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Emergency Department Nurses Perceived Barriers and Facilitators to Caring for Stroke Patients
Melissa Johnson, Jennifer Cohn, Tamilyn Bakas

ABSTRACT
Stroke is currently the 3rd leading cause of death in the United States and is the leading cause of severe, long-term disability. With the advent of recombinant tissue plasminogen activator/alteplase, there is a treatment option for ischemic stroke. Unfortunately, only a small number of eligible patients receive this treatment. Whereas much research has been performed on barriers to treatment related to prehospital delays, less research has been performed on in-hospital delays related to hospital staffs perceptions of stroke patients. In this qualitative exploratory study, focus group interviews were conducted to examine emergency nurses experiences in caring for stroke patients. A convenience sample was recruited using flyers distributed in the emergency department. Three groups of emergency nurses were interviewed in a private location within the facility. The 30-minute, semistructured interviews included 2 to 4 emergency nurses and were moderated by the investigator. Individual transcripts were analyzed for trends, patterns, and recurring themes. Three major themes regarding barriers to and facilitators of stroke care emerged: (a) nurses comfort with assessment of stroke patients, (b) feedback regarding nurse performance and patient outcomes; and (c) environmental issues such as staffing, competing priorities, and patient and family needs. Despite the various challenges facing emergency nurses, all groups verbalized a desire to provide excellent care to these patients. Further research is recommended to address these challenges and to explore potential solutions identified in this study to improve the care of stroke patients.

troke is currently the third leading cause of death in the United States, after cancer and heart disease, and is the leading cause of severe, longterm disability (Lloyd-Jones et al., 2009). With the advent of recombinant tissue plasminogen activator/ alteplase (rtPA), there is a treatment option for ischemic stroke. Unfortunately, less than 7% of ischemic stroke patients receive rtPA (Cocho et al., 2005), although the literature suggests that 20% of patients should receive rtPA (Boode, Welzen, Franke, & Van Oostenbrugge, 2007). According to the American Heart Association (AHA) guidelines, rtPA is a recommended therapy for patients who meet inclusion criteria (Summers et al., 2009). To break down fibrin clots, rtPA converts plasminogen to plasmin (Vallerand
Questions or comments about this article may be directed to Melissa Johnson, MSN RN CNS CNRN, at melajohn79@ yahoo.com. She is a critical care clinical nurse specialist at Scripps Mercy Hospital, Chula Vista, CA. Jennifer Cohn, MSN RN CNRN, is a clinical director at the St. Vincent Neuroscience Institute in Indianapolis, IN. Tamilyn Bakas, PhD RN FAHA FAAN, is a professor at the Indiana University School of Nursing, Indianapolis, IN. Funding for this study was provided by Indiana University School of Nursing Graduate Student Funds. Copyright B 2011 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0b013e318228e1cb

& Deglin, 2001). A randomized controlled study found that ischemic stroke patients treated with rtPA were more likely to have minimal or no disability 3 months after the event than were the control group treated with a placebo (National Institute of Neurological Disorders and Stroke Study Group, 1995). Whereas much literature has focused on barriers to treatment related to prehospital delays (Ferro et al., 1994; Maze & Bakas, 2004; Morris, Rosamond, Madden, Schultz, & Hamilton, 2000; Wester, Radberg, Lundgren, & Peltonen, 1999) and the knowledge deficit of stroke patients themselves (Barber, Zhang, Demchuk, Hill, & Buchan, 2001; Boode et al., 2007; Pancioli et al., 1998; Williams, Bruno, Rouch, & Marriott, 1997), less has been published on inhospital delays surrounding stroke care (Johnson & Bakas, 2010). The available literature that has been published on in-hospital issues includes five articles that focused on nursing (Blank & Keys, 2000; Ingram & Sedlak, 2002; Kavanagh, Connolly, & Cohen, 2006; Michael & Shaughnessy, 2006; Summers et al., 2009). One article detailed an institutions experience with their stroke protocol, along with case studies (Blank & Keys, 2000). Another article highlighted stroke risk factor modification with implications for acute stroke recovery and rehabilitation (Michael & Shaughnessy, 2006). Two articles addressed implementation of AHA guidelines to improve outcomes

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(Ingram & Sedlak, 2002; Kavanagh et al., 2006). The most valuable contribution to the literature in this area is a recent AHA scientific statement focused on nursing and interdisciplinary care of the acute ischemic stroke patient (Summers et al., 2009); however, evidence cited for most of the recommendations for emergency nursing care was somewhat limited (levels B or C) and based primarily on consensus opinion, case studies, standard of care, nonrandomized studies, or on the results of a single randomized trial. Although nursing literature is emerging regarding inpatient stroke care (Summers et al., 2009), research studies have not been found in the literature regarding emergency nurses perceptions of stroke patients and stroke care. The purpose of this study was to describe emergency nurses perceptions of specific barriers and facilitators to the care of stroke patients in the emergency department.

