The Lisbeth Hockey Community Nursing Research Training Fellowship 2008. Final report
Background Stroke is the most common cause of adult disability in the UK; the incidence is particularly high in Scotland, with more than 12,000 new cases per year. Stroke recurs in approximately 25% of patients and may result in death or an increased risk of disability or institutionalisation. Stroke is associated with a disadvantaged socio-economic profile and lifestyle behaviours which include smoking, unhealthy diet, excessive alcohol consumption and lack of exercise. Crucially, these factors are amenable to change by means of pharmacotherapy and/or the delivery of lifestyle interventions. While the provision of lifestyle interventions has the potential to improve health outcomes and reduce the extension of disability, there is currently a dearth of research in this area.
Estimates suggest that 80% of stroke survivors are living in the community, with approximately 50% of all stroke patients receiving district nursing care. It is therefore important that any intervention aimed at preventing stroke recurrence should be based in the community/primary care setting where it is known that the majority of contacts with health care personnel occur. Nurses based in the community/primary care setting are ideally placed to be part of the team that delivers such an intervention. Recognising the need to develop an effective lifestyle intervention that has the potential to prevent stroke recurrence, we have developed a programme of research to address this gap. Our approach follows the Medical Research Council’s recommendations for the development and evaluation of complex healthcare interventions. This framework describes a phased approach, which aims to improve the identification and utilisation of appropriate research methods, and to improve understanding of what constitutes an effective intervention in a particular context. The development phase requires the gathering and synthesising of evidence with which to inform the content, design and delivery mode of a community based family-centred, secondary prevention intervention. Also during this phase, appropriate theoretical approaches are identified and developed. Prior to the inception of the Training Fellowship, two research studies were undertaken as part of the developmental phase of our research, a survey of stroke nurse practice regarding secondary prevention of stroke and a focus group study that explored the lifestyle beliefs and lifestyle behaviour of patients and family members following stroke. At this stage in the development phase of our programme of stroke secondary prevention research, in December 2008, the Lisbeth Hockey Community Nursing Research Training Fellow joined the research team. Aims The Research Training Fellowship aimed to provide opportunities for the development of a range of transferable research skills by enabling a community nurse, the Research Training Fellow, to contribute to the development of a community-based model for a family-centred lifestyle intervention for people who have had a stroke and their family members. Three objectives were described, namely to: 1. Contribute to the development of the intervention development, 2. Enhance stakeholder involvement, and to 3. Contribute to proposal development.
Intervention development The principal objective was for the fellow to contribute to the development of a community-based model for an evidence-based, family-centred lifestyle intervention for people who have had a stroke and their family members. Research activities undertaken in fulfillment of this objective included the identification and synthesis of evidence. The principal synthesis activity was the conduct of a systematic review of the literature.
Systematic review As part of the research team, who are members of the Scottish Centre for Evidence Based Care of Older People, the Training Fellow undertook a systematic review entitled, A systematic review of the effectiveness of secondary prevention lifestyle interventions designed to change lifestyle behaviour following stroke. The review will be published in the JBI Library of Systematic Reviews. Key review findings indicate that lifestyle interventions have the potential to improve behavioural outcomes following stroke.
Identifying and developing the theory The intervention development stage of our programme of research also included the identification and development of appropriate theoretical approaches with which to underpin our developmental work and the design and delivery of a secondary prevention intervention. Acknowledging the complex psychological processes associated with lifestyle behaviour/behaviour change, the Theory of Planned Behaviour (TPB) was selected to inform our research. TPB describes and explains behaviour and behaviour change as determined by intentions to engage/not to engage in specific behaviours e.g. smoking. Intentions are informed by attitudes, motivation and perceived behavioural control; factors embedded in/influenced by intersubjective relationships within the family. Similarly, recognising the importance of the family construct, the Calgary Family Assessment/Intervention model (CFAM/CFIM) was selected to complement the TPB. CFAM/CFIM is a family systems theory centred on the family’s reciprocal relationships, including those with external agencies e.g. healthcare practitioners. CFAM/CFIM enables the family to understand its internal processes and how it ‘works’ as family by encouraging introspection and collaboration. It enables practitioners to take into account the uniqueness of families, their processes and needs, and facilitates an understanding of the process of an intervention rather than simply its outcomes.
Stakeholder involvement All elements of this programme of stroke secondary prevention research have a strong service user focus, as we believe that it is essential that patients and family members’ are involved in the development and the evaluation of healthcare interventions. The second objective of the fellowship was to enhance and facilitate lay representation on the Research Advisory Group, and to broaden the consultation process by seeking to meet with clinicians and managers to ascertain their views and priorities in relation to the design and delivery of stroke secondary prevention services. Enhanced lay representation was secured by establishing contact with pre-existing networks, conducting recruitment visits to voluntary sector organisations, developing lay versions of project information, and organising a pre-Advisory Group meeting for lay representatives to facilitate their meaningful participation in the full Research Advisory Group meeting. In 2009/2010, we broaden our consultation activities to include individual community-based clinicians and managers actively involved in developing and delivering stroke services. To enhance our understanding of their various roles and perspectives, and the relevance of the CFAM/CFIM to secondary prevention of stroke practice, the research fellow secured shadowing opportunities with stroke nurses in three Scottish health boards, working in a range of clinical settings.
Proposal development The third objective specified that the Training Fellow would contribute to the development of a research proposal for a pilot study of the intervention in a community setting. However, our programme of secondary prevention research had not progressed to this stage before the completion of the fellowship. Nevertheless, the Training Fellow contributed to the development of the systematic review protocol, which required acquiring and using skills that mirror those required for the development of a research proposal.
Future plans Members of the research team have secured funding from the QNIS for a mixed methods study, The Contribution of Perceived Stress in Stroke (COPerSS). COPerSS aims to explore perceptions of psychological stress in people with a diagnosis of transient ischaemic attack/minor stroke. Perceived stress is an emerging risk factor for stroke, which we aim to address in our secondary prevention intervention. In autumn 2011, we plan to move onto the next stage of our programme of secondary prevention research i.e. intervention modelling, development and feasibility testing.
Conclusion The Lisbeth Hockey Community Nursing Research Training Fellowship 2008 represents a key evidence gathering and evidence synthesising element of our programme of secondary prevention research. The fellowship enabled a community nurse to make a valuable and ongoing contribution to this important programme of research as well as honing and acquiring a range of transferable research kills, thus enhancing community nursing research capacity. The research fellow will continue to contribute to the work as a member of the Research Advisory Group.
Maggie Lawrence, Susan Kerr, Caroline McVey, and Dorothy Ferguson. "The Lisbeth Hockey Community Nursing Research Training Fellowship 2008. Final report" 2011
Available at: http://works.bepress.com/maggie_lawrence/30