This section addresses the important components of multidisciplinary team care in terms of the roles of the team members as defined by stroke unit trials, observational studies or expert opinion.

6.1 Nursing care

Whilst nursing stroke patients in specialised units is becoming more commonplace there are many other contexts where stroke care is still carried out. Many of the factors identified in this section could be equally applied wherever stroke patients are cared for. Nursing people with stroke requires nurses with knowledge, skills and interest to deliver effective therapeutic care and rehabilitation, and requires education and training in stroke care. Stroke nurses focus on working in partnership with patients and their families, involving them in decision making and taking responsibility for their own recovery. Nurses take into account the holistic needs of the patient and family, involving the physical, psychological and social aspects of care. As each patient and family is unique, nurses consider the individual’s needs. Stroke nursing is a continuous 24 hour process throughout the patient’s journey of care, wherever the setting.

6.1.1 THE KEY ELEMENTS OF GOOD STROKE UNIT NURSING CARE

The key elements of good stroke unit nursing care are:¹⁸

• removing the competition for nursing time
• allowing specialisation, e.g. swallow screening
• empowering nurses to become facilitators of rehabilitation, therapeutic interventions
  and enabling independence
• knowledge, interest and enthusiasm
• multidisciplinary team participation
• enabling nurses to co-ordinate patient care
• nursing assessment of the care needs of the patient, including a formal scoring of pressure sore risk and swallow screening
• nursing management of the patient’s care needs, maintaining the patient in a correct posture and position and regular observation of key characteristics, such as: airway, swallowing, nutritional status, continence and skin integrity
• active contact from nursing staff.

Stroke patients should be treated 24 hours a day by nurses specialising in stroke and based in a stroke unit.

6.1.2 LEVELS OF NURSING STAFF REQUIRED TO PROVIDE GOOD STROKE UNIT CARE

The levels of nursing staff relate directly to the provision of good stroke unit care. Nursing staffing levels and skill mix should be appropriate to the size of the stroke unit and dependency of the patients.¹⁸

Individual studies have defined and calculated staffing levels in different ways, with different degrees of cross-cover from other departments. The level of nursing staff also depends on the size of the stroke unit. An estimate for a hypothetical ten-bed stroke unit requires the input of 10 WTE nurses with a skill mix ratio of 2:1 trained/assistant staff.¹⁸

A minimum nursing level of 10 whole time equivalents per 10 beds is recommended.

6.2 Physician care

The physician members of the stroke multidisciplinary team will comprise consultant(s) and other career grade physicians and trainees at various stages of training. Roles will vary depending on experience and responsibility.

The physician should have a background and training in general medicine, clinical pharmacology, geriatric medicine, neurology, or rehabilitation medicine, and would be able to call on skills of colleagues when referral is appropriate.

The general role of the physician is to carry out appropriate responsibilities (as defined by the British Association of Stroke Physicians¹⁶⁵) and in many cases to lead, co-ordinate and develop the skills and decisions of the multidisciplinary team. Physicians will understand the concept of multidisciplinary working in stroke rehabilitation and the criteria for successful multidisciplinary working. There will be an appreciation of the roles of other professionals within stroke rehabilitation and an in-depth understanding of the role of the stroke physician within multidisciplinary stroke rehabilitation.

Particular skills and responsibilities will be appropriate to the nature and emphasis of the stroke unit (acute, rehabilitation).

Consultants with an interest in stroke, after adequate training and with appropriate continuing professional development, should be available to co-ordinate every stroke service or unit.

6.3 General practitioner care

The GP also has an integral role in the multidisciplinary management of patients with stroke.¹⁰ GPs working in a community setting have particular strengths in problem solving, treating co-morbidities in the patient and helping carers who may have illnesses of their own to cope with in addition to caring. GPs have a knowledge of services available both in the hospital and in the community, giving them a role in co-ordinating the various services including hospital-based services, social services and AHPs. The GP is responsible for key decisions at certain points in the patient journey, such as whether and where to admit the patient. The GP is responsible for and accountable for prescribing to patients in the community. The GP’s role is critical at the time of first diagnosis when decisions regarding further investigation and possible admission have to be made with the patient and the carers.

If the patient is to be admitted, the GP should communicate with the hospital staff the basis of the diagnosis, the premorbid condition of the patient, any relevant social factors and past medical history.

The GP also plays a pivotal role in the discharge of patients back to the community. These patients often have a complex treatment and rehabilitation strategy with multiple co-morbidities.

For successful discharge, the GPs and community staff should receive adequate information from the hospital prior to discharge.

The GP plays a key part in ongoing medical care of the patient, and in reinforcing education, support, lifestyle alterations and secondary prevention and is well placed to identify deterioration in function which may occur post-discharge and arrange for referral for further therapy.

6.4 Physiotherapy

Physiotherapists are experts in the assessment and treatment of movement disorders. Physiotherapy involves the skilled use of physical interventions in order to restore functional movement or reduce impairment, disability and handicap after injury or disease. These interventions commonly involve exercise, movement and the use of thermal or electrical treatments. Physiotherapists are generally involved in the care and rehabilitation of patients from the onset of the stroke, often daily and for many months and, in some cases, years.¹⁰ Physiotherapists work with stroke patients in a variety of settings, including stroke units, acute admission wards, general medical wards, rehabilitation units, day hospitals, community day centres, outpatient clinics and their own homes (see Box 2).