Little, if any, research has been conducted to date related to emergency nurses perceptions of stroke patients and their care. This study examines their perceptions of barriers and facilitators to emergency stroke care.
the investigator. Open-ended questions were used to guide the focus group sessions (Table 1). These questions focused on nurses previous work experiences, perceived barriers and facilitators to the emergency departments current stroke protocol, feedback they received on nursing care and patient outcomes, and recommendations for improving stroke care in the emergency department. Each interview session was audio-recorded and transcribed verbatim. Individual transcripts were analyzed for trends, patterns, and recurring themes (Knodel, 1993). Reliability was assessed by comparing statements within and across groups (Knodel, 1993). In addition, analysis of themes was performed by a team of three researchers. Disagreements between the researchers were discussed and consensus was reached in all cases (Knodel, 1993).

Methods
In this qualitative exploratory study, focus group interviews were conducted to examine emergency nurses experiences in caring for stroke patients. Such focus groups are fundamentally a way of listening to people and learning from them, and they can generate rich understandings of participants experiences and beliefs (Knodel, 1993). The study was approved by an institutional review board for the protection of human subjects. For this study, emergency nurses currently employed in an emergency department in a metropolitan region of the Midwest were invited to attend one of three focus groups. The hospital had been certified by The Joint Commission as a stroke center. A convenience sample was recruited using flyers distributed on site in the emergency department. Ten emergency nurses, all women, participated in the study. Most were Caucasian (n = 9) and worked the day shift (n = 9). The nurses ages ranged from 24 to 47 years, with a mean of 33.9 years. Length of employment as an emergency nurse in this facility ranged from 1 month to 17 years, and most had worked in the emergency department for more than 2 years (n = 7). The mean length of employment as an emergency nurse was 45 months. Although there was one nurse who had as little as 1 month of experience, interviews were conducted in a group setting and reflect the responses of nurses with varying amounts of experience as they interacted within groups. Data saturation was noted when no new information was being elicited from the groups. The three groups of emergency nurses were interviewed in a private location within the facility. The 30-minute, semistructured interviews included two to four emergency nurses and were moderated by

TABLE 1.

Focus Group Questions Asked During Each Interview Session

1. Tell me about your decision to work in the emergency department. 2. What has been your experience in caring for stroke survivors? 3. What are your thoughts about providing care for stroke survivors in comparison with other types of emergency department patients? 4. What kind of feedback do you receive from others while providing stroke care? 5. What are your thoughts about the current stroke protocol? 6. What do you perceive as potential barriers to implementing the stroke protocol? 7. What are facilitators or available resources that make the stroke protocol easier to follow? 8. What are your recommendations for making this process better? 9. Is there anything else you would like to share about caring for stroke survivors?

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Results
The participating emergency nurses verbalized an understanding of the importance of providing timely, high-quality care to stroke patients and expressed a desire to provide such care. These nurses identified barriers and facilitators to the care of stroke patients that fell into the following categories: comfort with stroke assessment, feedback about care and outcomes, and environment. Summaries of each theme follow.

