1. Ramazanu, Sheena
  2. Chiang, Vico Chung Lim

Article Content

A recent qualitative study reported that persons with stroke and their partner caregivers denoted stroke recovery as facing the "storm."1 Storm uncovers the analogy that poststroke recovery is the aftermath in the lives of persons with stroke and their partners as a care-recipient-caregiver dyad, underpinning the "reconceptualized uncertainty in illness theory" (RUIT).2 This reflection depicts on ways in which stroke dyads perceive uncertainty about their new life during the stroke recovery.


A stroke strikes like a sudden storm in one's life; therefore, it is crucial for the neuroscience nurse to be the first-line defense in guiding the patient through the process of education, coping, and healing. The storm strikes suddenly and brutally, just as if the stroke person is hit sharply to the ground by god. The storm is acute, but the impact extends to the trajectory of recovery. There are emotional, psychological, and life-altering effects on persons with stroke and their families. After a stroke, one is understandably in shock and often worried about poststroke disabilities and life thereafter. On the other hand, partner caregivers are also uncertain on why a stroke has happened to their loved one, and they may have to resume a job to provide financial support to their family.1 A longitudinal exploratory observational study found that caregivers of persons with stroke experienced high rates of physical and mental morbidities during the first 6 weeks after a stroke.3 Uncertainties revolve around new caregiving role of the partners after a stroke, which may contribute to negative health outcomes for them including higher stress, depressive symptoms, and poorer coping ability.3 As persons with stroke continue their rehabilitation, knowing that some things may never be the same as before, changes in physical and cognitive functioning are common, for example, poststroke disabilities such as paretic arm. It is thereby of paramount importance, as reflected upon, to understand the uncertainties, and intervene early for the needs of persons with stroke in their care-recipient-caregiver dyad. A recent study illuminated the dimensions of uncertainty after a stroke from the perspectives of stroke survivor and family caregiver dyads.4 Uncertainties in the persons with stroke and their care-recipient-caregiver dyads heightened because of the lack of poststroke information and predictability of events after a stroke.4 This also highlights the essential need for psychological and emotional support to the dyads.


The theoretical perspective of RUIT illustrates that, after a stroke diagnosis, uncertainty becomes a "natural" rhythm of life from illness to recovery for persons with stroke and their caregivers.2 The 4 main dimensions of uncertainty of RUIT comprises (1) vagueness about chronic health or illness; (2) complexity of health condition; (3) lack of available information on illness, prognosis, and recovery; and (4) unpredictability of chronic health condition and illness prognosis.2 Similar to the dimensions of uncertainty in RUIT, an interpretive descriptive study illuminated challenges in the provision of stroke care from the perspectives of Singaporean rehabilitation nurses.5 First, language barriers between rehabilitation nurses and stroke dyads heightened ambiguity related to stroke condition. Second, because of the complexity and unpredictability of a stroke prognosis, rehabilitation nurses in the study were also unsure on how to render a strategic care plan to meet the needs of persons with stroke and their partner caregivers. Third, as a result of staff shortages in the clinical setting, it was difficult for nurses to render timely information on illness, prognosis, and recovery, especially when nurses were juggling with routine care. Henceforth, it is pivotal for nurses to render information on stroke management and timely interventions to support persons with stroke and their caregivers to alley uncertainties from the stroke illness.


To overcome the uncertainty in stroke illness, the 3H (Head, Heart, and Hands) intervention that comprises informational support on stroke condition, shared decision making, and skills training was systematically developed and implemented for persons with stroke and their caregiver partners.1 This poststroke intervention was conducted at a stroke rehabilitation hospital, for 6 sessions and over a time frame of 3 weeks in the ward setting. After the persons with stroke and their partner caregivers had taken part in the intervention that targeted the psychological responses, knowledge, and caring skills, the dyads coped and adapted better with the stroke illness. In addition to gaining psychological, informational, and practical needs on stroke management, conversations between participants who took part in the intervention program enhanced their sense of mutual support.1 One unique element of 3H intervention is the incorporation of shared decision making as an interventional component, which is an evolving approach to improve care provision of stroke dyads.6 Guidelines of shared decision making include (1) engaging patient and family caregiver in the decision-making process, (2) describing the decision and options available for support, (3) further assessing patient-caregiver dyads' values and goals, and (4) making the decision together.6 Shared decision making promotes dyadic conversations and values clarification between stroke patient-caregiver dyad and stroke-related information verification, thereby reducing uncertainty in stroke illness and recovery. It is recommended that healthcare professionals adopt a dyadic approach to care provision after a stroke, giving due importance to holistically support both persons with stroke and their caregivers as dyads to cope with their stroke-related uncertainties and to promote well-being.




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6. Armstrong MJ. Shared decision-making in stroke: an evolving approach to improved patient care. Stroke Vasc Neurol. 2017;2(2):84-87. doi: [Context Link]