Post-Stroke Depression
Stroke is amongst the leading causes of disability and mortality worldwide (Mitchell, 2016). In the United States (US) alone, an estimated 750 000 individuals are affected by new or recurrent stroke annually. Survivors of stroke frequently experience some neurological-linked disability like hemiparesis and aphasia that lead to a loss of function. An estimated 50% of stroke survivors additionally experience long-term disability like partial paralysis while 25-50% of stroke patients require help in performing activities of daily living (Byun, 2012). Post-stroke disability is linked to additional symptoms such as depression, fatigue, and sleep disturbances. These symptoms have been correlated with reduced quality of life, poorer recovery, and a heighted subsequent risk of recurrent stroke and mortality. Depression, the second leading cause of disability globally, affects an estimated 30% of all stroke survivors and has been linked to increased disability, cognitive impairment, risk for falls, and mortality in the short and long term (Paolucci, 2008). Post-stroke depression occurs both the in the early and late stages after stroke. Notably, although depression significantly affects the recovery of stroke patients, it is often ignored as only a few patients are diagnosed and treated for the condition in clinical practice (Mitchell, 2016). This paper will describe a clinical scenario involving a patient who is exhibiting symptoms of post-stroke depression and fatigue following which it will describe and critically review a nursing article on nursing interventions for improving post-stroke depression and fatigue.
Clinical Scenario
The scenario involved a 45-year old male patient who was recovering from a stroke that had occurred two weeks previously. The stroke had left the patient with right-sided hemiparesis. He required assistance with activities of daily living. The patient was married with two teenage kids. His wife was a teacher. On this occasion, I noted that the patient’s mood was very depressed in spite of the fact that he had just been visited by his family. On talking to him, he informed me that he was worried about his family as he had been the main provider of his family. He said that he was worried that his family would no longer be able to make ends meet now that he had become incapacitated and his children would not be able to attend school. I enquired from my colleague who had nursed the patient previously whether she had noted any changes in the patient. My colleague also reported that the patient was not his usual jolly self and appeared depressed as he ate very little, slept a lot, and did not take pleasure in any activity. We informed the attending physician following which the patient was assessed and diagnosed with depression. This scenario prompted me to seek evidence-based information on nursing interventions that can help prevent or improve post-stroke depression. My search identified a primary research article by Kim (2012) entitled “Effects of an enjoyable nurse-led intervention to promote movement in post-stroke inpatients”.
Description and Critical review of the Article
The title of the study provides in a nutshell information about its aims, nature of intervention, and outcomes measured. The title of the study is thus appropriate. The abstract section concisely summarizes the background, aims, methods, sample, and results section of the study and in so doing provides a clear overview of the study. Readers can garner important information about the study from it. The introduction and background sections of the study are merged in the article. Nonetheless, the problem under investigation is clearly stated and easily identifiable. The section also cites evidence that shows the significance of the cited problem to nursing. The problem of concern in this study is movement impairments resulting from stroke that have been correlated with additional problems like sleep disturbances, fatigue, and depression. The additional problems are of significance to nursing because they impact on the prognosis of stroke survivors through mortality, reduced quality of life, recurrence of stroke amongst others. The literature review section summarizes current knowledge on the problem of concern, dependent, and independent variables, and the link between them. It mostly incorporates primary studies conducted within the past five years and a few non-empirical sources. The literature review section also incorporates sources more than 5 years old. It lays a solid foundation for the study by establishing what is known about the problem of concern and gaps in knowledge that need to be explored. In particular, it notes that there is little information on interventions aimed at improving movement in stroke patients in inpatient settings and none led by nurses. In addition, it concludes that most interventions that have been implemented to relieve depression, fatigue, and sleep disturbances have failed. The aim of the study is clearly stated. The study sought to examine the effects of an enjoyable nurse-led intervention on fatigue, sleep, depression, and functional status of inpatients with hemiparesis admitted in a rehabilitation unit in an acute care setting.
