Feasibility of the Post-Stroke Depression-toolkit
Condition: Depression; Stroke
MeSH terms: Stroke; Depression; Depressive Disorder
Study type: Observational [Patient Registry]

Summary: 
      Rationale: Depression is a frequent complication after a stroke. In stroke guidelines several
      recommendations focus on early screening, and treatment off depression after stroke.
      Introducing clinical practice guidelines into routine daily practice however, is a difficult
      process. In order to make the recommendations applicable to clinical practice a toolkit was
      developed (the Post Stroke Depression-toolkit), which provides assessment tools for the early
      detection of depression after stroke, and a set of interventions in case of a positive
      screening for (risk on) depressive symptoms.

      Objective: to investigate the feasibility of the Post Stroke Depression-toolkit in daily
      practice.

      Study design: An explanatory mixed-methods, before-and-after study design. Study population:
      Nurses working on the neurological wards of one university hospital and two general hospitals
      in the Netherlands were included in the study. Additionally, data were obtained from patient
      charts.
    

Detailed description: 
      Worldwide, approximately 50 million people who survived a stroke cope with physical,
      cognitive, and emotional impairments, and many of these survivors depend on caregivers to
      manage activities of daily living (Miller, et al., 2010). Stroke is the third leading cause
      of disability (Johnson, et al., 2016). Depression is a frequent and serious complication
      after stroke impeding rehabilitation outcome, and is associated with a higher mortality risk,
      and a lower quality of life (Kutlubaev & Hackett, 2014; Robinson & Jorge, 2015).

      There is growing evidence for successful treatment of depression after stroke (Robinson &
      Jorge, 2015). Recommendations of stroke guidelines on the early management of depressive
      symptoms have not been structurally implemented in current practice, and only a minority of
      the acute care stroke teams assess mood on a systematic way in daily care (Hart & Bowen,
      2008; Bowen, et al., 2005). Hence, depression is still one of the most underdiagnosed and
      undertreated complications after stroke (Miller et al., 2010), resulting in worse patient
      outcomes and delayed recovery (Robinson & Jorge, 2015). In a feasibility study of the Nursing
      Rehabilitation Guideline for Stroke (Hafsteinsdóttir & Schuurmans, 2009) it was suggested
      that simplifying the guideline and integrating the recommendations into a stroke care pathway
      could gain a more positive attitude towards the guideline and improve its feasibility
      (Hafsteinsdóttir et al., 2013). Therefore, the Post-Stroke Depression toolkit (PSD toolkit),
      an intervention for the early management of depression after stroke, has been developed.

      The feasibility of this intervention was tested following phase two of the British Medical
      Research Council (MRC) guidelines (Craig et al., 2013). In this study, feasibility (Polit &
      Beck, 2008) is measured in terms of (1) fidelity, defined as the extent to which the
      components of the PSD toolkit are delivered as intended, and (2) acceptability, defined as
      whether the PSD toolkit is judged suitable and satisfactory by the nurses (Gearing et al.,
      2011). After evaluating implementation, the sustainability of the PSD toolkit requires
      evaluation as well (Scheirer, 2005). Sustainability is defined as fidelity to the PSD toolkit
      six months after completing implementation.

      The aims of the study were (1) to explore the feasibility of the PSD toolkit in terms of
      fidelity and acceptability in three phases-a pre-implementation phase, an implementation
      phase, and a sustainability phase six month after-and (2) to identify elements for further
      refinement and improvement in the toolkit to enhance its feasibility in daily stroke care
      during the hospital stay.

      Design: An explanatory mixed-methods, before-and-after study design(Creswell, 2008).

      Data were collected by patient chart audits and surveys among nurses. Individual and focus
      group interviews with nurses followed the quantitative data collection to explain the
      findings (Creswell, 2008).

      Data were collected pre-implementation in March and April 2012, during implementation from
      April 2012 until December 2012 and during the sustainability phase from December 2012 until
      June 2013.

      A team with expertise in stroke care, consisting of two researchers and five nurses from the
      participating nursing teams, guided the implementation.

