FEATURE

Couples’ Coping After Stroke—A Pilot Intervention Study Gale Robinson-Smith 1, PhD, RN, Catherine Harmer2, MPH, MSN, RN, CRRN, NEA-BC, Robin Sheeran3, BSN, CRRN & Eileen Bellino Vallo3, MSN, RN 1 College of Nursing, Villanova University, Villanova, PA, USA 2 Main Line Health System, Bryn Mawr, PA, USA 3 Bryn Mawr Rehabilitation Hospital, Main Line Health System, Malvern, PA, USA

Keywords

Abstract

Stroke; family issues; older adults. Correspondence G. Robinson-Smith, Associate Professor, College of Nursing, Villanova University, Villanova, PA. E-mail: [email protected] Accepted February 2, 2015. doi: 10.1002/rnj.213

Purpose: This mixed-methods pilot study examined the impact of a psychoeducational intervention (PEI) to expand coping skills and identify themes for focused nursing strategies to assist poststroke couples. Design: Outcome variables, including dyadic coping, quality of life, depression, and self-care self-efficacy, were measured in experimental and control groups initially and after PEI was created with experimental couples in six home sessions. Method: Repeated measures analysis of variance compared control (n = 5 stroke survivors; n = 5 spouses) and experimental groups’ (n = 5 stroke survivors; n = 5 spouses) on outcomes. Findings: Significant increase occurred in experimental group stroke survivors in coping by oneself and quality of life; depressive symptoms decreased. Significant increase in positive dyadic coping occurred for experimental group spouses. PEI intervention generated a major theme. Conclusions: Nurse-initiated cognitive coping intervention was supported by experimental group’s elements. Clinical Relevance: Nurses may use psychoeducational techniques to motivate stroke couples.

Introduction As stroke is a major cause of disability in the United States (Go et al., 2014), nurses have frequent contact with stroke survivors and their families. Poststroke sequelae for survivors include hemiparesis, balance and strength problems, dysarthria and aphasia, and memory changes. Depression is common after stroke and limits survivors’ progress (Robinson & Spalleta, 2010). Consequently, nurses need interventions that maximize patients’ functional abilities, as recovery times vary and patients return home to spouses and other family members in a few weeks. Spouses experience first-hand challenges that stroke survivors face after discharge from rehabilitation services, and are a “hidden” resource in care of stroke survivors (Levin & Idler, 2010). They often assume major responsibility for providing assistance with patients’ mobility, bathing, dress© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

ing, and instrumental activities of daily living at home. Stroke affects interpersonal relationships between stroke survivors and spouses. Nursing efforts sustain or reestablish comfort in couple relationships after stroke. Interventions must focus on identifying family concerns, setting goals, solving problems, and developing active coping strategies (Achten, Visser-Meily, Post, & Schepers, 2012; Barskova & Wilz, 2007). This mixed-methods pilot study (Grove, Burns, & Gray, 2013) was conducted with stroke survivors and spouses during home visits after inpatient rehabilitation. The purpose of the quantitative approach was to examine the effect of a nurse-administered psychoeducational intervention (PEI), comprising couple poststroke coping, on outcome variables, measured as dyadic coping, self-care self-efficacy, depression, and quality of life. Psychoeducation is defined as an intervention that assists clients and families to gain

