Research

A culture of caring: how nurses

promote emotional wellbeing
and aid recovery following a stroke
Beverley Bennett

E very year, one in six people worldwide

experience a stroke (World Stroke
Organisation, 2012), 152 000 of whom
live in the UK. Stroke is the second greatest
cause of death in people over 60 years of age
and the single greatest cause of severe
disability (Stroke Association, 2016). Its
effects are often complex, affecting not only a
person’s physical functioning but also their
communication, cognition, mood and social
relationships; all requiring input from a
multiprofessional stroke care team
(Intercollegiate Stroke Working Party, 2012).
Nevertheless, it is the impact of stroke on
patients’ emotional wellbeing that is arguably
one of the most challenging aspects of
rehabilitation, for the person affected and
their family, as well as service providers
(Stroke Association, 2013).
Since the 1980s, research into the emotional
response of stroke survivors has largely
focused on anxiety and depression and
approaches to their assessment and
management. This is not surprising, as
depression is estimated to affect at least 30%
of stroke survivors (NHS Improvement,
2011) and such severe emotional distress
clearly needs attention to ensure that health
care services can best meet survivors’ needs.
Recommendations for practice are embedded
in the National Clinical Guideline for Stroke
(Intercollegiate Stroke Working Party, 2012).
The needs of stroke survivors who
experience severe emotional distress must not
be underestimated. Yet viewing this 30%
statistic from a different perspective, it
suggests that 70% of survivors maintain their
emotional wellbeing and avoid the distress
experienced by others. The emotional impact
Abstract
Experiencing a stroke can significantly impact on a person’s emotional wellbeing. As nurses
play a key role in stroke rehabilitation, their responses to the emotional experience of stroke
may be crucial to the wellbeing of the patient and their relatives. This interpretive
ethnographic study involved a purposive sample of 10 cases, with each ‘case’ comprising a
patient, their closest relative and the nurses who provided their care. Data were constructed
through participant observation, interviews and document review. Analysis revealed that
the relationships built and sustained between nurses, patients and relatives are central to
creating a positive culture of caring, which promotes emotional wellbeing and aids recovery
in stroke rehabilitation. The importance of this culture should be more fully acknowledged,
both within nursing and the wider multiprofessional rehabilitation team.
Key Words Stroke rehabilitation, emotional wellbeing, nursing, culture of care
Authors Beverley Bennett; Senior Lecturer, Department of Nursing and Midwifery, Sheffield Hallam University
Correspondence bev.bennett86@gmail.com
Accepted August 2016
This article has been subject to double-blind peer review
Literature review nurse’s role in providing emotional support to
The scope and range of literature relating to stroke patients during hospital-based
the survivor’s emotional response to stroke, rehabilitation prompted further study.
and professional approaches to promoting More recent searches, focusing specifically
emotional wellbeing, have been previously on nursing interventions for promoting
reviewed by the author in this journal, from emotional wellbeing following stroke, have
both biomedical (Bennett,  2007) and revealed an increased interest in this field,
sociological perspectives (Bennett, 2008). The which remains diverse in its scope and
former focused on medical and psychological methodological orientation. Much of the
research into the assessment and management literature has prioritised the assessment of
of mood disturbance, particularly depression mood disorders, often urging nurses to take a
and anxiety, while the latter summarised more active role in this assessment (Gurr,
social science research and personal narratives 2011; Lightbody et al, 2007a; 2007b;
of the emotional experience of stroke. The McGinnes, 2009; Ross et al, 2009).
purpose of these reviews, based on systematic Intervention research includes a systematic
database searches for literature published review of the nurse’s role in therapeutic
over more than three decades, was to explore interventions for depression following stroke
knowledge of the emotional experience of (de Man-van Ginkel et al, 2010), where a
© 2016 MA Healthcare Ltd

of stroke will naturally be influenced by
multiple factors; therefore exploring what
enables people to remain positive could
provide valuable insights to inform
professional practice and patient care delivery.
stroke and how nurses might use this to
inform and enhance their role. It was
anticipated that, by identifying gaps in the
literature, opportunities for research could be
found. The scarcity of research relating to the
variety of potential approaches are identified.
However, the authors caution that because of
the routines of daily nursing practice, nurses
may be unable to actively participate in many
of these interventions, such as motivational

