Very often, the information availability for a patient with cerebrovascular accident (CVA) in an emergency department does not receive enough attention by hospital personnel (Smith, Foster, House, Knapp, & Young, 2008; Virtanen, Paavilainen, Helminen, & Åstedt-Kurki, 2010). Information availability is important for a patient with CVA because it has been seen to affect their ability to adjust to living with the disease and to emotional problems (Rodgers, Bond, & Curless, 2001). An informed patient will actively participate in the treatment and gain a sense of security from coping at home, and this will support the patient in taking care of practical matters and adjusting to the new life situation caused by the disease (Virtanen et al., 2010; Yonaty & Kitchie, 2012).
The tissue damage caused by a CVA affects the patient’s functionality in many ways. A CVA can cause permanent or temporary paralysis in different parts of the body or impairment of language functions and/or other mental functions (Käypä Hoito, 2011). A patient who has had a CVA often has difficulties in everyday life: difficulty moving, eating, getting dressed and with personal hygiene as well as with forming and maintaining social relationships. A patient with CVA can get confused with the different tests, procedures, and technical equipment involved in the treatment (Hancock et al., 2003; King & Semik, 2006).
A patient with CVA wants information on the symptoms of the disease, prognosis, tests, treatment, and medication as well as on the activities of the ward and their own part in the treatment. The information must be accurate, encouraging, and honest (Rodgers et al., 2001; Virtanen et al., 2010). The patient wants the attending staff to listen and to offer sympathy, trust, and encouragement, especially in acute situations (Virtanen et al., 2010).
The end result of treatment of a patient with CVA is improved by early examination and treatment of temporary symptoms and by ensuring that the patient receives follow-up care (Brereton & Nolan, 2002; Käypä Hoito, 2011). The wide knowledge and neurological expertise of the staff at the emergency department is a key factor in good end results of treatment (Virtanen et al., 2010). The staff should receive feedback from patients and their families on the information they have given so that the patient’s actual needs for information and observed shortcomings in information availability can be identified (Rodgers et al., 2001; Smith et al., 2008; Virtanen et al., 2010).
The aim of the study is to describe the information availability for a patient with CVA and to find out how the training intervention has affected it.
The research questions are the following:
1. How has the information availability for a patient with CVA been realized in an emergency unit after an intervention has been organized for the staff?
2. Which of the background factors of the patient with CVA are connected to information availability in the emergency department?
3. How has the intervention changed information availability for a patient with CVA in the emergency department?
The target group of the study included the patients with CVA of the emergency departments of two university hospitals. Altogether, 1,000 patients with CVA were selected during two measurement stages (surveys; n = 500 + 500). The patients who were chosen have had a CVA for the first time and been treated in the emergency department. Interfering factors were controlled by defining specific selection criteria for the patients. Those patients with CVA who were chosen had visited the emergency department within the current month, and a form was sent to their home addresses. The list excluded the following types of patients: (1) patients whose diagnosis had changed during their time in the emergency department, (2) patients whose condition or prognosis was so severe that they could not answer the questions, (3) patients who were treated as a number one priority in the emergency department (this group includes, e.g., patients who had received anticoagulant treatment), (4) patients who had two new diagnoses that both required immediate treatment (e.g., a CVA and a pelvic fracture), (5) patients who died during their stay in the hospital, and (6) patients who were diagnosed with a severe dementia.
The method of data collection used in the study was a structured survey form that included one open question. Theory on information availability, guidance and counseling as well as the researcher’s work experience were utilized in devising the survey form (Burns & Grove, 2005; Smith et al., 2008). The survey was used to determine how the information availability for a patient with CVA was realized in an emergency department. The survey form was enclosed with a covering letter providing information on the study, a form of consent for participation in the study, and a return envelope. The first set of data for the study (n = 190/500) was collected before the training intervention, from October 1, 2006, to June 14, 2007, and the second set of data (n = 170/500) was collected after the intervention, from October 17, 2007 to July 20, 2008, by giving a survey form to patients with CVA visiting the emergency department in two university hospitals.
The questions in the survey measured the patient’s experience of information availability in the following areas: staff treatment (10 questions), tests (6 questions), intravenous therapy (7 questions), disease (5 questions), symptoms (7 questions), patient instructions (6 questions), follow-up care (5 questions), and keeping informed the patient (10 questions) and their family (5 questions). In the survey, the respondent was able to choose the option that best described their experience. The open question was used to determine what other information the patient would have wanted during their stay in the emergency department. The components of information availability were evaluated on a 4-point Likert scale (4 = strongly agree, 3 = partly agree, 2 = partly disagree, 1 = strongly disagree, and 0 = this did not concern me).