Box 2: Physiotherapy role

As stroke frequently results in physical deficits which impair the ability to move, a central aim of physiotherapy will be to work with other team members to promote the recovery of movement and mobility. Physiotherapists will plan and implement treatments for individual patients, based on the assessment of their unique problems. Key elements of these patient-specific treatment strategies may involve restoring balance, re-educating mobility, and promoting functional movement. Physiotherapists should set and meet relevant short and long term goals, which have been discussed, where appropriate, with patients, carers and other team members.

Physiotherapists work closely and intimately with stroke patients and should have the ability to empathise with patients in the most challenging of circumstances. Physiotherapists should aim to achieve an evidence-based approach to stroke management through regular training and updating; and should be involved in appropriate investigation, audit and research activity.

All patients who have difficulties with movement following stroke should have access to a physiotherapist specialising in stroke. Physiotherapy treatment should be based on an assessment of each patient’s unique problems.

6.5 Speech and language therapy

SLTs are an integral part of the stroke care team. Their particular field of expertise lies in the assessment and management of communication disorders and dysphagia following stroke (dysphagia is the subject of a separate SIGN guideline⁷).

Fuller details of SLT practice are available for aphasia and dysarthria in two publications of the Royal College of Speech and Language Therapists (see box 3 for a summary).^{166, 167}

Box 3: SLT role

Speech and language therapists should be involved in stroke management at all stages in the recovery process and should liaise closely with all related healthcare professionals, with outside agencies, both statutory and voluntary, with the individual who has suffered a stroke and with his/her carers.

6.6 Occupational therapy

Occupational therapists treat people who have impairments, restricted activity levels and limited ability to participate as a result of injury or illness, in order to achieve the highest level of independence possible. The state registered occupational therapist works in partnership with the patient, carer and other healthcare and voluntary personnel at all stages from acute through to outpatient and community care.

The occupational therapist will identify the individual aspects, which make up a person’s ability to carry out selected activities, (i.e. physical, cognitive, perceptual, psychological, social, environmental and spiritual) and will include jointly agreed goals and purposeful activity in their interventions (see Box 4). They will use purposeful activity to promote the restoration of function and to maximise participation in meaningful activities i.e. occupations of self-care, domestic, social and work roles.¹⁰

Box 4: The key elements of occupational therapy with stroke patients

All patients who have problems with activities of daily living following stroke should have access to an occupational therapist with specific knowledge and expertise in neurological care. Occupational therapy treatment should be based on an assessment of each patient’s unique problems.

6.7 Social work

The social worker is a member of the multidisciplinary team delivering care to stroke patients.¹⁰ The social worker, who is employed by the local authority, should have an understanding of the illness and its effect on the patient, the carers and family. As well as being aware of the physical problems of a stroke, the social worker should also be aware of the psychological and emotional effects of stroke illness so that he/she can best understand the patient’s needs.

The social worker works closely with individual members of the multidisciplinary team and is especially aware of therapist’s reports in thinking about the needs of the patient. Social workers become involved with patients at different stages of the rehabilitation process, depending on what problems the patient and his family may have. Some patients will need advice and information from the social worker early in their journey of care because of financial, relationship or housing problems.

The social worker requires to have a wide knowledge of resources in the community so that he/she is able to advise the team and the patient about what is available for the patient on discharge. It is the social worker’s role to advise the team about the timescale for implementing care packages and for discussing alternative forms of care if that is required.

As the time for discharge approaches, the social worker will normally become more involved with patients, especially those who have complex needs. The social worker will complete community care assessments for patients in consultation with the multidisciplinary team, patient and the family. It is important for the social worker to be aware of the patient’s own goals and expectations and to be able to assess any risk that the patient may be in. The social worker will then organise the appropriate care, either in the community or in residential homes as may be required. The social worker will then go on to work with the patient and family for a period of time after discharge to ensure that rehabilitation plans are meeting their needs in whatever setting and to support patients and families in organising and re-assessing any difficult situations that may arise.

A social worker should be a member of the multidisciplinary team and should have a key role in the discharge planning process.

6.8 Clinical psychology

Emotional and personality changes and some degree of cognitive impairment are present in many patients after a major stroke. These problems can be a significant concern for relatives and a source of stress related illness.

The role of the clinical psychologist working within this field is to define neuropsychological impairment, to alleviate psychological distress and promote well being and quality of life by developing, applying and promoting the proper application of psychological knowledge, skills and expertise (see Box 5).¹⁶⁸ This is carried out through direct clinical work or indirect consultancy, as judged appropriate by the clinical psychologist. Indirect work may include supervision, teaching, research and audit. Clinical psychologists who are members of the division of Clinical Neuropsychology of the British Psychological Society have additional training and experience in neuropsychology, and are able to provide higher level specialist skills within this field.

Box 5: The key elements of a clinical psychcologists’ work with stroke patients

Other professionals are also qualified to work with patients with mood disorders or emotional changes after a stroke. For example psychiatrists have a role in working with complex mood and behavioural disorders while counselling may be generic or may be offered by a more highly trained professional using specific theoretical models.

Each multidisciplinary stroke team should have access to a clinical psychologist and psychiatrist.