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Every day around 24 New Zealanders –75 per cent of them aged over 65 – have a stroke. These 9,000 or so ‘brain attacks’ a year are the major cause of serious adult disability in the country, but stroke nursing is a specialty still relatively in its infancy in New Zealand. FIONA CASSIE finds out more from nurses working in the field.

Julia Slark	Ginny Abernethy	Allison Gallant

Nursing stroke patients has always required time-consuming, quintessential nursing skills. Stroke nursing now also offers the adrenalin rush of being on call to offer life-changing thrombolysis in the tiny window available after a stroke event. And the nurses working in the specialty love it.

Seeing somebody regain everyday functions lost through a devastating stroke means stroke nursing has special rewards, says stroke clinical nurse specialist Dr Julia Slark. And the puzzle of unravelling whichever part of your patient’s brain has been affected also has its own fascination, says fellow stroke CNS Olivia Browne.

Stroke is the third largest killer in New Zealand and most ‘brain attacks’ share the same cardiovascular disease (CVD) risk factors as heart attacks, such as hypertension, high cholesterol, smoking, obesity, diabetes, inactivity and a family history of CVD. Of the 9,000 strokes that occur in New Zealand each year, about 2,500 people die as a result (around 10 per cent are aged under 65) and an estimated 60,000 stroke survivors are living with a disability at any one time.

Stroke is a major ongoing health issue in New Zealand but until relatively recently stroke services have been a Cinderella of the health system – with acute stroke patients treated in general medical wards and stroke rehabilitation often regarded as an adjunct to older people’s health – despite the fact that a quarter of strokes are in people under 65.

The specialty of stroke nursing was likewise slow to come into its own – even five years ago probably only a handful or more of nurses throughout the country focused on stroke. Back in 2003 the first call came for each DHB to have dedicated acute stroke services or units (depending on DHB size) with a ‘”knowledgeable and enthusiastic” interdisciplinary team. But by 2008 only eight DHBs met this criteria and just over a third of stroke patients were admitted to stroke units.

In 2014 the National Stroke Network, which connects health professionals in the field, set new criteria for membership of a multidisciplinary acute stroke team (which should include a physiotherapist, occupational therapist, speech and language therapist and social worker, as well as physicians and nurses) by requiring each centre to have a designated lead stroke physician and a lead stroke nurse.

Ginny Abernethy, the coordinator of the National Stroke Network, says the call to have stroke lead physicians and nurses is essential.

“Where that doesn’t happen … it is like the country without a prime minister – no-one owns [stroke] and stroke care doesn’t get prioritised.”

She says the increased impetus and value placed on having stroke nurses in the past three to five years means there are now between 15 and 20 stroke clinical nurse specialists at any one time and less than a handful of DHBs are currently not meeting acute stroke unit or service requirements. The Ministry of Health is aiming for 80 per cent of acute stroke patients to be admitted into an acute stroke unit and, from 1 July, for stroke patients to be transferred from acute to rehabilitation services within seven days of admission.

The network a couple of years ago also set up the Stroke Nursing Work Group – chaired by Julia Slark and including key leading stroke nurses across the country – to develop New Zealand’s first Acute Stroke Nursing Guideline as well as role descriptions for stroke ward nurses and stroke clinical nurse specialists (see web link in ‘Resources’ sidebar).

Stroke nursing no longer the poor cousin

It’s all come a long way since Alison Gallant found herself thrust into stroke nursing courtesy of being the charge nurse manager of the general medical ward designated to be Christchurch Hospital’s – maybe also the country’s – first acute stroke unit. There were five medical wards to choose from and in 2004 they chose her ward which – fatefully for what was to come – was situated on the hospital’s top floor.

“So we [the nursing team], unlike the allied health staff, were all novices in stroke nursing expertise.”

Gallant says initially the ‘stroke nurses’ felt like the poor relation but in time they not only developed the expertise but also grew to love their new specialty, and stroke started to get attention right at the ‘top table’ of the DHB.

The February 2011 earthquake, not unexpectedly, stalled the stroke unit’s ongoing development, particularly as the top floor ward was forced to evacuate for two and a half years across town to The Princess Margaret Hospital. On its eventual return to the main hospital campus the 12 dedicated acute stroke beds were assimilated into another medical ward and Gallant stepped into a new role as nurse coordinator for acute stroke.

“My role is wherever stroke touches,” says Gallant. “So that can range from working with people involved across the whole ‘patient journey’ – from ambulances, acute and inpatient rehabilitation services [the latter sited off the main hospital campus] to the transfer from hospital to home and beyond, including working with relatives.”

Gallant says that innovations such as thrombolysis and thrombectomy (see ‘Christchurch case study’ sidebar) and the hope they bring means stroke is now no longer a poor cousin, but one of the ‘sexier’ specialties.

Hutt Hospital clinical nurse specialist Olivia Browne would agree. From the outset of her career she was attracted to ‘neuro’ by the fact that no patient presents the same.

The Kiwi nurse was drawn to specialise in stroke nursing in particular after being invited to work on stroke research projects while working at University College London’s cutting-edge National Hospital for Neurology and Neurosurgery.