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Research

interviewing or structured group activities.
Vohora and Ogi (2008) also recognise that
time and resource constraints limit the ways
in which nurses can respond to patient’s
emotions. Acknowledging these constraints,
Ross et al (2009) purposely focused on
strategies that would enable ward-based
nurses to integrate psychosocial care into
everyday practice. It is the methods that
nurses use to achieve this and actively promote
emotional wellbeing following a stroke that
are the focus for the study reported here.
Research design
and methods
The aims of the study were to explore
patients’ emotional experiences following a
stroke during hospital-based rehabilitation. It
also aimed to examine how nurses use their
knowledge to inform their interactions with
patients and families. An interactionist theory
of emotion underpinned the research,
whereby emotions are conceptualised to arise
within relationships and are seen as essentially
communicative expressions occurring
between people (Savage, 2004). This
interactionist perspective offered great
potential for illuminating the experiences of
the person affected by a stroke. In addition, it
is also able to shed light on the perspectives of
the nurses who interact with these experiences
within the context of relationships established
between nurses and patients and their families
as part of daily interactions. In the wider
study of stroke rehabilitation, such
relationships have received limited specific
attention (Close and Proctor, 1999; Jones et
al, 1997), although interactionist perspectives
are evident in broader research that has
focused on person-to-person relationships in
nursing, and the emotional labour of nursing
(Smith, 1992; 2012; Pryor et al, 2009).
Interpretive ethnography was identified as a
methodological approach consistent both
with the study aims and the underpinning
theoretical concept, as it combines the
perspectives of the researcher as well as the
‘researched’ (Savage, 2004).
Study participants
The setting was a 28-bed combined acute and
rehabilitation stroke unit in the north of
England. The unit was selected because
Ethical approval was granted by the
researcher’s university and Trust research
ethics committee. Over an 18-month period, a
purposive sample of consecutive cases was
identified for inclusion in the study, with each
‘case’ comprising a patient, their closest
relative(s) and the nurses and health care
assistants (HCAs) who provided their care.
Ethnographic research using a case study
design inevitably focuses on small numbers of
cases in order to study them in sufficient
depth and detail (Mays and Pope, 1995). The
strength of this approach however, is in its
ability to deal with a wide variety of evidence
arising from the multiple sources of data
collected (Yin, 2003).
Following preliminary discussions with
senior nursing staff, it was agreed that they
would identify potential participants. All
patients would be considered and only those
who were physiologically unstable or too
physically frail would be excluded, as were
patients who had been assessed to have such
severe communication or cognitive
impairments that their competence to
understand and agree to participate would be
questionable (Braunack-Mayer and Hersh,
2001). Guidance for involving people with
aphasia in stroke research was followed
(Swinburn et al, 2007; Palmer and Paterson,
2013) and appropriate training was
undertaken by the researcher.
Table 1. Participants and the extent of their involvement in the study
Case Patient and
Relative
No. age
I Celia – 62 Husband – 14 days
(did not participate)
2 Gavin – 39 Wife – 60 days
(did not participate)
3 Lily – 75 Daughters –
Mel and Kim
4 Fred – 49 Wife – Thelma
5 Sid – 48 Wife – Mandy
Daughter – Sally
6 Ingrid – 73 No regular family
visitors
7 Helen – 71 No regular family
visitors
8 June – 82 No regular family
In total, 10 patients and their relatives
agreed to participate. Identities were protected
by the use of pseudonyms (Table 1). In each
case, to ensure understanding, the information
booklet was discussed with patients and their
relatives together, where possible. There were
four patients who had no regular visits from
family members during their stay on the unit.
In two cases, relatives declined to participate
in the study themselves, but had no objections
to the patient doing so. Consistent with
ethical practice, all participants gave their
written consent. Some ethical guidelines
recommend that if participants are unable to
legibly sign a consent form, their consent
should be witnessed by an impartial observer;
however, this process was not required by
either the National Research Ethics Service
or the local research ethics committee.
Therefore, those patients who were unable to
produce a signature made their mark on the
consent form in the presence of the researcher.
All but 2 of the 16 nurses and 17 HCAs
agreed to be included, from whom 9 nurses
and 3 HCAs emerged as key informants to be
later interviewed. Consent was requested to
observe the nurses’ interactions with patients
and relatives, to hold interviews, to access
care records and to attend shift handovers
and team meetings. Although the study did
not intend to directly involve other members
of the multi-professional team, their presence
Researcher Key nursing/
Length of stay
contact time HCA informants
3 days Nurses:
Gary
15 days Emily
Angie
56 days 36 days
Felicity
Isabel
87 days 51 days
Donna
70 days 52 days
Christine
Julie
32 days 17 days
Karen
19 days 15 days
HCAs:
19 days 15 days Barbara
© 2016 MA Healthcare Ltd

