient rehabilitation clinics 5 (6)
- At home by a mobile rehabilitation team 3 (3)
- Other 68 (76)

Secondary Prevention
• Is there a structured program for control of secondary 90 77 (86)
prevention?
• Are the following factors included in the program? * 89
- Hypertension 73 (82)
- Smoking 71 (80)
- Lack of physical exercise 47 (53)
- Atrial fibrillation / other cardiac diseases 68 (76)
- Diabetes 74 (83)
- Overweight / Obesity 54 (61)
- Underweight / Weight loss 45 (51)
* More than one option has been marked
† Other team members: OT-Occupational therapist, SLT-Speech language therapist, PT-Physiotherapist,
NA-Nurse
Assistant

This article is protected by copyright. All rights reserved.