ABSTRACT: There is limited research related to perceived educational needs among the newly diagnosed first-time stroke population. This descriptive correlational study was conducted to determine the perceived importance to learn about specific stroke-related topics and the degree of satisfaction with stroke education. Seventy-one newly diagnosed stroke patients from two metropolitan hospitals received a self-report Likert-type questionnaire consisting of eight domains related to different aspects of stroke education. The questionnaire was distributed 24-72 hours after admission to the hospital, upon discharge, and 2 weeks postdischarge. The data were analyzed using descriptive statistics, t tests, and repeated measures analysis of variance. Medical knowledge and medication treatment were rated the most important to learn. Treatment of stroke with herbal or alternative medicine and dietary habits were the least important of the eight domains. Overall, patients were not satisfied with stroke education.

Very often, stroke patients have their own questions about their disease that they perceive as valuable and want answered. Answering such questions and educating newly diagnosed stroke patients about stroke-related information that is presumed to be important to them to learn is vital in the prevention of further illness and complications after a stroke as well as in the recovery phase. To date, however, there are no data suggesting a well-defined method for identifying learning needs among newly diagnosed stroke patients. Studying this population may assist in identifying the gap that currently exists so that optimal measures to meet the learning needs of newly diagnosed stroke patients may be practiced.

The purpose of this study was (a) to determine if there is a change in the perceptions of what individuals newly diagnosed with stroke perceive as important to learn about stroke during different times of their stroke recovery and (b) to determine the perceived level of satisfaction among newly diagnosed stroke subjects with the stroke education provided.

Method

The study included a convenience sample of 71 newly diagnosed, first-time stroke subjects from two metropolitan hospitals in the Northeast. The hospitals are designated stroke centers approved by the American Heart Association. The power analysis was estimated at 80%. Stroke patients who presented to the emergency room of the two metropolitan hospitals were evaluated by a physician specializing in neurology. The specializing physician, known as a "neurologist," performed a complete neurological examination. Evidence of a neurological examination and evaluation for stroke was documented and found in each potential subject's chart. A pilot study preceded this study to check the feasibility and improve the design of the actual study.

Eligibility

After an introduction and explanation of the study, potential subjects were asked whether or not they wanted to participate. No potential subject refused to participate in the study. Subjects were asked to read and sign the consent. Subjects who did not have the ability to write were allowed to have a legally authorized representative sign the consent form. Five subjects were eliminated from the study secondary to early discharge and the incompletion of the initial questionnaire.

Before the distribution of the questionnaire at the time of admission and again at the time of discharge, a screening tool consisting of six questions was used to determine the subject's ability to make a reasoned decision. In addition, the screening tool assessed if each of the subjects was able to express a free choice and clearly communicated that choice. A score of less than 4 for any of the questions eliminated the subject from the study.

The initial questionnaire was completed by the subjects within 24-72 hours of their admission to the hospital, given that they were medically and neurologically stable. The time frame, 24-72 hours for the initial questionnaire, was chosen, as this is the general time frame in which peak swelling of the brain generally occurs, causing the risk of deterioration to be at its highest. Stabilization is primarily determined by the patient's mental status and level of consciousness. In some cases, stability occurred after 72 hours, and the initial questionnaire was distributed at the time of stability, preceded by the level of understanding tool to ensure eligibility.

Instrument

TABLE 1. What I Want to Learn About Stroke

Results

Is there a change in the perceptions of what individuals newly diagnosed with a stroke think is important for them to learn about stroke during hospitalization and postdischarge?

Repeated measures of ANOVA were conducted for the 32 subjects who completed the questionnaire on admission (Time 1), upon discharge from the hospital (Time 2), and after discharge from the hospital (Time 3). t Tests were conducted for the 39 subjects who did not complete the questionnaire after discharge.

How satisfied are patients with their understanding of the information they were taught about stroke during hospitalization and postdischarge?

TABLE 7. Summary of Level of Satisfaction

Discussion

Level of Perceived Importance

All of the subjects identified a level of importance of learning about control of risk factors for stroke. However, subjects who completed the study in its entirety also identified "neutral" as a level of importance for learning about control of risk factors for stroke. The subjects who chose "neutral" may not have had identifiable risk factors for their stroke or they were aware and knowledgeable about their risk factors and therefore did not perceive it as important to learn about this domain. The individual questions "how important is it for you to learn about high cholesterol and stroke?" and "how important is it for you to learn about exercise and stroke?" were particularly perceived as important for patients to learn.

Treatment of Stroke With Medications

The findings for this study and domain suggest that subjects are consistent in their perceptions that it is important to very important for them to learn about the treatment of stroke with medications over time.