The study employed a quantitative pre-and post-research design. A quantitative research design was appropriate for the study as the variables can be measured quantitatively. Blinding in the study was not feasible because all participants stayed in the same unit making it impossible to blind the control group. A control group was used for comparisons which enhanced the interpretability of the findings of the study. The study population is adequately described and included post-stroke patients with hemiparesis. The sample is also adequately described and included 20 patients in the experimental group and 25 patients in the control group. Patients were recruited into the study if they met a predetermined inclusion criterion. The researchers do not describe the sampling method used but based on the provided information, they used convenience sampling. Use of a non-random sample may have introduced bias into the study. A power analysis was not conducted to estimate the sample size needed. The researchers, however, computed the power of the study which they found to be 0.73 using a significance level of .05, sample of 46, and mean effect size of 0.78. The mean effect size was based on existing data. The intervention is clearly described hence it can be replicated in future studies. It involved the use of children’s toys to promote physical activity and focused on movement of upper and lower limbs on the side affected by the hemiparesis. The intervention was competitive, led by nurses, and conducted in groups of 20 patients. 3 sessions were held per week over 2 weeks. Each session lasted 30-40 minutes.
On data collection and analysis, the key variables were operationalized using appropriate methods. The specific instruments used to collect data on the main variables are adequately described and were appropriate. For instance, fatigue was assessed using the Brief Fatigue Inventory that evaluates the severity and impact of disease-related fatigue. It consists of 9 items measured using a 10-point graphic rating scale. Scores for individual items are summed up to get a composite score. Higher total scores indicate greater fatigue. The inventory has a Cronbach’s alpha of .95-.96 and thus has high internal consistency and validity. Noticeably, the researchers do not provide information on whether informed consent for participation in the study was sought from participants or their families. The data collected was analyzed using SPSS version 18. Demographic and clinical variables were summarized using descriptive statistics. Parametric (t-tests) and non-parametric (X2 tests and Mann-Whitney test) were also used to analyze variables as appropriate that is depending on the level of measurement as well as distribution of each variable. The level of significance for two-tailed tests was .05.
Regarding the findings of the study, the results are adequately summarized using good tables. They are also surmised in narrative form. The findings provide evidence with regards to the aims of the research. The study found that sleep, depression, fatigue, and functional status were more improved in the experimental group than in the control group. The differences were statistically significant for fatigue and sleep. The discussion section of the study contextualizes the major findings of the study in light of findings from previous evidence-based studies and non-empirical knowledge. The limitations section of the study, on the other hand, describes the shortcomings of the study such as confounding from occupational and physical therapy that usually occurred one hour prior to each session. The study validity may also have been impacted by the novelty effect as the intervention was new for all participants. Importantly, there are important limitations of the study not described by the researcher. These include the fact that the study failed to control for important clinical variables that could have influenced the outcome of the study such as type, region, and severity of stroke and the relatively short period over which the study was conducted that is 2 weeks. On recommendations, the researchers recommend that nurse-led interventions intended to improve fatigue, depression, and sleep in post-stroke patients should be designed and tested using larger samples and in different settings.
Engaging in this exercise has helped me realize the important roles nurses can play in the diagnosis and management of post-stroke depression and fatigue especially since they spend the most time with patients. Further, it has opened my eyes to the fact that a plethora of evidence-based literature exists with regards to the topic of post-stroke depression. The exercise has also helped to sharpen my skills for searching for evidence-based information. For instance, I have realized that I can use the reference section of a research article to identify related articles. In addition, the exercise has helped enhance my knowledge and skills with regards to critical appraisal of research articles.
Conclusion
In summary, this paper has critiqued a research article related to a clinical scenario that involved a stroke survivor who was exhibiting signs of post-stroke depression and fatigue. The article by Kim (2012) is entitled “Effects of an enjoyable nurse-led intervention to promote movement in post-stroke inpatients.” The introduction/literature review section of the article provided a basis and justified the need for the study. The aim of the study is clearly stated. The research design used was appropriate for the study. The data collection and analysis procedures are adequately described. It is unclear, however, whether informed consent was sought from the study participants. The findings of the study are clearly presented and contextualized in light of current knowledge in the discussion section. Implications of the study are also well described. However, the study had significant limitations that threaten the internal and external validity of its findings. Engaging in this exercise has helped to enlighten me on the roles nurses can play in the diagnosis and management of post-stroke depression. The exercise has also enhanced my evidence-based practice knowledge and skills.
References
Byun, E. (2012). Commentary on effects of an enjoyable nurse-led intervention to promote movement in poststroke inpatients. Clinical Nursing Research, 21(4), 406-410.
Kim, I. (2012). Effects of an enjoyable nurse-led intervention to promote movement in poststroke inpatients. Clinical Nursing Research, 21(4), 390-405.
Mitchell, P. H. (2016). Nursing assessment of depression in stroke survivors. Stroke, 47, e1-e3.
Paolucci, S. (2008). Epidemiology and treatment of post-stroke depression. Neuropsychiatric Disease and Treatment, 4(1), 145-154.
