Elements of a nurse-coordinated post-stroke home care rehabilitation in the Philippines: A cross-sectional study

Concept Identification

The developed tool was anchored on Donabedian’s model of Evaluating Quality Health Care (Donabedian, 2003). The items generated in the following step were sorted as “Structure,” “Process,” or “Outcome” elements.

Item Generation

A systematic review (Blaquera et al., in press) was conducted to generate the items. Published articles from 2012-2022 focusing on home-based stroke rehabilitation were retrieved from PubMed, CINAHL (EBSCO), ProQuest, and ScienceDirect. Keywords were “stroke,” “home care services,” “domiciliary care,” “self-care,” “physical function,” and “activities of daily living.” A total of 758 studies were retrieved and screened based on the inclusion criteria: 1) studies involving only patients post-stroke discharged to home; 2) studies focusing on home-based rehabilitation, programs, or interventions; 3) type of articles: quantitative and mixed methods. The interventions in the included studies were analyzed based on their structures, processes, and outcomes. Items were then newly generated based on the themes of “structures,” “processes,” and “outcomes,” and the initial version of the tool consisted of 48 items.

Modified e-Delphi Technique

A modified e-Delphi technique (Keeney et al., 2011) established consensus on the items to be included in the final version of the tool. Purposive sampling was used to select the members of a multidisciplinary stroke expert panel from the Philippines and Japan. Considering Japan’s established transitional and community rehabilitation system, the panel’s composition ensured diversity in opinions and experiences in stroke rehabilitation systems. It was ensured that they met the inclusion criteria: having a post-graduate degree and at least five years of professional experience in post-stroke care. The ten-member panel comprised two Physiatrists, a Neurologist, four Nurses, a Speech-Language Pathologist, a Physical Therapist, and an Occupational Therapist. Seven members were from the Philippines, and three were from Japan.

Two rounds of modified e-Delphi technique were conducted. The initial version of the tool was electronically sent to the expert panel. The experts assessed the degree of relevance of each item on a scale of 1 to 4, with 1 as having no relevance and 4 as very relevant. The same panel of experts was also asked to suggest modifications to the items. Further, they were asked to suggest additional items. The experts’ ratings on relevance were analyzed by computing the I-CVI (Item-level Content Validity Index) and S-CVI (Scale-level Content Validity Index). The experts’ responses on suggested modifications and additional items were analyzed through content analysis.

The final version of the tool was based on the results of the synthesis of quantitative data (CVI) and qualitative data (content analysis of responses to suggested modifications and additional items). The items had an I-CVI range of 0.90-1.00, above the acceptable 0.78 (Polit & Beck, 2017), and an S-CVI of 0.99, above the acceptable value of 0.90 (Polit & Beck, 2017). The final version of the tool had 55 items (Structure: 23, Process: 18, Outcome 14).

Pilot Testing

The tool was electronically distributed to nurses involved in stroke care. A total of 22 nurses, which is within the 15 to 30 recommended number by Gray and Grove (2021), participated in the pilot test. An additional choice of “I don’t understand” was provided for each item. The participants completed the survey for an average of 15 minutes and did not report any items they did not understand. Their mean years of professional experience is 6.2 years. The number of participants working in hospital-based settings was 14 (77.27%) and 8 (36.36%) in community-based settings.

Samples/Participants

Nurses who were available and willing were recruited to take the survey. The sampling size was based on the 300 “good” sample size recommendation by Comrey and Lee (1992). The inclusion criteria were: 1) currently employed as a nurse in the Philippines, 2) handling patient or patient populations that include patients with stroke, 3) at least one year of professional experience, and 4) able to access and complete the survey. The exclusion criteria were those nurses who did not have direct contact with patients with stroke.

Data Collection Procedure

Four tertiary hospitals in the Philippines were given letters of permission to conduct the study. Additionally, purposive sampling was used to recruit nurses to ensure sampling adequacy. The survey was conducted in March 2024. Using the Survey Monkey© platform, the participants were given a link to the electronic copy of the study’s nature, informed consent form, questions on demographic profile, and the developed tool. Those who agreed to participate were asked to answer the demographic profile questions and the developed tool. In the developed tool, the participants were asked to rate the items in terms of “importance.” as follows: 5 - Highly Important, 4 - Fairly Important, 3 - Important, 2 - Slightly Important, 1- Not Important at all.