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knowledge and skills to understand a health condition (Leffler, Young, & Fristad, 2008). The purpose of the qualitative part of the study was to identify themes of coping that may provide guidance for focused nursing strategies to assist poststroke couples. Comments of stroke survivors and stroke spouses were recorded on field notes during home visits. Content analysis techniques identified themes (Marshall & Rossman, 2011) from survivors’ and spouses’ recorded narratives. This article will explain quantitative aspects of the study first; qualitative aspects will be discussed next. Finally, quantitative and qualitative study aspects together will be described to provide a more holistic view of study results. Review of the Literature Dyadic Coping A systemic view of stress poststroke posits that stroke survivors and spouses will have an impact on each other, as they experience stress after stroke (Barskova & Wilz, 2007; Randall & Bodenmann, 2009). Dyadic coping is the way that couples indicate and respond to stress in each other and cope to maintain marital stability (Bodenmann, 1997; Kayser & Scott, 2008). In a study of stroke dyads, Godwin, Swank, Vaeth, and Ostwald (2013) reported that the quality of the dyadic relationship influenced stroke spouses’ perceived stress. Lutz, Young, Cox, Martz, and Creasy (2011) reported that caregivers lack understanding about role changes poststroke and that stroke couples need more time to handle the crisis of stroke. In a systematic review of qualitative studies, Mackenzie and Greenwood (2012) advocated that healthcare professionals assist stroke spouses with coping skills to recognize both positive and negative experiences associated with caregiving and acknowledge complex issues and uncertainty after stroke. The interdependence of individual and dyadic perspectives about the personal and shared impact of stroke may encourage stroke recovery. Self-Care Self-Efficacy Self-care self-efficacy is defined as “the confidence a person has in his or her ability to perform appropriate/significant self-care activities” and was originally developed to understand confidence and self-care management in people living with cancer (Lev & Owen, 1996). Self-care self-efficacy has been studied in stroke survivors (Robinson-Smith, 2002). Although evidence has shown that self-efficacy inter-

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ventions are influential in promoting quality of life after stroke, nurses have not adopted these strategies in practice (Korpershoek, van der Bijl, & Hafsteinsdottir, 2011). Depression Depression is associated with stroke survivors, and spouses may react with depression over time because of perceived lack of harmony in the relationship and decreased social support (Visser-Meily et al., 2009). Depressive symptoms are mood changes expressed in feelings of sadness, pessimism, sometimes despair, and somatic symptoms, such as loss of appetite, trouble with sleep, and decreased interest in daily activities (Townsend, 2014). Learning to verbalize supportive, realistic thoughts to replace automatic negative thoughts individually and for each other is important and may lead to positive behavior changes that improve coping and decrease depression poststroke (Beck, 2011; Hoffmann, Asmundson, & Beck, 2013). King et al. (2012) reported a trend toward decreased depression and anxiety in caregivers who received a problem-solving intervention in the first 6 months after stroke. Quality of Life Quality of life is defined as satisfaction with and importance of health and functioning, socioeconomic, psychological/spiritual, and family domains (Ferrans & Powers, 1992). Spousal health quality of life was associated with effective coping, sense of self-worth, hope, and optimism after stroke (Visser-Meily et al., 2009). In a systematic review, Van Mierlo et al. (2014) recommended interventions to bolster psychological resources after stroke because of their association with health-related quality of life. Activity and Mobility Physical recovery is considered a hallmark for ability to mobilize in older age, especially among frail elders (Fairhill et al., 2012). It was measured in this study at baseline in control and experimental groups. Activity and mobility limitations are defined as difficulty with carrying out daily tasks and were measured with the Short Form Activity Measure for Post-Acute Care (AM-PAC, Jette et al., 2007). Quality of life, depression, and self-efficacy measurements were selected for the study because evidence confirms these variables are affected poststroke. Dyadic coping measurement was chosen because stroke survivors © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