patients entered at the point of diagnosis and visitors Hilary

remained there until the in-patient phase of 9 Norman – 80 Wife – Elsie 58 days 44 days Lloyd
their rehabilitation had been completed, thus
enabling continuous nursing contact, 10 Iris – 77 No regular family 76 days 66 days
potentially over a period of several weeks. visitors

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 Research

could not be excluded, because they worked
with patients in such close proximity to the
nursing staff. All staff who regularly worked
on the ward were therefore provided with
information and asked to consent to
participate, although their involvement
extended merely to being present when data
were being collected.
Data collection and analysis
Ethnography is essentially the study of culture
and usually involves a number of data
collection methods, including participant
observation, interviews and documentary
records (Atkinson et al, 2001), each of which
were used in the study. Field notes detailed
observations of participant interactions and
day-to-day conversations, including those
with the researcher. Semi-structured
interviews with patients, willing relatives and
key nurse/HCA informants were digitally
recorded and transcribed verbatim. A
reflective research journal recorded the
researcher’s engagement with the participants,
the progress of the study and the process of
preliminary data analysis.
Preliminary analysis while the data sets
were being constructed enabled the
exploration of emergent ideas and sensitising
concepts that could be further investigated as
the study progressed. Managing the volume
of data sources was challenging and needed
to be broken down into manageable units for
formal analysis. This was achieved by
organising the data into blocks and files to
facilitate the identification of key themes.
Concept maps were used to creatively explore
the interrelationships between the data
(Gbrich, 2007).
Figure 1: An emergent relationship model of promoting emotional wellbeing and aiding
recovery following stroke
Ensuring methodological rigour
throughout the study was essential. The main
criteria for establishing rigour in ethnographic
research are: prolonged engagement in the
field, persistent observation, triangulation of
sources, methods and theories, member
checks and audit trails (de Laine, 1997). Each
was considered in the design, implementation
and evaluation of the study. To demonstrate
trustworthiness, that is ‘the degree to which
the researcher has remained true to the data
and to the boundaries of the sample’ (Long
and Johnson, 2000:35), the process of
decision-making was exposed by the
researchers through writing reflexively and
creating an audit trail.
Analysis revealed a complex interplay
between the participants’ core values, personal
attributes and approaches to recovery. The
findings represent the patient’s journey, from
initial admission to the final transfer of care.
An emergent theoretical model illustrates the
processes of building, sustaining and
reframing relationships between nurses,
patients and relatives during the patient’s
stroke journey as being central to promoting
patients’ emotional wellbeing and recovery
(Figure 1). Each of these components is
summarised in this overview of the key
findings that resulted from this study.
Developing relationships:
establishing trust and the
culture of care
In order to support patients and their families
through the traumatic, early stage of recovery,
a key priority for the nurses was to build
relationships, establishing a basis for the work
ahead. Creating trust was a vital first step in
which considerable time and effort would be
invested. Nurses and HCAs recognised that
this was essential to engaging patients and
their relatives in the process of rehabilitation.
As HCA Lloyd explained:
‘You’ve got to have some foundation there.
When you’re going to be working with
somebody for a long period, it’s important
to get off on the right foot.’
Reassuring patients and relatives that they
were in good hands was also a way of helping
them feel secure, particularly when the patient
was heavily dependent upon the nurses for
their physical wellbeing. Essential caring
activities provided opportunities for patients
and nurses to talk, contributing to the rapport
that participants identified as essential to
building a good relationship between the
patient and the nurses.
The first few days could be very challenging
for the nurses, as uncertainty about recovery,
and not always being able to give relatives the
answers they wanted, required careful
handling. For many relatives, the admission
of the patient to the stroke unit triggered a
period of heightened vigilance, marked by
anxiety, fear and distress. This did not go
unnoticed by the nurses who took part in the
study, who expressed sympathy for the
relatives as well as the patients. As nurse
Angie suggested:
‘It’s as bad for them as it is for the person
that’s had the stroke.’
For relative Kim, entrusting her mother to
the care of others was:
‘heart wrenching; like leaving your baby.’