Data Analysis

The data were organized in Excel and analyzed using Jamovi (Version 2.5) (The Jamovi Project, 2024). PCA was conducted to extract important items of a nurse-coordinated post-stroke home care rehabilitation in the Philippines. PCA is a data reduction technique used when there is sufficient correlation among the variables (Alavi et al., 2020). The items in the validated tool were carefully categorized manually and with expert judgment based on Donabedian’s domains. PCA aimed to identify important items from each domain; hence, the items were subjected to PCA separately based on the Structure, Process, and Outcome domains. The assumption tests used were Bartlett’s test of sphericity and Kaiser-Meyer-Olkin (KMO) measure, which verified the sampling adequacy for the analysis. The PCA used a fixed number of components to identify the most important items in each domain. No rotation was applied. A component loading threshold of 0.50 was applied, often used by researchers (Polit & Beck, 2017). Cronbach’s alpha was used to evaluate the internal consistency of the developed domains.

Structure

The first principal component highlights the human, material, technological, organizational, and financial structures of the rehabilitation process. These results provide insights into the important underlying structures related to nurse-coordinated post-stroke home care rehabilitation. The interdisciplinary professionals form a cohesive team based on the specific needs of patients with stroke. Specifically, the interdisciplinary team must be composed of a physician, nurse, physical therapist, occupational therapist, speech-language pathologist, social worker, nutritionist-dietician, social worker, and other healthcare providers that address the patient’s co-morbidities. This is similar to the findings of Fisher et al. (2021) in the composition of a multidisciplinary team for the organization of home-based rehabilitation for patients with stroke and severe disability.

The nurses perceive that alignment with established stroke rehabilitation clinical practice guidelines and standards approved by the Department of Health of the Philippines is also important. However, international stroke nursing and rehabilitation guidelines have yet to be established. This highlights the importance of advocating for shaping and maintaining the standards of care. In 2016, the World Stroke Organization provided guidelines for the implementation, monitoring, and evaluation of stroke services globally. Country-specific guidelines have a strong consensus. However, it is still recommended that guidelines be contextualized based on the country’s health system (Mead et al., 2023). A policy may be a national, local, or institution-specific guideline that specifies health provider roles and responsibilities. It clarifies the roles of different stakeholders in the healthcare system, ensuring accountability, coordination, and alignment of efforts to achieve the overarching goals of the national health agenda. This policy ensures that funding is allocated to support patient services, including rehabilitation, in line with the national health priorities.

The use of telehealth has increased in response to the Covid-19 pandemic (Noceda et al., 2023). The participants perceived telehealth as an important element. Although some of these nurses might not have directly experienced telehealth delivery, they may have seen the impact of remote consultation, monitoring, and care delivery using technology. Telehealth facilities utilize technology to deliver healthcare services remotely, enabling patients with stroke to access rehabilitation services from the comfort of their homes.

A safe home environment includes assessing and addressing potential hazards in the home environment, implementing safety measures, educating patients and caregivers on injury prevention, and equipping the home with necessary assistive devices and modifications to support mobility and independence. Post-stroke care must be delivered with sensitivity to the cultural and religious beliefs, values, practices, and preferences of patients with stroke and their families. This approach acknowledges the diverse cultural backgrounds of patients. It aims to provide respectful, responsive, and appropriate care within the cultural context, thereby promoting trust, engagement, and positive health outcomes.

Item “17. Services paid ‘out-of-pocket’ by patients” did not significantly contribute to the variance explained by the first principal component. This item captures aspects of inadequate financial considerations and social insurance issues for rehabilitation services. In the Philippines, the financial coverage of rehabilitation services is limited. Hence, patients and their families are forced to pay for rehabilitation services out-of-pocket (Collantes et al., 2021). Thus, it has been considered that the nurses feel that item “17. Services paid ‘out-of-pocket’ by patients” is not aligned with the financial services system in the structure domain. It could be considered that item 17 did not include the Structure domain. In contrast, the nurse participants perceive that government and non-government insurance coverage for rehabilitation services is essential. This again highlights the roles of nurse leaders in lobbying and policymakers in crafting equitable insurance coverage and/or financial support in stroke home care rehabilitation.

Process

The effectiveness of the planning, implementation, and evaluation process of home care rehabilitation among community-dwelling patients with stroke explicitly represents the first principal component of the Process domain. The important Process elements are collaborative planning, evidence-based practice, patient and family engagement, periodic evaluation, and nurse-led care coordination.

Planning must begin before acute care discharge. The interdisciplinary team must be able to collaborate and set goals based on patient needs. These plans must be evaluated periodically to ensure the goals are achieved and amendments are made based on patient progress.