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and spouses influence each other, as they deal with poststroke stress. Interventions are needed to improve quality of life and self-efficacy, and decrease depression poststroke that include stroke survivors and spouses. Method Sample and Setting The sample was obtained from a major rehabilitation hospital in the northeastern United States. Following an education session with two registered nurses from the stroke unit set up through the hospital’s nursing department, these nurses identified patients who met study criteria and notified the nurse researcher. The study and patient inclusion criteria were described in writing and shared with staff members, including nurses, physicians, case managers, and psychologists on the stroke unit. A convenience sample included 10 couples (N = 20) identified from charts on the stroke unit. The experimental group included five stroke survivors and five spouses; the control group consisted of five stroke survivors and five spouses. Inclusion criteria consisted of: (a) admission to the inpatient rehabilitation from an acute care hospital within 2 weeks of stroke; (b) absence of other neuromusculoskeletal conditions that interfered with function, such as multiple sclerosis or Parkinson’s disease; (c) absence of major psychiatric disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders-V (American Psychiatric Association, 2013) ruled out through patient selfreport and chart; and (d) cognitive function adequate for participation in the study. Cognition and memory were evaluated from chart descriptions on patients’ orientation to time, place, and person and from registered nurses’ insights about patients whom they cared for regularly. In addition, the nurse researcher administered the Mini-Cog (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005; Doerflinger, 2007) in the hospital after informed consent was obtained to ensure stroke survivors had adequate cognitive function to participate. Couples were randomly assigned to either control or experimental group after informed consent was obtained. Age and other demographic characteristics of stroke survivors and spouses are found in Table 2. The sample size of 20 participants (10 couples) was chosen due to the study’s pilot status. Two couples in the experimental group dropped out of the study after initial home visits. All patients in this study received outpatient rehabilitation at the study’s inception after being discharged from the inpatient rehabilitation. © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

Ethical Considerations Institutional review board (IRB) approval was obtained at the rehabilitation hospital and the university that employed the first author. Two staff nurses and two staff psychologists evaluated stroke survivors on the unit and gave patients a researcher-developed recruitment form. If the stroke survivor agreed to talk with the researcher after reading the explanatory form, the nurse met with the stroke survivor and spouse during daytime and evening hours. The researcher visited stroke survivors and spouses in the hospital and explained the research protocol in more depth before obtaining informed consent from stroke survivors and spouses. If couples agreed to participate, the nurse began scheduled home visits after discharge. After assessing at least one coping strength and weakness that stroke survivors and spouses identified, the nurse interventionist asked if couples would consider alternate coping techniques to deal with stroke challenges. If couples agreed, the nurse interventionist wrote specific cognitive and communication strategies for each individual and couple based on indicators of stress verbalized; these were modified through stroke survivor and spouse comments during home sessions. Intervention The PEI was adapted from the Partners in Coping Program (Kayser & Scott, 2008), with specific open-ended questions about the impact of stroke on survivors and spouses. The PEI or nurse-initiated cognitive coping intervention consisted of six sessions and was carried out with the experimental group after baseline data collection. Table 1 presents the adapted PEI incorporating interventions that were introduced during each home visit and supported by comments from stroke survivors and spouses in the experimental group as the sessions unfolded during the study’s implementation phase. The researcher, a seasoned psychiatric nurse, studied and trained clinically in family systems’ nursing and counseling theory. After baseline data were collected, the nurse met with each couple in the experimental group to ask about their experiences with stroke from its occurrence to the present. The nurse drew a genogram and explained its purpose. The genogram focused on the family as a whole system for a picture of a family’s overall life pre- and poststroke to understand family roles and emotional closeness and distance between members (Townsend, 2014). Guiding questions evaluated stroke impact, current

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Table 1 Major theme—nurse-initiated cognitive coping intervention aligned with Kayser and Scott’s (2008) discussion points: supported by experimental group’s indicators Match with Kayser & Scott’s Discussion Points (2008)

Elements Counseling to take a balanced view

Advising to take one step at a time

Focusing on present

Focusing on reasonable goals

Positive reframing

Communicating support to spouse

Integrating body image changes into self-concept Incorporating social and pleasurable activities into a new reality

• Teaching about stress response and cognitions • Building cognitive skill to • • •

•

• •

• •

build range of constructive responses Teaching about stress response and cognitions Building cognitive skills to expand range of constructive responses Exploring instrumental support for tasks of daily living and how couples are dealing with stroke demands and daily routine Exploring instrumental support for tasks of daily living and how couples are dealing with stroke demands and daily routine Teaching stress-reduction strategies to manage physical and emotional stress Assisting with communications that allow expression of feelings to gain empathy for each other’s views and provide mutual support Assisting with body image concerns and ways to increase and regain intimacy Discussing return to work and social activities

family structure, and social network to highlight couples’ major strengths. The initial interview elicited challenges couples faced and provided guidance for tailoring PEI sessions and creating nurse-initiated coping interventions over the course of the study. In addition, the nurse interventionist highlighted issues that could be discussed in home sessions based on common problems encountered after stroke.