She was hooked and when seeking to return home hunted out some New Zealand delegates at an international stroke conference in France that led to the creation, seven years ago, of her stroke CNS post in Hutt Hospital’s newly established acute stroke unit (see more about her role in Hutt Hospital case study above).

Stroke nursing, says Browne, is one of the areas of nursing in which a patient can be wheeled into your ward quite disabled and six weeks later, after intensive work by a stroke team, can walk out the door. “It’s very rewarding.”

She says there is also a puzzle-like appeal to working out which parts of the brain have been affected by observing what the newly admitted stroke patient can or cannot do, and piecing those findings together with the scan results to get a more comprehensive picture of the patient.

In London Browne worked in a comprehensive stroke unit where patients received both their acute and rehabilitative stroke care in the same unit with the same team.

She believes this is a model that New Zealand should aspire to as it provides continuity of care and a decrease of duplication, builds staff expertise and improves patient, family and staff satisfaction as there is no constant changing of faces.

English stroke clinical nurse specialist Dr Julia Slark was also working in stroke in London before arriving in 2013 to take up a role at The University of Auckland’s School of Nursing. She is now offering the country’s first specialist stroke nursing paper, adding another training option to the multidisciplinary stroke paper already offered by AUT.

Her initial review of stroke services soon after arriving left her with the impression that stroke nursing in New Zealand, beyond clinical nurse specialists like Browne and leaders like Gallant, was “slightly behind the eight ball” in being developed as a specialty for bedside nurses upwards, particularly as it may have been just happenstance that a nurse finds themselves a ‘stroke nurse’ because their ward is selected to become a stroke unit. And, unlike Gallant, not all of them are taken by the idea.

“That’s why you can’t just rename a ward and stick a sign that says ‘stroke unit’,” says Slark. “It’s very important that you train the staff to understand the pathophysiological but also the psychological impact of stroke, which is immense for patients and their family.”

Slark’s Auckland paper covers the whole stroke patient journey from admission through rehabilitation, but says the reality is that stroke services are often more delineated, with nurses specialising in acute or rehabilitation services.

Slark remains an appointed member of the National Stroke Network and, while the nursing working group has been disbanded, stroke nurses now have a network online forum to keep them connected. She says while the concept of everyone in a stroke service from the ward nurse to the nurse manager being trained in stroke and feeling they belong to a nursing specialty is still “fairly new” it is “definitely getting there”. And there’s so much enthusiasm, she says.

Every nursing interaction is therapy

Enthusiasm and expertise are needed to ensure the best outcomes for stroke patients recovering from the resulting brain damage.

Increasingly techniques like thrombolysis and thrombectomy are reducing the disability caused by stroke, but Slark says they are still at best a partial answer for some people. And while stroke services are often demarcated into ‘acute’ and ‘rehabilitation’, right from the outset, rehabilitation is key while the brain still has the ability to recover.

“In the nursing stroke world we have to start [rehab] from day one,” says Slark. Even in the first 48 hours, when the patient may be unstable and still being assessed for swallowing to mobility and communication to continence, the nurse and stroke team also need to think about rehabilitation.

When educating people about stroke, Slark says she uses the imagery of the brain as a tree with stroke affecting the biggest branches (like the carotid arteries clogged through atherosclerosis) or the tiniest branches (the small vessels that may be damaged by high blood pressure or long-term, poorly controlled diabetes).

“Stroke rehab is all about trying to retrain the brain to create new branches,” says Slark, “which we know does happen now as we know that neuroplasticity does exist and you can try and train new pathways.”

This is both ‘exciting’ and ‘full on’ for stroke teams.

“What nurses need to do is use every interaction as an opportunity for therapy,” says Slark. While the stroke literature calls for at least one hour of therapy being offered each day by the physiotherapist, occupational therapist and speech language therapist members of the stroke team, it is nurses who are with patients for the other 23 hours.

Browne echoes this, saying stroke nursing is about knitting together the work of the rest of the multidisciplinary team because everything the nurse is doing with the patient is therapy.

Slark acknowledges this can be very time consuming.

“It takes twice as long to get someone to clean their own teeth when they are apraxic and they don’t really know where their mouth is than just doing it yourself,” says Slark.

The aim is to encourage recovery by helping the patient to be as independent as possible. “Which takes time and a certain type of person to ‘care about’ rather than ‘care for’ a patient.”

And being able to make patients feel safe when aphasia has left them unable to understand a word you are saying also requires nurses to be very aware of their non-verbal communication techniques. “Like the use of touch, and being gentle around people and not rushing them. You can’t rush people who don’t understand what you are saying.”

But if you get it right – and contribute to a patient regaining abilities they had lost – that is what is so powerful and rewarding about stroke nursing, believes Slark.

Gallant agrees, saying stroke nursing encapsulates much of the essence of what nursing is all about. She says a patient once quoted to her ‘that what nurses do is they take away the fear and give hope to people who have strokes [and their families]’. Gallant thinks that really captures what stroke nursing can offer. “I think the presence of nurses 24/7 for people with stroke can’t be overvalued – it’s really, really important.”

‘Brain attack’ nursing may still be a few steps behind ‘heart attack’ nursing when it comes to being a specialty, but stroke nursing has come a long way in the last decade with its combination of quintessential nursing skills and technological innovations.