Recognising and responding to relatives’

Developing relationships emotional distress enabled the nurses to help
Establishing trust and the culture of care them feel more at ease when visiting the
stroke unit and raised confidence in the
nurses’ commitment to looking after the
Sustaining patient. Once this had been achieved, relatives
Engagement and Relationships would start to talk more openly to the nurses,
The relationship model Managing challenges call them by their first names and begin to
working together
towards recovery to recovery develop a relationship with them. As nurse
Gary said:
© 2016 MA Healthcare Ltd

‘It’s very important to become almost a

Reframing relationships friend to the family … They must feel that
Disengaging and moving on they can trust you and they must feel that
they can talk to you about any issues
they’ve got … ’

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Research
Patients and relatives often commented
upon the nurses’ friendliness and
approachability, but for the nurses themselves,
becoming ‘a friend to family’ was also
enjoyable. Getting to know patients and their
families, gaining their trust and confidence
was mutually rewarding. In nurse Angie’s
view, the nurses were all there for the same
reason: to care for the patient.
In summary, by building a therapeutic
relationship with patients and relatives, a
culture of care could be created, which the
nurses believed would help to enable patients
and relatives to achieve the maximum benefit
from their time spent there. These relationships
were perceived as essential foundations for
recovery and, once established, the nurses
would work to sustain them throughout the
patient’s rehabilitation journey.
Sustaining relationships:
engagement and working
towards recovery together
When questioned, nurses conceptualised
recovery as a person’s ability to deal with
their changed situation and find ways of
adjusting to the effects of the stroke. In their
view, everyone had the potential for recovery,
but this could be difficult to achieve.
Sustaining patient and relative engagement in
rehabilitation required a purposeful and
focused nursing approach, involving empathy,
encouragement and positive feedback. The
nurses tried to appreciate the distress that
patients experienced as a result of the effects
of the stroke, such as the loss of independence
and the reliance on help. Essential personal
and intimate caring activities had to be
undertaken with sensitivity and
understanding; but they also provided an
opportunity to talk in private, which therefore
allowed patients to feel more comfortable
when discussing their concerns or sharing
information with health professionals. As
nurse Emily commented:
‘That’s usually when they tell you the
things that they forgot to tell you before …
or when they tell you they’re upset about
such-and-such a thing.’
Achieving recovery also depended upon the
patients’ and relatives’ own approaches to
rehabilitation, and the nurses believed that
personal attributes, such as a positive attitude
and determination, were an essential part of
the process. Nurse Gary suggested that
recovery could most likely be achieved when
S24
everyone shared these same core values and
when patients could see this:
‘They like a positive attitude; they
definitely like people to be positive about
their condition’
From observing day-to-day intractions, the
author saw an evident focus on achievement;
emphasising the things that patients could do,
rather than what they could not do. Patients
themselves likewise focused on activity and
the need to overcome obstacles. Patient Lily
described the stroke as a hurdle to overcome