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Stroke Survivor Indicators

Spouse Indicators

I want to help myself stay fit and well during therapy. If I push too much, then I’m being unfair to myself

He may feel this way all day but he may not. Perhaps we can find a way to make his not feeling well more manageable today I get impatient that I can’t get anything done

I’m imagining the worst; I can’t be worrying about things that haven’t happened

I’m making progress and can do more than I could last month

I can walk to the front door and get the paper and can make coffee now

I can cope with the frustration. Some things will just get done later. I can breathe more easily now and have less tension in my neck I want to do more stretching exercises each morning

I can be persistent like my neighbor and MD who have medical problems

My wife is still a good listener since her stroke

I would feel supported if you check on me before going downstairs for television; I can find some fun activities that we can do together

If we focus on constructive goals, I’ll be more hopeful; I would feel supported if you put dishes in the dishwasher after a meal when I’m working We have shared bed at times even though we can’t sleep together We look at photo albums together

I want to walk upstairs so that we can sleep together I am reading short stories and playing computer games with virtual planes

Quantitative Aspect of Study The quasi-experimental, repeated measures (Grove et al., 2013) approach of the study was designed to measure the impact of a PEI versus standard care after stroke on dyadic coping (dyadic coping instrument [DCI]), quality of life (quality of life index-stroke version [QLI]), depression (Center for Epidemiologic Studies-Depression [CES-D]), and self-care self-efficacy (strategies used to promote peo© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

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ples’ health [SUPPH]). Quantitative data were collected in the first home visit (baseline) with control and experimental groups. Quantitative data were measured again with control and experimental groups after PEI sessions ended. Quantitative Measures The DCI is a 37-item scale (range 1 “very rarely” to 5 “very often”) with scores ranging from 37 to 185. Each partner responds to items separately. The DCI measures couples’ dyadic coping and stress communication as understood by (1) each partner’s own coping and how this is communicated to the partner (“I let my partner know that I appreciate his/her practical support, advice or help”; “My partner shows me through his/her behavior that he/she is not doing well or when he/she has problems”); (2) each partner’s perception of the other’s coping (“My partner shows empathy and understanding to me”; “I express to my partner that I am on his/her side”); and (3) each partner’s observation of how they cope as a couple (“We engage in serious discussion on the problem and think through what has to be done”; “I am satisfied with the support I receive from my partner and the way we deal with stress together” [Bodemann, Pihet, Shantinath, Cina, & Widmer, 2006]). The Cronbach’s alpha coefficient reported for the total score DCI was .92, while subscale reliabilities ranged from .63 to .93 (Bodemann et al., 2006). Criterion and construct validity for the DCI have been reported. The internal consistency coefficient for DCI was .883 in this sample for stroke survivors and .883 for spouses. The QLI-stroke version assesses quality of life in stroke survivors and asks them to rate satisfaction and importance of domains that include health and functioning, social and economic, psychological/spiritual, and family subscales (Ferrans & Powers, 1992). Subjects respond to 36 items on a 6-point scale (1 = very dissatisfied to 6 = very satisfied; 1 = very unimportant to 6 = very important). The QLI has been used with people with a number of chronic conditions (AFFIRM Investigators, 2005; Huang, Le, Chien, Liu, & Tai, 2004; Katsuno, 2005; Korkut, 2007). Reliability and construct, and concurrent validity were established (Ferrans & Powers, 1992). King (1996) and Robinson-Smith (2002) used the QLI with stroke survivors. Cronbach’s alpha for the QLI was .90. Cronbach’s alpha was .899 for this sample of stroke survivors. Self-care self-efficacy was measured by the SUPPH (Lev & Owen, 1996). The SUPPH was adapted for use with stroke survivors and has a reliability coefficient of .95 (Robinson-Smith, Johnston & Allen, 2000). Scores on © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