Background questions (seven questions) were used to determine the patient’s sociodemographical factors (marital status, profession, and education), the number of emergency department visits, the waiting time for tests, whether the doctor arrived to examine the patient quickly enough, and presence of family in the emergency department. The functionality, logic, comprehensibility, clarity, and ease of use of the measure (survey form) were ensured by a pilot study wherein the survey form was given to 10 patients. On the basis of the feedback, the measure did not need any changes (Virtanen et al., 2010).
The ethical board of the healthcare district gave a favorable opinion on the study, and the appropriate research permissions were received from the healthcare districts. Patients were informed about the purpose of the study, the confidentiality of their responses, and the voluntary nature of their participation (Burns & Grove, 2005). The patients were allowed to fill in the survey form anonymously, and the form was returned in a sealed envelope to the University of Tampere. When analyzing the forms and devising the report, care was taken to protect the identity of participants (Burns & Grove, 2005).
Content of the Training Intervention
The target group of the study was the patients with CVA in the emergency departments of two university hospitals. The patients with CVA and healthcare staff in the emergency department of one hospital formed the test group, and those in the other hospital formed the control group. A training intervention was devised for the healthcare staff in the test group. The training intervention included a training program for the healthcare staff in the emergency department and written instructions for the patients with CVA visiting the emergency department. The contents of the training and the instructions for the patients with CVA were devised together with a neurologist, nurses participating in the treatment of neurological patients, and the researcher.
Altogether, 85 persons of the healthcare personnel (nurses, practical nurses, ward secretaries, clinical health assistants, doctors) working at the emergency department of the test group hospital participated in the training, which was carried out in autumn 2007. Training sessions were held as often as the whole emergency department’s staff was able to participate. One training session consisted of two 45-minute parts, the first of which was on the diagnostics and treatment of patients with CVA and the diversity of symptoms. The second part discussed the monitoring of the health and symptoms of a patient with CVA, discussing tests and treatment with the patient, staff treatment, patient instructions, and issues related to follow-up care. In addition, the significance of the presence of family to the treatment of the patient with CVA was discussed. The written instructions had information on the symptoms, risk factors, and relapse of a CVA. The instructions contained a telephone number for additional information and Web site addresses to the instructions online.
The data were analyzed with an SPSS program (SPSS Statistics for Windows, version 17.0, SPSS Inc., Chicago). The statistical methods used were frequency and percentage distributions, the Mann–Whitney U test and the Kruskal–Wallis test, the Spearman correlation, and a linear regression model. The means were calculated from the responses for the different components. Only the responses of those who had answered at least 80% of the questions were accepted for each component. This means that one to two of the questions might have been unanswered, depending on the number of questions for each component. In the regression model, the mean of each component in the survey was explained by gender, presence of family, waiting time (continuous), higher education (polytechnic or university), earlier visits to an emergency department, marital status (married, unmarried, divorced, widowed), age (under 65 years old or at least 65 years old), time of measurement (survey, 2006 or 2007), and test or control hospital. An interaction term was included for the two binary variables, time of measurement and test or control hospital, to measure the effect of the intervention. There were only a few responses to the open questions, and they were short. The limit for statistical significance was a p of <.05.
First, the results related to information availability after the training intervention will be presented, and the factors related to them will be examined. After this, the information availability changes will be analyzed between the two surveys, before and after the intervention.
The Background Information of the Participants of the Study After the Training Session
One hundred seventy patients with CVA in specialized care took part in the study. The response rate was 34%. Most of the respondents (62%) were at least 65 years old. Thirty-nine percent of the respondents were women, and 61% were men. Most of the respondents (67 %) were married or in a common-law marriage, and 14% were widowed. Nearly half of the patients (40%) stated common school or middle school as their highest level of education. In addition, 40% had received treatment in the emergency department for the first time in the hospital in question, and a little over half (59%) had been treated there before.
Information Availability for a Patient With CVA in an Emergency Department
The patients felt that discussing the tests (e.g., why and what test is going to be done; n = 153, mean = 3.44) and staff treatment (e.g., kindness, introducing oneself, listening; n = 155, mean = 3.40) were the aspects that were best realized regarding information availability. The aspects that were worst realized were discussing symptoms (n = 137, mean = 2.54) and the patient instructions given (n = 107, mean = 2.77; Table 1).
Factors Connected to the Information Availability for Patients With CVA
When examining the connection between marital status and how information availability was realized from the patient’s point of view with regard to discussing symptoms, widows/widowers gave a lower score of satisfaction about information availability when compared with patients with another marital status. The mean with widows/widowers was only 1.94 (the mean for the whole component was 2.54, the Kruskal–Wallis p = 0.028 for the difference between marital statuses).
The patients who had been in an emergency department before experienced the treatment as more positive than patients who were in the emergency department for the first time. This was seen in following components: the staff treatment (means for yes/no = 3.45/3.36, Mann–Whitney p = 0.022), discussion of the disease (means = 3.12/2.90, p = .048) and patient instructions (means = 2.95/2.64, p = .05).