and patient Celia described being determined
to get out of bed and move, stating that:
‘Lying and sitting’s no good, it’s just no
good.’
Reminding patients of what they had
achieved so far during their recovery was also
a way for nurses and HCAs to enable them to
see how much they had improved since they
were first admitted. Reinforcing these
improvements in their ability, and emphasising
the likelihood that they would continue to
make such improvements, was thought to be
a motivating strategy. Patient Helen described
how helpful she found this encouragement,
and commented:
‘Oh, they’ll [the nurses] say “You’re
coming on, you’re doing better today” or
“you’re coming on lovely … you’re
standing better ... ” you don’t think that
they’re noticing but they are. They’re
noticing what you’re doing and how you’re
going and it’s really good.’
Keeping positive and providing
encouragement were motivating influences
that were achievable through everyday
conversations, in which the nurses, patients
and relatives engaged. A perception frequently
expressed by the nurses when questioned about
how they offered encouragement, was how
much patients appeared to enjoy hearing about
their lives outside work. The patients welcomed
opportunities to become better acquainted
with the people caring for them, just as the
nurses attempted to discover as much as
possible about the people in their care. As
nurse Isabel commented:
‘You have to give a little bit of yourself
don’t you? … let them know that you’re
human.’
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Again, when questioned about ways of
helping patients to keep positive, the nurses
recommended humour as an effective way of
sustaining a positive outlook. Light-hearted
interactions between nurses, patients and
relatives were observed to be commonplace
and the nurses recognised their therapeutic
value. They believed that jokes could help
patients feel relaxed and this approach was
also valued by relatives, who thought that the
nurses’ laughter and banter with patients kept
their spirits up and made them feel better.
Nurse Emily asserted that patients and
relatives could still enjoy themselves on the
stroke unit, even though they were generally
not having a good time. This was illustrated
by patient Lily, who said:
‘You’ve got to have a laugh, haven’t you?
You’ve got to have joy in your life, even
though you’re in hospital.’
HCA Hilary noted that, in her view, most
relatives did not:
‘want to come on the ward and see that
there’s just no fun … because it’s not
encouraging.’
Nurse Isabel also commented on the
importance of humour to the nurses:
‘ … it lifts you both really. You get on with
your job better, you’re happier at work.’
In summary, aligning patients’, relatives’
and nurses’ positive attitudes enabled a
therapeutic relationship to be sustained.
Stroke rehabilitation could, however, be
both physically and emotionally demanding
and, inevitably, there would be times when
determination and a positive outlook might
waver in the face of new challenges.
Sustaining relationships:
managing challenges
to recovery
Recovery did not always progress smoothly
and less positive elements of the rehabilitation
experience could generate negative emotions
of impatience and frustration. One of the
most common causes of frustration voiced by
participants was the length of time that they
© 2016 MA Healthcare Ltd
were left without anything to do. Patient
Norman described that while he sat doing
nothing, he was in ‘turmoil,’ because of the
long hours he spent thinking. Patient Iris’s
experience was similarly expressed:
October/November 2016