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23 items range from 23 to 115 on a 5-point Likert scale (1 = very little to 5 = quite a lot). Content validity was established with cancer and stroke patients; construct validity of the factorial type was reported in patients with cancer (Lev & Owen, 1996; Lev et al., 2007). Cronbach’s alpha was .96. The SUPPH internal consistency coefficient was .955 in this sample for stroke survivors. The CES-D, a frequently used self-report scale that measures depressive symptoms in the general population, may be used for evaluating poststroke patients (Roger & Johnson-Greene, 2009). Questions ask subjects to rate depressive symptoms on 20 items in the last week (0 = less than 1 day; 1 = 1–2 days; 2 = 3–4 days; 3 = 5–7 days). Scores range between 0 and 60 on the 20-item scale with higher scores indicating more depressive symptoms (Huba & Melchior, 1995). Interrater and internal consistency reliability and construct validity for the CES-D have been established (Hann, Winter, & Jacobsen, 1999; Radloff, 1977; Shinar et al., 1986). Cronbach’s alpha in this study for stroke survivors was .843, and for spouses was .842. The AM-PAC, administered at baseline, comprises three separate scales and measures functional ability after acute hospitalization. It provides data on physical function as a hallmark of stroke recovery (Haley et al., 2004). The Daily Activity and Mobility scales were administered in this study. Scores on the 15-item Daily Activity scale (4-point rating) range from 15 to 60, with higher scores reflecting lower function and more difficulty with items such as “tying your shoes” and “pounding in a straight nail to hang a picture.” Scores on the 18-item Mobility scale (4-point rating) range from 18 to 72 with higher scores reflecting lower function and more difficulty with items, such as “bending over from a standing position to pick up a piece of clothing from the floor without holding on to anything” and “moving up in bed” (e.g., “reposition self”). Designed to assess negative and positive patient outcomes during rehabilitation, the AM-PAC was more sensitive to changes when compared with the Functional Independence Measure (FIM; Coster, Haley, & Jette, 2006). The AM-PAC was measured once at baseline. Content validity was established for the AM-PAC. Cronbach’s alpha was .947 for the Mobility Scale and .967 for the Daily Activity Scale in stroke survivors. Procedures for Quantitative Data Collection and Analysis Quantitative data were collected in the first home visit (baseline) with control and experimental groups. The

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researcher read questionnaire items to stroke survivors because reading ability is often affected after stroke. Spouses answered questionnaires independently in another room. Quantitative data were measured again with control and experimental groups after PEI sessions ended. Quantitative data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS, IBM Corp, 2012). A series of repeated measures analysis of variance tests were used to analyze differences between means for control and experimental groups on major variables. Dependent vari-

ables included quality of life, depression, dyadic coping, and self-care self-efficacy. Mobility and activity were measured on stroke survivors at baseline only. Quantitative Results Age and other demographic characteristics of stroke survivors and spouses are found in Table 2. Frequencies, means, standard deviations, and ranges are listed for variables by experimental and control group stroke survivors and spouses.