Concerning the length of the waiting time of the patients in the emergency department, the Spearman correlation showed that the longer a patient waits, the less satisfactory their experience of the information availability will be. Patients who felt that the doctor did not arrive to examine them quickly enough also felt that all components of the information availability were realized worse when compared with other patients (Table 2).
The Effect of the Training Intervention on the Information Availability for a Patient With CVA Between the First and Second Measurements (Survey)
In the study’s intervention, 360 patients with CVA who had been treated in emergency departments were included. Table 3 shows patients’ experience of how the different components of information availability were realized in an emergency department in different time points separately for control and test hospital. Changes in test hospital information availability between 2006 and 2007 and between 2007 and 2008, in relation to control hospital, were examined using interaction term in regression analysis. Because of missing data, there were 151–282 respondents in the analyses, depending on the components.
The quicker the doctor arrived to examine the patient, the better the patients felt that the information availability had been realized for each component. When the patient was 65 years old or older, the information availability was experienced as worse about the component of intravenous therapy when compared with patients under 65 years old. Patients with CVA who had visited the hospital previously felt that staff treatment (e.g., kindness, introducing oneself, listening) was better than did those patients who had not visited the hospital before.
There were indications of the training intervention having had some effect on some components of information availability but were not statistically significant regarding the means of the components. When compared with the change in the results of the control hospital, the effect of the intervention in the test hospital was at best with improvement of 0.5 units in the means (in the component of intravenous therapy).
On the basis of the study, the patients with CVA felt that the information availability in the emergency department had been well realized on average. The components of discussing results and staff treatment were best realized, and the components of discussing symptoms and patient instructions were worst realized. The results support earlier studies (Smith et al., 2008; Virtanen et al., 2010).
Widows/widowers experienced the component of discussing symptoms to have been realized worse than did patients of other marital statuses. In earlier studies, it has also been found that the need for information availability and support especially increases when the patient is an elderly widow/widower with diminished capabilities (Isola et al., 2007; Virtanen et al., 2010). On the basis of this study, patients with CVA who had been in the emergency department before experienced the treatment more positively than did patients who were in the emergency department for the first time. The result is in line with earlier studies (Paavilainen, Salminen-Tuomaala, Kurikka, & Paussu, 2009; Virtanen et al., 2010).
The training intervention was seen to have had some indicative effect on information availability but did not have any statistical significance when adjusted to the situation in the control hospital. The results support the idea that, in addition to an effective and versatile training intervention, a broad neurological knowledge and the ability to adopt information based on research results regarding the treatment of patients with CVA are required from the emergency department staff to improve information availability.
Reliability Evaluation of the Study
The results of the study may indicate that the survey form used as the measure was not sensitive enough to measure the changes in the information availability from the point of view of the patient with CVA. It might have been possible to elaborate on the data by additionally carrying out thematic interviews. Moreover, if the staff training intervention had been longer and more systematic, it might have been more effective. In this study, it was not possible to carry out a longer intervention because of practical reasons. Despite the careful selection of the hospitals and development of the intervention, the reliability may have been weakened in practice because of problems that were not under the researcher’s control. Such reasons to especially consider are the motivation of the staff to fully focus on the training and the motivation to apply the training into their practice.
The training intervention involved one training session consisting of two 45-minute parts. Although the aim of the training session was to make it interactive and the participants were able to ask questions and talk about their own experiences treating patients with acute-stage CVA, the effectiveness of the training depends on the commitment of the trainee to the treatment of patients with CVA. It was not possible to conduct the intervention so that only specific members of staff were trained because the entire staff of an emergency department participates in the treatment of patients with CVA. On the other hand, the intervention might have been more effective if only those specific members of staff who were motivated about the treatment of patients with CVA were trained. The data collection after the intervention lasted 10 months, and during this time, the staff was no longer trained. This fact might have a negative effect on the results of the study as it is challenging to measure and show the effectiveness of a one-off training intervention.
Conclusions and Relevance to Clinical Practice
This study provided information based on the survey results regarding the information availability of patients with CVA in an emergency department. On the basis of the results, the following conclusions can be drawn:
1. The waiting time at the emergency department is connected to how the information availability was experienced. The systematic monitoring of waiting times, the reporting of issues, and the utilization of the results should be prioritized as development targets, as a long waiting time predicts poor information availability for the family members.
2. Training related to the information availability for patients with CVA should be developed based on the information and feedback received from patients with CVA. More personalized and versatile ways of sharing information should be found to support the functionality and working ability of patients with CVA. The existing telephone counseling practices should be developed further at the emergency department, and the information availability should also be ensured.
3. Resources should be allocated to the systematic adoption of research information as it can affect the coping of a patient with CVA at home. Especially in the case of patients with CVA, this is emphasized, because the CVA causes 6.1% of the total expenses of the Finnish healthcare.
4. Healthcare staff specially trained for treating patients with CVA is needed when developing the practices in practice.