‘They’re very boring days … you think,
“Oh, what am I going to do?” You get
right down in the dumps.’
The nurses expressed their awareness of the
effects of boredom on patients, and recognised
that spending long periods of unoccupied time
could have a negative impact on patients’
emotional wellbeing. However, inactivity and
lack of stimulation appeared to be largely
outside the nurses’ control, because the time
they had available both to socialise with
patients and to provide diversional activities to
avert or remedy boredom was limited.
The nurses believed that the time when
patients most appeared to suffer emotionally
was when they realised the full extent of the
stroke effects. They described that recognising
that they might not be able to walk again,
drive again or do other activities was an
extremely distressing experience for patients
and their emotional distress negatively
impacted upon their continued recovery and
rehabilitation. This was surmised by nurse
Felicity, who said:
‘I think it’s when that kind of reality hits
them, you know; they’ll say like “Oh, this
arm’s useless” or “I’m useless.”’
Sensitivity to a patient’s emotional
wellbeing enabled nurses to identify when
patients were not feeling too good. By
empathising with how they might be feeling
about their situation, it was possible to
appreciate something of what they might be
experiencing. The responses showed that it
was important to understand what might be
worrying or upsetting them, in order to
respond in the most appropriate way. When
asked to relate how the nurses typically
expressed emotional support, nurse Angie
explained that:
“We give it without even realising that
we’re doing it … you don’t even think
about it; you just do it … it’s incorporated
into your working day … every time you
have a conversation, every time you do an
intervention, you look at that patient and
you know that they’re upset about
something, you just do it naturally …. I
don’t think any of us think: “I’ve got to
© 2016 MA Healthcare Ltd
give this patient emotional support;” we
just do it.’
However, there were occasions when it was
important to devote specific time to respond
BJNN/Stroke Association supplement October/November 2016
to emotional distress; to listen without
interruption. Just taking ten or fifteen minutes
to sit with each patient and talk with them
was in nurse Donna’s view:
‘better than all the medicine that you can
give them.’
The nurses were also sensitive to relatives’
emotional wellbeing. Most patients relied
upon their relatives to visit every day and the
nurses expressed their awareness of how
challenging this could be for them. Patient
Lily’s daughter Mel summarised the demands
of daily visiting:
‘It’s tiring and there’s times when you can
think, “Oh God, I can do without this
tonight.” I work seven til three and I’m
actually only spending about four hours a
day in my house, awake. But it’s just
something you do – it’s just life, isn’t it?
You know, I mean, you just get on with it’
Therefore, the nurses would suggest to
relatives that they should take a break,
perhaps just go for a drink or a walk.
Alternatively, they might make them a drink
on the ward and invite them to use the quiet
room.
The nurses’ focus was clearly upon easing
the journey through rehabilitation, even in the
presence of potential challenges to recovery.
These less positive experiences did not appear
to undermine patients’ and relatives’
relationships with the nurses however; indeed,
it was the strength of these relationships that
enabled the nurses to provide support and
offset the inevitable frustrations generated by
being in hospital. It was important that
patients and relatives continued to trust them,
as progress towards discharge from the stroke
unit often brought additional emotional
challenges, which are elucidated below.
Reframing relationships:
disengaging and moving on
Sustaining engagement throughout the reha-
bilitation journey required a collaborative
effort in order to combine personal resources
with practical strategies for recovery. One fac-
tor that appeared to positively contribute to
this was early planning for discharge, although
preparing to return home would naturally
evoke emotions both of excitement and appre-
hension. For some patients and relatives,
additional feelings of impatience, anger and
frustration could also be generated.
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Research
Some patients started to make plans quite
early on in their rehabilitation, even before
the full extent of their potential recovery was
known. As patient Celia exclaimed:
‘Getting back to a proper, normal life … ’
... was the ultimate goal. Sharing personal
goals with the nurses and therapists enabled
the detailed planning necessary to ensure
discharge strategies that could be tailored to
individual needs. These conversations offered
frequent opportunities to discuss possible
options, resolve problems and help to sustain
motivation. In nurse Gary’s view, what all
patients needed was a definite date for
discharge, as this gave them a goal that made
bearable the length of time it often required
to organise aids and equipment, home care
and continuing rehabilitation packages.
However, the delays to discharge that were
observed during the study did appear to be a
particular source of frustration for patients.
For example, because of patient Norman’s
high level of physical dependency, arranging
his home care package caused delay. Having
been given a date for discharge, he described
how he was devastated to hear that it would
now be a further  3 days before the carers
could begin visiting and that both he and his
wife had broken down and cried in response
to the news:
‘I know at the end of the day, they’re all
going to say exactly the same thing: “It’s
not long … just be patient.” I haven’t got
any patience left though … I had my heart
set on it’
The day before patient Fred’s discharge, his
wife Thelma was asked if she was ready for
his homecoming. In response, she described
how she had spent a long time thinking about
what it would be like when Fred came home
and that it had only just struck her how
different things would be. Even though Fred
had been really ill on the day of his stroke, he
had walked out of the house but 3 months
later, he would be returning in a wheelchair.
She said that she felt very anxious about the
arrangements for Fred’s care and how they
would manage. Sid’s wife Mandy and
Norman’s wife Elsie both expressed similar
concerns during the study.
A patient’s departure from the stroke unit
could be an emotionally charged experience
for all concerned. As a tangible expression of
patients’ and relatives’ appreciation, a ‘Thank-
S25
Research