Table 2 Stroke and medical characteristics of sample—stroke survivors and spouses (N = 20) Experimental Demographic Attributes Age (years) M SD Range Gender (n) Male Female Side of brain lesion (n = 10) Right Left Type of stroke (n) Ischemic Hemorrhagic Comorbid conditions* Hypertension Dyslipidemia Carotid stenosis/aortic stenosis Atrial fibrillation/pacemaker/defibrillator Gastro-esophageal reflux disease Diabetes, Type 2 Asthma Chronic obstructive pulmonary disease Hypothyroid Obstructive sleep apnea Rheumatoid arthritis Macular degeneration/cataracts Parkinson’s disease Depression Osteoporosis Cancer, past diagnosis

Control

Stroke Survivor

Spouse

Stroke Survivor

Spouse

65.2 14.9 53–76

65.4 15.0 51–74

75.6 7.4 70–80

75.6 10.1 69–88

3 2

3 2

3 2

3 2

3 2

4 1

4 1

8 4 2 1 5 3 0 2 2 1 2 1 0 2 0 1

AM-PAC (Short Form Activity Measure for Post-Acute Care) Mobility Activity

3 2

3 3 0 1 0 0 2 0 0 0 0 0 1 2 1 1 Mean (SD) 36.5 (13.9) 29.0 (15.2)

*Some stroke survivors and spouses had more than one comorbid condition.

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FEATURE

Couples’ Coping After Stroke—A Pilot Intervention Study Gale Robinson-Smith 1, PhD, RN, Catherine Harmer2, MPH, MSN, RN, CRRN, NEA-BC, Robin Sheeran3, BSN, CRRN & Eileen Bellino Vallo3, MSN, RN 1 College of Nursing, Villanova University, Villanova, PA, USA 2 Main Line Health System, Bryn Mawr, PA, USA 3 Bryn Mawr Rehabilitation Hospital, Main Line Health System, Malvern, PA, USA

Keywords

Abstract

Stroke; family issues; older adults. Correspondence G. Robinson-Smith, Associate Professor, College of Nursing, Villanova University, Villanova, PA. E-mail: [email protected] Accepted February 2, 2015. doi: 10.1002/rnj.213

Purpose: This mixed-methods pilot study examined the impact of a psychoeducational intervention (PEI) to expand coping skills and identify themes for focused nursing strategies to assist poststroke couples. Design: Outcome variables, including dyadic coping, quality of life, depression, and self-care self-efficacy, were measured in experimental and control groups initially and after PEI was created with experimental couples in six home sessions. Method: Repeated measures analysis of variance compared control (n = 5 stroke survivors; n = 5 spouses) and experimental groups’ (n = 5 stroke survivors; n = 5 spouses) on outcomes. Findings: Significant increase occurred in experimental group stroke survivors in coping by oneself and quality of life; depressive symptoms decreased. Significant increase in positive dyadic coping occurred for experimental group spouses. PEI intervention generated a major theme. Conclusions: Nurse-initiated cognitive coping intervention was supported by experimental group’s elements. Clinical Relevance: Nurses may use psychoeducational techniques to motivate stroke couples.

Introduction As stroke is a major cause of disability in the United States (Go et al., 2014), nurses have frequent contact with stroke survivors and their families. Poststroke sequelae for survivors include hemiparesis, balance and strength problems, dysarthria and aphasia, and memory changes. Depression is common after stroke and limits survivors’ progress (Robinson & Spalleta, 2010). Consequently, nurses need interventions that maximize patients’ functional abilities, as recovery times vary and patients return home to spouses and other family members in a few weeks. Spouses experience first-hand challenges that stroke survivors face after discharge from rehabilitation services, and are a “hidden” resource in care of stroke survivors (Levin & Idler, 2010). They often assume major responsibility for providing assistance with patients’ mobility, bathing, dress© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

ing, and instrumental activities of daily living at home. Stroke affects interpersonal relationships between stroke survivors and spouses. Nursing efforts sustain or reestablish comfort in couple relationships after stroke. Interventions must focus on identifying family concerns, setting goals, solving problems, and developing active coping strategies (Achten, Visser-Meily, Post, & Schepers, 2012; Barskova & Wilz, 2007). This mixed-methods pilot study (Grove, Burns, & Gray, 2013) was conducted with stroke survivors and spouses during home visits after inpatient rehabilitation. The purpose of the quantitative approach was to examine the effect of a nurse-administered psychoeducational intervention (PEI), comprising couple poststroke coping, on outcome variables, measured as dyadic coping, self-care self-efficacy, depression, and quality of life. Psychoeducation is defined as an intervention that assists clients and families to gain