Comfort With Assessment

During focus group interviews, emergency nurses verbalized lack of comfort with assessing stroke patients using the National Institutes of Health Stroke Scale (NIHSS), as well as the desire to have more trained stroke nurses available. One nurse stated, The stroke scale can be very intimidating. I Im just not a big fan of the stroke scale myself because I think its very subjective and can be interpreted differently by every single person in the room. A second nurse said, I think the largest barrier is the comfort level. I I keep thinking Im going to be the one making the decision? Wow, okay, I hope I make the right decision. Another nurse chimed in, saying, We dont have as many stroke nurses as we should because they havent done the certification process. Additional quotes described the emergency nurses perceptions of physician comfort with assessment of stroke patients and activation of the stroke team. I tell the docs, FLets just call it and let the stroke team decide when they come down._ But I think thats the barrier right now. Although barriers to stroke assessment were evident, facilitators were discussed as well. Emergency nurses in this sample emphasized the value of having trained stroke nurses available and having the stroke protocol for consistency. I really like the stroke one nurses [stroke team nurse]. That is a huge help. Where my experience lacks, they can come in and do an assessment and kind of get a better feel for whats going on. That takes a little of the burden off. Another nurse said, Theyre really focusing on stroke now more than they were before because now were a stroke center and everything. I Now everything is very quick, its very well orchestrated, and theres a definite plan in place to get these patients functioning as well as possible. Another nurse continued, Its nice to have everyone on the same page so we all know no matter what day or time, this is what you do.

the following: I think it would be good to know we make a difference.; So I think that sometimes these people have complications later on that might have been able to be prevented if we had feedback about what those complications are.; and We really dont know what happens to them once they leave us. Other nurses said things like, But I think it would be nice to hear, FOh, you moved really quickly and you worked really hard and made a difference in this patient._ Their symptoms resolved or theyre going to have better quality of life of just knowing that it was the right thing. or Unfortunately, in the ER, we see so many patients that we usually only hear about things when we do something wrong. So if we miss something, then youll hear about it. But its kind of expected what youre supposed to do, so its not like good job. Another nurse stated, Anytime you get praised for doing something or just hearing that your patient did well, it makes you even just a little bit feel good inside. Instances where this feedback was available are discussed as facilitators to the care of stroke patients. For example, one nurse said, So I take care of a lot of stroke patients and I have seen a few really good saves where they take them to interventional and they pull the blood clot out and the person regains some function. I So its kind of exciting to see the procedures and things that theyre coming up with. Another nurse reflected on a specific situation. She said, It was the most amazing thing because he came in and was completely limp on one side and then he was functioning by the time he left to go upstairs. Another added, I think we get a lot of feedback currently because we have the stroke scale and theyre trying to become stroke certified so especially now they encourage all of the emergency department nurses to be stroke certified. So I think we hear a lot about it.

Environment
Environmental barriers included competing demands in the emergency department and staffing challenges during busy times. One nurse said, Id say more often than not, were understaffed. I If you have a couple of traumas and a couple of hearts and if you have a cath lab patient and to throw a stroke in, there too is just a little overwhelming at times. Another said, If you have people coming into the hallway or you have alarms going off next to you, you really are not focusing on the patient as much as you should. Another nurse compared stroke care with trauma care. Just like they make it for trauma, they have an assigned person for each trauma bay. So I think if they are really serious about wanting to be recognized for their abilities in taking care of a stroke

Feedback About Care and Outcomes

All groups expressed concern regarding the lack of feedback they received about patient outcomes and nursing performance. Some of the quotes included

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patient, I think that they need to treat it with the same priority. The groups also identified stroke patients and their families to be particularly challenging to care for and as requiring more nursing time. A nurse shared her perceptions regarding stroke patients in general. I think they can be very, very challenging patients and very hard patients, but you just really have to be patient and kind because they cant understand you and theyre frustrated. Another nurse said, I think as challenging as the patients are, if they have family, you almost have to double the amount of time youre taking with the patient to deal with the family, or you should. Its hard to do down here because were so crazy busy usually. But to be fair you have to give, the patient is scared and confused, and the family doesnt know what to do and they dont understand. The doc may come in and talk to them but try as they may they dont take the time. Family was an issue with another nurse as well. I think that just the family aspect its hard because you cant tell them exactly whats going to happen. I Its kind of wait and see. Within the environment theme, the importance of kindness in caring for stroke patients and their families was emphasized. I think its very nice having somebody (stroke one nurse) to come and just be able to focus on that patient. Another nurse shared this personal experience, One of my close friends had a stroke and so I saw how people treated him and how patient they were. Ive really appreciated the nursing profession for their kindness in caring for him. One nurse reflected on the nursing profession, So the whole caring part of being a nurse, to me, this is really a patient population where we can really shine with the education piece, with the caring piece, with also having the autonomy as a nurse to do what the patient needs. Another nurse added, Make sure youre giving them the best care you can.