you’ card and gift of chocolates or other
treats were often presented to the nurses for
sharing with the team. On the day before
patient Sid was discharged, his wife Mandy
brought two greetings cards, a box of fruit
and a tin of sweets to the staff base. One card
was from Sid and Mandy and the other from
their daughter Sally, on behalf of herself and
baby Johnnie. After the preliminary thanks
for looking after their dad, Sally’s card read:
‘You guys are the reason he’s still with us
and for that, we will be eternally grateful.’
Nurse Gary remarked on how important it
was for the nurses to receive appreciation
such as this, and to see that their work was
valued. HCA Hilary agreed that patients’ and
relatives’ gratitude affirmed that they were
seen to be doing their best, both for the
patient and their relatives.
For all the patients and relatives who took
part in the study, the discharge of the patient
from the stroke unit marked the end of the
first stage in their journey towards recovery.
Throughout their stay in hospital, the nurses
had attended to their needs, befriended them,
encouraged and supported them. For the
nurses and HCAs, their reward was seeing
patients leave the stroke unit as well prepared
as possible for the life that lay ahead of them.
Discussion: refining
the relationship model
of promoting
emotional wellbeing
It could be argued that the study findings do
not actually reveal anything more than what is
known already, or at least tacitly understood.
Nevertheless, what this study demonstrates is
that the relationships built and sustained
between nurses, patients and relatives during
their time on a stroke rehabilitation unit form
a multi-layered approach, central to promoting
emotional wellbeing and enabling recovery.
This is a far more complex process than is
implied in the term ‘emotional support’.
Although there are specific interactions or
interventions that can be more clearly identified
as emotionally supportive, often in the presence
of emotional distress, these represent only one
element of a much more pervasive, relationship-
focused approach, central to every interaction.
daughters, exemplified this when she said that
she did not expect the nurses to offer her
emotional support, as they demonstrated this
by looking after her mother. It was their ‘being
there’ that was important. This suggests that
patients and families do not necessarily want
or need nurses to discuss their emotional
wellbeing but just to demonstrate, through
their approach and actions, that they care.
Nurses’ statements also demonstrated that
providing emotional support was something
they achieved through routine interventions,
by being ‘tuned-in’ to the patients and relatives
with whom they had established relationships.
The nurses espoused and expressed a set of
core values, based on their knowledge of the
emotional experience of stroke, acquired
through multiple episodes of working with
patients and relatives. These values were used
with their personal and professional
attributes, to sustain trusting relationships
that enabled patients to use their own personal
qualities to recover, supported by and
engaging with the nurses’ approaches and
interventions. This created and strengthened
a positive culture of caring that promoted
emotional wellbeing and aided recovery.
Although a comprehensive description of
the components of the nurse’s role in stroke
rehabilitation was not intended, similarities
can be identified between this model and
elements of others that explore the role of the
stroke rehabilitation nurse more generally
(Kirkevold, 1997; 2010; Barreca and Wilkins,
2008; Long et al, 2001; Burton, 2000;
O’Connor, 2000a; 2000b), all of which sought
to explain the processes by which nurses
interact with patients and their relatives to
enhance recovery following stroke. Studies
within the wider context of rehabilitation
nursing have also exposed the centrality of
the relationships and the idea of working in
partnership to promoting emotional wellbeing
(Tyrell et al, 2012; Pryor, 2009; Pryor et al,
Figure 2: Refined model for promoting emotional wellbeing and aiding recovery after stroke
Patients’/nurses’/relatives’
core beliefs and values
Patients’ attributes Nurses’ attributes
2009; Pryor and Smith, 2002). Pryor (2000)
highlighted the importance of these
relationships to the therapeutic environment
in supporting a positive culture of care.
The main point of divergence is that, rather
than confining the promotion of emotional
wellbeing to a single element of the nurse’s
role, the findings indicate that all nursing
interactions with patients and relatives could
potentially promote emotional wellbeing.
Furthermore, these relationships are
constructed by a skilful and deliberate
process, combining the core beliefs of nurses,
patients and relatives, to enable personal and
professional resources to strengthen coping
strategies and sustain engagement (Figure 2).
This study is essentially proactive, aiming
to help generate positive emotion, since
nurses on the stroke unit believed that
thinking positively about stroke recovery was
essential. Indeed, keeping positive was
identified by most participants as a major
contributor to recovery. A fuller exploration
of the role of positive emotion has been
articulated but goes beyond the scope of this
paper (Bennett, 2012).
Limitations of the study
Of course, there are limitations to the study
that need to be acknowledged. As the study
focused on a small number of cases in a
unique context, there are obvious limitations
to any claims for extending the findings
beyond these boundaries. In addition, by
excluding patients with severe communication
and cognitive impairments, there was a risk
that significant data from patients most
severely affected by a stroke would not be
represented in the study. The study also
focused exclusively on nurses and their
interactions with patients and relatives, to the
exclusion of the therapy staff with whom they
also interacted. The culture of care on the
stroke rehabilitation unit cannot be fully
Relatives’ attributes
© 2016 MA Healthcare Ltd