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spouse initiated cognitive skills, courage and quality of life, and intimacy. Stroke survivors described role changes poststroke. They hoped to drive their cars and missed involvement in former activities, such as volunteer work. Spouses were working more at home and on the job and had less freedom. Because the normal balance in their relationship had changed, poststroke, spouses expressed a heightened sense of personal vulnerability. Stroke survivors described that reciprocity with spouses changed because they needed assistance to perform daily activities. Most couples had modified household tasks, such as managing finances and doing housework. Describing self-talk that was negative, stroke survivors worried about regaining strength and wanted to avoid becoming a “burden.” They were frustrated with physical challenges poststroke. Spouses felt impatient that previous activities, such as housework or getting exercise, could not be accomplished easily. Stroke survivors independently initiated positive coping skills to stay active in daily life. They modified activities and sometimes focused on the present even when encountering setbacks. Couples addressed quality of life in how they managed intimacy in poststroke life with descriptions of talking more, reminiscing, and looking at family photos. Being together poststroke required more adjustment. Nurse-initiated cognitive coping interventions—Experimental group The major theme identified in experimental group comments was nurse-initiated cognitive coping intervention. The major theme, nurse-initiated cognitive coping intervention, and its associated elements (counseling to take a balanced view, advising to take one step at a time, focusing on present, focusing on reasonable goals, positive reframing, communicating support to spouse, integrating body image changes into self-concept, and incorporating social and pleasurable activities into a new reality), constitute activities of the cognitive restructuring PEI. Its outcome was improved coping for stroke patients and spouses over several months following hospital discharge. The cognitive coping intervention is presented in Table 1; activities were initiated in Week 2 through Week 6 for the experimental group of dyads. The following section describes examples of topics discussed during the intervention period. Counseling To Take a Balanced View Coping techniques, as an example of PEIs, included encouraging supportive, positive thinking to replace automatic, and negative thoughts that stroke survivors and

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spouses verbalized that could result in depressive symptoms. Recommendations were presented to promote selfunderstanding and improve confidence and quality of life. Couples were asked to reevaluate emotional responses after trying adaptive coping techniques. Advising To Take One Step at a Time Couples who forecasted difficulty with the day ahead were advised to identify ways to make the day more manageable. Rather than worrying about what difficulties might occur, instead they were encouraged to focus on taking small steps and anticipating success. Focusing on Present The nurse fostered thinking about present concerns and what could be accomplished productively each day. Stroke survivors and spouses were encouraged to recognize self-criticism and use positive reinforcement for accomplished activities. Focusing On Reasonable Goals Couples were advised to consider alternative, short-term goals in the context of their progressive recovery. Using adaptive strategies was encouraged, such as creating a sling rather than using a basket to carry laundry down stairs. A stroke survivor may not be able to cook but could put dishes in a dishwasher seated in a wheelchair. Instead of writing checks, another survivor printed them. These coping skills enabled couples to modify their expectations and activities. Positive Reframing Couples were daunted by physical and emotional sequelae of the stroke experience, and sometimes expressed negativity. On the other hand, they also recognized small gains in function. They were advised to examine what they had already accomplished and to use self-encouragement to continue striving and working at goal setting and strategies for recovery. Communicating Support to Spouse The nurse assisted stroke survivors and spouses with communicating support to each other. Slowing down to listen was offered as a first step to increase empathy. The nurse advocated taking time to listen without rushing to suggest solutions and validated feelings while each person in the dyad expressed his or her point of view whether positive or negative. Spouses especially tended not to ask for assistance or expect encouragement, even when stroke © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 0, 1–11