Treatment of Stroke With Surgery

The means for the perceived level of "importance" to learn about the treatment of stroke with surgery ranged from neutral and important to important over time among subjects who either completed the study in entirety or not. An explanation for this difference across time may be that some patients may not have felt it was as important to learn about treatment of stroke with surgery because they were being discharged to home; however, once they were home, perhaps anxiety levels increased or their symptoms did not improve or perhaps symptoms worsened and the topic of surgery and stroke became more important. Or some patients may have found the topic of surgery and stroke important after discharge because they were out of the acute phase and therefore had more time to absorb the effects of the stroke and the implications of preventing strokes in the future.

Treatment of Stroke With Herbal or Alternative Medicine

Subjects who completed the study in entirety may represent a population of patients who did not require to be discharged to a more intensive rehabilitation center. However, they may have required outpatient or home services for physical therapy, occupational therapy, and/or speech therapy, which may explain why the perceived level of importance of learning about rehabilitation ranged between neutral and important. Lastly, subjects who did not complete the study in its entirety may represent patients who were discharged to a rehabilitation center and, therefore, perceived this topic as important to learn. In addition, this may also explain why these subjects did not complete the study in its entirety; their strokes may have been too severe so that it was too difficult to complete and there was no one to assist with the questionnaire, or once discharged to the rehabilitation center, subjects may have neglected to complete the questionnaire at Time 3 for various reasons.

Dietary Habits After Stroke

All subjects who participated in this study showed a perceived level of importance for learning about dietary habits over time that ranged from between neutral and important. Overall, this domain was rated as one of the least important topics for patients to learn despite the means. One might assume that "neutral" was chosen as the level of importance because of the lack of awareness patients have related to their risk factors for stroke. Many patients are not aware of having high blood pressure, high cholesterol, or diabetes; nor are they aware of how their diet affects such risk factors. The choice of "neutral" may also reflect that patients think they are already knowledgeable about dietary habits related to stroke and do not feel they require additional information about this topic. Subjects who responded with "important" may have seen the need to improve their diet, given the role of diet as a risk factor for stroke.

Other Topics

The increased perceived level of importance among subjects who did not complete the questionnaire in its entirety compared with subjects who did complete the questionnaire in its entirety may be attributed to the severity of stroke. One might assume that subjects with more severe strokes and symptoms perceived this domain to be more important to learn about because many of the topics within this domain pertain to the physical abilities of the subjects after a stroke. An assumption might also be made that those subjects with more severe strokes did not complete the questionnaire in its entirety because of the physical and psychological effects of the stroke. An explanation for the significant increase over time for perceived level of importance of learning about "what other people will think" may be attributed to this being a sensitive topic for patients who may have thought that their stroke symptoms would disappear completely before discharge from the hospital. The findings may represent a population of patients who become increasingly concerned about others' perception of them with their stroke deficits.

Level of Perceived Satisfaction

The level of satisfaction never reached a level of 4 (satisfied) on the Likert scale for any of the eight domains. Despite the findings that two domains were perceived as not important for patients to learn (treatment of stroke with herbal or alternative medication and dietary habits after stroke), patient perceptions of learning about these topics were rated below a level of satisfaction, suggesting that they were either not taught about the topic area or perceived the content of teaching as unsatisfactory.

Implications for Future Research

The findings for this study suggest that healthcare professionals need to be aware of the significance in meeting the educational needs of newly diagnosed stroke patients perceived as important for them to learn. Although it is important for healthcare professionals to not withhold information related to stroke and to educate patients about all aspects of stroke, knowing what is perceived to be important for them to learn may mean spending more time on those topics. It is important for healthcare professionals to educate patients about the individual questions that indicated a level of significance and to use additional methods to disseminate information and educate this population by utilizing videos, handbooks, and selected Web sites.

This study did not address the preferred method of stroke education. Future studies are required to address the preferred method by which stroke education is taught as perceived by newly diagnosed stroke patients as well as time spent on patient education. This study was limited to newly diagnosed stroke patients and their perception of stroke education during hospitalization and 2 weeks postdischarge. Future studies are required to address the need for follow-up stroke education beyond 2 weeks postdischarge and the effectiveness of the education as well to evaluate the efficacy of treatment adherence.

Implications for this study include (a) replicating this study using an experimental approach, (b) individual patient assessment by nurses to determine patient perceptions related to their stroke, (c) developing a hospital protocol requiring nurses to utilize a screening assessment tool similar to the content on the questionnaire used for this study to identify what patients want to learn about stroke, (d) developing a uniform method by which stroke education is taught in acute care settings, (e) designing and developing a stroke educator role within the acute care setting, (f) designing and developing a stroke education model, (g) designing and developing a continued stroke education plan for the outpatient setting, and (h) future studies that include the families and primary caregivers of stroke patients.

Limitations of This Study

The primary researcher was the only person involved in obtaining participants, thus restricting availability to recruit all potential subjects. Some subjects were unable to complete the second questionnaire due to early discharge. Subjects were limited to two designated stroke centers. The study was self-reporting. The format of the questionnaire caused some subjects to miss questions. The number of subjects for the study could be larger. The study utilized a descriptive design.

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