Emotional support thus conveys a genuine

sense of caring and resonates with suggestions
that concern does not necessarily involve Approach to wellbeing
talking about emotional issues directly (Ellis- and recovery
Hill, 2008). Mel, one of patient Lily’s

S26 BJNN/Stroke Association supplement October/November 2016

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Use for licensed purposes only. No other uses without permission. All rights reserved.

represented without consideration of the
whole team and the contribution by therapy
staff and others to patients’ and relatives’
emotional wellbeing had not been explored.
Consequently, the nurses’ contribution may
have been overemphasised. Nevertheless,
based on the nurses’ expressed perceptions of
the differences between the therapists’
priorities for care and their own, the findings
have illuminated potential tensions in their
different approaches. The impact of these on
the emotional wellbeing of patients and
relatives could benefit from further
exploration, to which Burton et al (2009) and
Pryor (2008) have already contributed.
Conclusion
In contrast to focusing on the negative
emotional experience of stroke, this research
has illuminated how, by recognising and
supporting patients’ personal strengths and
coping strategies, nurses can embed into their
interventions purposeful strategies that focus
on positive emotion and enhance recovery. It
appears therefore that these may be factors
that enable stroke survivors to transcend this
potentially damaging mood state and
maintain their emotional wellbeing. Within a
context of rapidly changing service
organisation and delivery, which emphasises
measurable outcomes and cost containment,
there is a significant risk that nurses’
contribution to stroke rehabilitation will
become increasingly focused on technical care
and remain otherwise therapeutically non-
specific. Therefore, the importance of the
relationships that nurses build and sustain
with patients and their relatives to promote
emotional wellbeing and recovery, needs to be
more fully acknowledged; both within the
profession itself and within the wider
multiprofessional rehabilitation team.  BJNN
Declaration of interests:
The author has no conflict of interest to declare
Acknowledgements:
The author would like to thank all those who partici-
pated in the study.
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