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survivors were able physically and emotionally to offer help. Integrating Body Image Changes into Self-Concept The physical changes for stroke survivors created daily challenges and often performance of daily activities was compared with prestroke life. A stroke survivor selected manageable tasks, such as doing laundry in the basement, but could not continue quilting due to visual changes. While survivors admitted to seeing functional improvements over time, they appreciated success at task completion even though more time was required.

survivors at multiple times beyond 4–5 months of the study could have provided additional data to measure the effect of the intervention on outcome variables. Clinical Practice Implications

Incorporating Social and Pleasurable Activities into a New Reality Stroke survivors called their friends to reestablish connections and to offer and receive support. For one survivor, returning to work at home provided socialization and decreased isolation. Watching baseball games and helping others in a day treatment program assisted some survivors achieve a sense of purpose in life.

It is important for nurses to provide positive, realistic support after stroke, such as giving positive reinforcement along with time to gain skills. Pierce, Thompson, Govoni, and Steiner (2012) discussed interventions that focus on increasing caregivers’ sense of control and decreasing physical and emotional strain to maintain health and selfcare after stroke. This study’s quantitative and qualitative findings support their recommendations for spouses. Ostwald, Godwin, and Cron (2009) reported that strong spousal relationships were associated with higher life satisfaction for stroke survivors and spouses, and this study validates their findings offering holistic evidence through its quantitative and qualitative results. Nurses must work on supporting stroke survivors and spouses to meet poststroke challenges.

Discussion

Research Implications

The quantitative and qualitative results of the pilot study provide a structure for a nurse-initiated coping intervention or PEI. Following implementation of the intervention and compared to the control group, stroke survivors’ depression decreased, quality of life increased, and dyadic coping for themselves increased over the study period. Compared to the control group, experimental group spouses demonstrated an increase in positive dyadic coping over study weeks. This study may add to nursing science by delineating a nursing intervention grounded in a dyadic coping model in support of people after stroke and their spouses. Qualitative results strengthened quantitative results and highlighted specific cognitive and communication strategies stroke survivors implemented to lessen depressive symptoms and improve quality of life and coping spouses’ use of positive dyadic coping improved with the PEI intervention and was noted in recorded comments. Quantitative aspects as measured with standardized instruments and qualitative aspects reinforced each other through the PEI intervention. There are several limitations of this study. The sample size was small and obtained at one rehabilitation hospital; all couples were Caucasian. This study lacked sufficient power because of the small sample size. Testing stroke

Radcliffe, Lowton, and Morgan (2012) suggested further investigations on how marital relationships affect coping with disabilities such as stroke. Nurses could develop and measure results of brief couple interventions through television or computer programs that stroke couples could access while waiting for physical or occupational therapy sessions (Hahlweg, Baucom, Grawe-Gerber, & Snyder, 2010). Developing a standardized patient and spouse education program based on International Classification of Functioning, Disability and Health (ICF) criteria could be helpful for future studies (Sabariego et al., 2013). Researchers must continue to work on stating behavioral interventions precisely to improve power in studies, and continued efforts to refine screening instruments for poststroke depression are needed (Roger & Johnson-Greene, 2009).

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Conclusion This study examined the effects of a pilot program, a nurse-initiated coping intervention, with couples following stroke. Statistically significant results for survivors and spouses were found; comments volunteered by stroke survivors and spouses augmented quantitative findings; and, these findings together afford a holistic interpreta-

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Couples’ Coping After Stroke

Key Practice Points  A psychoeducational intervention (PEI) resulted in significant increase in experimental group stroke survivors in coping by oneself and quality of life; depressive symptoms decreased.  PEI resulted in significant improvement in positive dyadic coping for experimental group spouses.  PEI intervention generated a major theme: Nurse-initiated cognitive coping intervention supported by experimental group elements.  Nurses may use psychoeducational techniques to motivate stroke couples.

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