Discussion
Care of stroke patients may be improved by addressing the challenges identified in this study through research. A concern expressed by all groups was lack of comfort with the assessment of stroke patients, particularly with the NIHSS. Many nurses viewed the scale as subjective and difficult to use. Nurses in the groups suggested that NIHSS training be conducted in an interactive class instead of the traditional computer-based training. The use of different modalities of NIHSS training for staff may increase their comfort with the use of the scale to assess stroke patients. This could potentially improve outcomes for these patients. Emergency physicians may also require additional education. A survey of 98 of the

126 accredited emergency residency programs in the United States found that very little time was spent on neurological emergencies beyond didactic material (Stettler, Jauch, Kissela, & Lindsell, 2005). Providing emergency physicians with additional education regarding assessment of stroke patients may increase their comfort with consulting neurology staff and the stroke team. Frequent neurological/stroke assessments by highly trained emergency personnel, including nurses and physicians, has been recommended in the scientific statement by Summers et al. (2009). Feedback regarding patient outcomes as well as nurses performance may also enhance the care of stroke patients. In a study involving Veterans Affairs hospitals, those that were high performers in terms of clinical practice guideline adherence provided timely, individualized, nonpunitive feedback to staff (Hysong, Best, & Pugh, 2006). Hospitals that were more variable in the provision of feedback had poorer adherence to clinical practice guidelines (Hysong et al., 2006). The few nurses in our study who stated that they had received feedback regarding performance received it through standardized facility-level reports. Individual feedback on the nurses performance may better facilitate guideline implementation as suggested by Hysong et al. (2006). The nurses in this study who received feedback regarding particular patients received that feedback only when they sought it out themselves. Research is recommended to explore whether providing feedback to emergency nurses regarding patient outcomes and nurses performance may increase adherence to stroke clinical practice guidelines and improve patient outcomes. All groups discussed struggles regarding competing priorities and the complex, time-consuming nature of dealing with stroke patients and their families. It was suggested by many group members that stroke patients should have dedicated stroke nurses available to care for patients and families upon their arrival and throughout their emergency department stay. There may be the potential to improve stroke care through evaluating current staffing practices in the emergency department. In addition to staffing challenges, the literature indicates that the public is not knowledgeable about stroke (Barber et al., 2001; Boode et al., 2007; Pancioli et al., 1998; Williams et al., 1997), which may potentially add to the anxiety of patients and their families as well as increase the workload for emergency nurses. Readily available patient and family stroke education materials could streamline the work of emergency nurses as an adjunct to face-to-face patient and family stroke education, particularly when the patient is not admitted to the hospital. Stroke education is recommended by The Joint Commission for all stroke patients, and

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for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke, 38, 1655Y1711. Barber, P. A., Zhang, J., Demchuk, A. M., Hill, M. D., & Buchan, A. M. (2001). Why are stroke patients excluded from TPA therapy?: An analysis of patient eligibility. Neurology, 56(8), 1015Y1020. Blank, F., & Keys, M. (2000). Thrombolytic therapy for patients with acute stroke in the emergency department setting. Journal of Emergency Nursing, 26(1), 24Y30. Boode, B., Welzen, V., Franke, C., & Van Oostenbrugge, R. (2007). Estimating the number of stroke patients eligible for thrombolytic treatment if delay could be avoided. Cerebrovascular Diseases, 23(4), 294Y298. Cocho, D., Belvis, R., Marti-Fabregas, J., Molina-Parcel, L., Diaz-Manera, J., Aleu, A., I Marti-Vilalta, J. L. (2005). Reasons for exclusion from thrombolytic therapy following acute ischemic stroke. Neurology, 64(4), 719Y720. Ferro, J., Melo, T., Oliveira, V., Crespo, M., Canhao, P., & Pinto, A. (1994). An analysis of admission delay of acute strokes. Cerebrovascular Diseases, 4, 72Y75. Hysong, S. J., Best, R. G., & Pugh, J. A. (2006). Audit and feedback and clinical practice guideline adherence: Making feedback actionable. Implementation Science, 1(9), 1Y10. Ingram, S. R., & Sedlak, S. K. (2002). New age in stroke treatment: The role of fibrinolytic therapy. American Journal of Nursing, 102, 17Y21. Johnson, M., & Bakas, T. (2010). A review of barriers to thrombolytic therapy: Implications for nursing care in the emergency department. Journal of Neuroscience Nursing, 42(2), 88Y92. Kavanagh, D., Connolly, P., & Cohen, J. (2006). Promoting evidence-based practice: Implementing the American Stroke Associations acute stroke program. Journal of Nursing Care Quality, 21(2), 135Y142. Knodel, J. (1993). The design and analysis of focus group studies: A practical approach. In: D. L. Morgan (Ed.), Successful focus groups (pp. 35Y50). Newbury Park, CA: Sage. Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, B., Flegal, K., I Hong, Y. (2009). Heart disease and stroke statistics 2009 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 119, e21Ye181. Maze, L., & Bakas, T. (2004). Factors associated with hospital arrival time for stroke patients. Journal of Neuroscience Nursing, 36(3), 136Y155. Michael, K. M., & Shaughnessy, M. (2006). Stroke prevention and management in older adults. Journal of Cardiovascular Nursing, 21(5S), S21YS26. Morris, D. L., Rosamond, W., Madden, K., Schultz, C., & Hamilton, S. (2000). Prehospital and emergency department delays after acute stroke: The Genetech Stroke Presentation Survey. Stroke, 31(11), 2585Y2590. National Institute of Neurological Disorders and Stroke Study Group. (1995). Tissue plasminogen activator for acute ischemic stroke: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. New England Journal of Medicine, 333(24), 1581Y1587.

