VOL: 97, ISSUE: 14, PAGE NO: 38
Jonathan Webster, MSc, BA, RN, is practitioner/clinical team leader, community stroke rehabilitation service, Eastbourne and County Healthcare NHS TrustSam Davids was 32 when he had a stroke. He returned home from work one evening feeling generally off-colour. 'I couldn't put my finger on what was wrong,' said Mr Davids, who had been diagnosed with diabetes at the age of 28. 'I went upstairs and checked my blood sugars. They were a bit high, but nothing unusual for me. That's all I can remember. The next thing I knew I was in hospital.'
Sam Davids was 32 when he had a stroke. He returned home from work one evening feeling generally off-colour. 'I couldn't put my finger on what was wrong,' said Mr Davids, who had been diagnosed with diabetes at the age of 28. 'I went upstairs and checked my blood sugars. They were a bit high, but nothing unusual for me. That's all I can remember. The next thing I knew I was in hospital.'
Mr Davids was recently married and has two children aged under five. Before his stroke he had been in the army and served in the Gulf War. After leaving the army he worked as a training manager for an insurance company. 'The work was hard - I had to work long hours - but I enjoyed it.'
Mr Davids described his home life as 'hectic'. His free time was taken up with his family, playing rugby or occasionally playing in the darts team at the local pub.
He was referred to the community stroke rehabilitation service six months after he had a stroke. I arranged to see Mr Davids at home to discuss his rehabilitation and complete a screening assessment. When I met him and his wife, they described how they had been living since his stroke.
Physically Mr Davids was independent around the home, but he easily became fatigued and exhausted. He spent most of the day upstairs watching television and felt that he had lost interest in life. 'I had always been so busy. Life was really full and suddenly it was all taken away,' he said.
His wife recounted a story about when they were out shopping after he first came out of hospital. It was a Saturday morning, the shops were busy and Mr Davids was unsteady on his feet. While they were out he stumbled and nearly fell. His wife tried to steady him, dropping her shopping bag in the process. She heard one passer-by say to another: 'Look at that poor young woman with the two children. It's only 10 o'clock and her husband is already drunk.'
During my first and subsequent visits to the household much time was spent listening and discussing what had happened to Mr Davids and the impact it had on his family.
Establishing a therapeutic relationship
Mr Davids was seen by the occupational therapist in the team. Initially, joint visits were arranged with the dietitian and physiotherapist, who advised on diet and specific exercises to promote normal movement. These were incorporated into Mr Davids' programme of rehabilitation, the key focus of which was to regain 'normal' living skills.
Mr Davids felt shut away from the outside world, not because he could not physically go outside but because he lacked the confidence and motivation to venture out on his own. As a young man this was foreign to him because he had always enjoyed mixing and socialising.
It took time for him to identify exactly what he wanted to achieve with the team's support and to start trusting us. Building a therapeutic relationship with Mr Davids and his wife was vital. An integral part of this was psychological care, such as listening, explaining, reassuring, encouraging and supporting (Binnie and Titchen, 1999).
As a team we firmly believe that our practice should be client-centred. Key elements in this are flexibility, individualisation and personalisation - in which practitioners and clients become therapeutically close.
This contrasts with the institutional model - which is rigid and where innovations in practice are blocked, people are depersonalised and a social distance is maintained between practitioners and the client.
Planning a rehabilitation programme
In planning Mr Davids' rehabilitation programme, the key areas for the team were:
- How best to build a therapeutic relationship with Mr Davids and his family, based on a model of client-centred empowerment;
- How best to enable Mr Davids to become as independent as possible;
- How best to develop his skills for life after stroke;
- How best Mr Davids could remove the obstacles preventing him from reintegrating into the community (Zimmerman and Warschausky, 1998);
- The need for effective coordination and interdisciplinary supervision;
- The ability to focus and support Mr Davids and his family during times of despondency.
Rodwell (1996) defines the key elements of empowerment as a partnership that values the self and others and involves mutual decision-making about the use of resources, opportunities and authority. Empowerment also confers the freedom to make choices and accept responsibility.
Initially we suggested that additional support could be offered by a voluntary organisation, but Mr Davids and his wife were reluctant to have 'someone new' to relate to. He felt guilty because he saw himself as reliant on others and felt that he was the cause of increased pressure on his family.
Mr Davids had come into contact with other health care practitioners in the past, but had always felt let down or thought he had not been listened to. He said nobody had ever asked him what he wanted.
The key focus of the team's relationship with Mr Davids was to support him and his wife and help them to work towards his goals for rehabilitation.
His long-term goal was to return to work. His short-term goals were to be able to walk his son to school, use the gym at the local leisure centre and feel confident in socialising again.
Client-centred goal setting is essential to effective rehabilitation. According to Davis and O'Connor (1999): 'Client-centred goals enable the team to identify where the client and their family are in their thinking regarding their rehabilitation programme, and whether they are focussing on realistic goals or not.'
Mr Davids' most pressing short-term goal was to walk his son to school. The activities that he and the occupational therapist identified aimed to help him achieve this and included identifying review dates, which served as milestones to measure and evaluate his progress.
This one goal focussed on Mr David's physical ability to walk to the school and his psychological ability to carry it through. It was agreed that he would walk short distances outside, initially supported and then independently. It was important that the activities had a purpose, such as walking to the local shop to purchase a newspaper, and that they were not seen in isolation from normal day-to-day living.
It was also important to be sensitive, not only to Mr Davids' but also to his family's wishes as he functioned within a family network. As time went on it became evident how involved the family was, particularly during the review of his goals.
Post-stroke rehabilitation wasn't about 'doing' rehabilitation to Mr Davids but about providing him with support, facilitation and encouragement so that he could take control of his life.
Six months after being accepted by the community stroke rehabilitation service he has achieved all his short-term goals. He is not back in full-time employment, but is doing a training programme that will provide him with new skills and, hopefully, a new career.
In spite of the stroke, Mr Davids feels extremely optimistic about life: 'If someone had said nine months ago that I'd be doing all the things I'm doing now, I would never have believed them,' he said.