The results further emphasize the importance of evidence-based interventions. This is aligned with the results of Fisher et al. (2021), who recognize that interventions should be based on the best available evidence. Evidence-based stroke rehabilitation can reduce the burden of disabilities arising from stroke (Platz, 2019). Interventions must also address the cognitive, behavioral, and psychomotor dimension needs of patients and their families. This ensures that patients receive holistic care, eventually improving their overall quality of life.

Communication must not be limited among team members but should involve the patient and their family in every stage of the care process. They communicate regularly throughout the care process, from planning and implementation to evaluation. This communication facilitates the sharing of expertise, coordination of interventions, and adjustment of care plans based on evolving patient needs. Patient and family engagement improves function in patients with stroke (Chaiyawat & Kulkantrakorn, 2012).

The results highlight the role of nurses in (1) directly providing patient care, (2) leading the coordination of the entire rehabilitation process, and (3) performing tasks delegated by other professionals. The nurse takes on a leadership role in coordinating the interprofessional team, facilitating communication, collaboration, and aligning efforts among various healthcare professionals involved in the patient’s care. The nurse participates in the discharge planning and receives the attending physician’s endorsement. The nurse ensures that all structure and process elements are accessible to the patient. With the lack and maldistribution of rehabilitation specialists in the Philippines, nurses become a valuable human resource in providing rehabilitative care.

Outcome

The primary focus of post-stroke home care rehabilitation is improving patient and family outcomes across the cognitive, psychomotor, and behavioral domains of the patient. These pertain to the improvement of overall QoL, which is an important outcome measure (Araújo et al., 2020; Chen et al., 2016; Wong & Yeung, 2015). Rehabilitation goals must be patient- and family-centered, ensuring that interventions are aligned with patients’ needs, preferences, and priorities as agreed upon by several studies (Drenth et al., 2023; Kylén et al., 2023; Majid et al., 2023). To achieve the above, it is also important that the healthcare policy and health insurance system provide excellent support for community care and rehabilitation (Boeykens et al., 2023).

Nurse-coordinated post-stroke home rehabilitation must provide optimal outcomes during the transition from stroke to community rehabilitation. The nurse must be able to communicate changes and improvements to team members and the patient/family to recalibrate interdisciplinary team plans and interventions (Zampolini et al., 2022). With the complexity of outcomes to be monitored for each patient, the nurses’ role is crucial in evaluating outcomes.

In terms of cognitive functioning outcomes, it is essential that the patient maintains or improves their ability to think, reason, and process information effectively. However, in setting cognitive outcome goals, the interdisciplinary team must also consider the presence of cognitive impairments, which often occur with stroke (O’Callaghan et al., 2024). Education initiatives increase the patient and their family’s knowledge of stroke, including its causes, symptoms, treatment, and prevention strategies. This is parallel to the result of Hess Engström et al. (2024), wherein health literacy is associated with patient self-efficacy.

Improving psychomotor outcomes facilitates independence in daily activities and self-efficacy. Furthermore, promoting adequate support and caregiving to the family will improve the family’s skills and confidence in providing stroke care. Chu et al. (2020) have shown that nurse-trained, family-delivered rehabilitative care improved physical recovery among patients. In particular, coaching swallowing and assisting during feeding ensure safe and efficient nutrition intake. The eating and nutritional aspects of QoL post-stroke are critical outcomes (Perry & McLaren, 2004). Robinson et al. (2022) emphasize that it is important for family members to maintain previous eating and drinking routines and that healthcare professionals should be able to consider these in setting targeted goals.

Similarly, enhanced communication abilities enable effective interaction and expression. Wray et al. (2019) suggest that developing tailored strategies based on the patient’s uniqueness is crucial in strengthening confidence to manage long-term communication difficulties. In addition, improving sensory awareness is crucial in enhancing the patient’s ability to perceive and respond to stimuli. Serrada et al. (2021) similarly showed that sensory awareness is correlated with clinical outcomes of QoL, self-efficacy, and motor abilities.

Addressing the affective domain outcomes supports the patient’s emotional well-being and adjustment to life after stroke. The patient must be supported in re-establishing family and social roles, fostering meaningful relationships and community engagement. This parallels the results of Verberne et al. (2022), who encourage psychoeducation and emotional support to empower patients, consequently leading to better outcomes. Furthermore, these promote positive patient behavior toward home care and facilitate cooperation and engagement in the rehabilitation process. Ultimately, the patient and their family experience an improved quality of life, characterized by enhanced well-being, satisfaction, and fulfillment.