providing this education is required in certified stroke centers (Adams et al., 2007).

Limitations
The small convenience sample of emergency nurses was from a single facility where NIHSS training was only recently initiated. The participants in these focus groups were self-selected, often familiar with one another, and may not have verbalized their true feelings about the subject. Despite these limitations, findings from this study have revealed several potential areas for future research.

Conclusions
Emergency nurses are on the frontline in the care of stroke patients. This study has underscored the importance of comfort with stroke assessment, particularly with reference to the use of the NIHSS. Further research regarding interactive training modalities for stroke patient assessment is recommended. Research regarding individualized feedback to nurses on their performance in providing stroke care, as well as the outcomes of their patients, is recommended. Given the complexity of care and competing demands that emergency nurses face in caring for stroke patients, alternate staffing patterns may be explored, as well as the availability of dedicated stroke nurses during all shifts. Research is also recommended related to the use of existing patient and family educational materials to supplement their interactions with patients and families during this stressful time. Despite multiple barriers to the care of stroke patients in the emergency department, nurses working in this setting continue to strive to provide excellent care to these patients. The barriers identified in this study, including lack of comfort with assessment of stroke patients, feedback regarding nurse performance and patient outcomes, and environmental issues such as staffing, competing priorities, and patient and family needs, have important implications for future research. Care of stroke patients may be improved by addressing these challenges faced by emergency nurses.

Acknowledgments
The authors thank Phyllis Dexter, PhD, RN, assistant scientist and editor, Indiana University School of Nursing, for her helpful review of the manuscript and the nurses who participated in this study.

References
Adams, H. P., del Zoppo, G., Alberts, M. J., Bhatt, D. L., Brass, L., Furlan, A., I Wijdicks, E. F. (2007). Guidelines

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Pancioli, A. M., Broderick, J., Kothari, R., Brott, T., Tuchfarber, A., Miller, R., I Jauch, E. (1998). Public perception of stroke warning signs and knowledge of potential risk factors. Journal of the American Medical Association, 279(16), 1288Y1292. Stettler, B. A., Jauch, E. C., Kissela, B., & Lindsell, C. J. (2005). Neurologic education in emergency medicine training programs. Academic Emergency Medicine, 12(9), 909Y911. Summers, D., Leonard, A., Wentworth, D., Saver, J. L., Simpson, J., Spilker, J. A., I Mitchell, P. H. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute

ischemic stroke patient: A scientific statement from the American Heart Association. Stroke, 40, 2911Y2944. Vallerand, A. H., & Deglin, J. H. (2001). Daviss drug guide for nurses (7th ed.). Philadelphia, PA: FA Davis. Wester, P., Radberg, J., Lundgren, B., & Peltonen, M. (1999). Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: A prospective, multicenter study. Stroke, 30(1), 40Y48. Williams, L. S., Bruno, A., Rouch, D., & Marriott, D. (1997). Stroke patients knowledge of stroke: Influence on time to presentation. Stroke, 28(5), 912Y915.

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