      Participants and setting Nurses working on the neurological wards of one university hospital
      and two general hospitals in the Netherlands were included in the study. Additionally, data
      were obtained from patient charts.

      Implementation strategies Evidence-based implementation strategies were used to facilitate
      the implementation of the PSD toolkit: (1) education and training of the nurses in applying
      the PSD toolkit, (2) opinion leaders, and (3) audit and feedback by the researcher (Van
      Achterberg et al., 2008).

      Data collection Baseline data To gain insight into the patients in whom the toolkit was used,
      data on gender, age, marital status, living arrangements, type of stroke, length of hospital
      stay, and discharge destination were collected. The demographics collected on the nurses
      included gender, age, education, years working on the ward, and full-time equivalent.

      Patient chart audit Fidelity was measured in terms of the extent to which the components of
      the PSD toolkit were applied as intended; patient chart audits were performed to establish
      the number of patients who were screened for depressive symptoms and who received nursing
      interventions in the case of a positive screening.

      The Barriers and Facilitators Assessment Instrument To obtain a thorough understanding of the
      experiences and opinions of the nurses that influence fidelity, perceived barriers were
      evaluated using the Barriers and Facilitators Assessment Instrument (BFAI) (Peters et al.,
      2002)consisting of 18 statements, both positively and negatively formulated. One of the
      authors of the original questionnaire reviewed and approved the adaptations, confirming the
      content validity. The nurses indicated, on a five-point Likert scale, if they (dis)agreed
      with a statement. The scale ranged from 5 (strongly agree) to 1 (strongly disagree). To
      identify barriers, the percentage who agreed and strongly agreed with the positively
      formulated statements were recoded into disagree and strongly disagree; an item score of >3
      (agree/strongly agree) indicating a barrier.

      The Clinical Utility Questionnaire Acceptability was measured in terms of the clinical
      utility (Harris & Warren, 1995) of the PSD toolkit as perceived by the nurses. Clinical
      utility was assessed using an adapted version of the Clinical Utility Questionnaire including
      19 items addressing nurses' views on the toolkit, focussing on item clarity, acceptability of
      time investment, utility of the instruments, and relevance and utility of the nursing
      interventions. The content validity of the adapted questionnaire was assessed by one of the
      authors of the original questionnaire (de Man-van Ginkel et al., 2012).

      Interviews with nurses To explain the results of the audits, BFAI and the Clinical Utility
      Questionnaire, semi-structured with the nurses on the participating wards were performed at
      the end of the implementation phase and three focus group interviews were conducted at the
      end of the sustainability phase. The interview guides consisted of the following topics
      derived from results of the audits and questionnaires: (1) presentation of the quantitative
      results, (2) possible explanations for the changes (decrease/increase) in fidelity, (3)
      nurses' views on barriers or facilitators to use of the PSD toolkit and its clinical utility,
      and (4) suggestions to further improve the toolkit.

      Procedure Pre-implementation phase Data was collected on daily nursing care regarding the
      management of depressive symptoms after stroke. The researchers examined the charts of all
      patients admitted to the participating wards using a data extraction form.

      Furthermore, all nurses and nursing students received education and training sessions
      totalling three hours, which covered (1) depression after stroke (causes, consequences, and
      the importance of early detection of depressive symptoms), evidence-based nursing
      interventions, and (2) the content and procedures of the PSD toolkit.

      Implementation phase The researcher visited the participating wards four times per week for
      patient chart audits to collect baseline data and data on fidelity of the PSD toolkit by
      registering the frequency of delivery of the components of the PSD toolkit by the nurses. The
      researchers sent the results of the patient chart audit (e.g., the proportion of patients who
      were screened for depressive symptoms and who received nursing interventions) to the opinion
      leaders. Subsequently, the opinion leaders used this overview to provide feedback and to
      remind the nurses to screen a patient for depressive symptoms and apply appropriate nursing
      interventions.

      At the end of the implementation phase, the researchers sent the BFAI and Clinical Utility
      Questionnaire to the nurses. After two weeks, a reminder was sent to all non-respondents.
      Subsequently, the researchers conducted individual interviews with a random sample of five
      nurses from each of the participating nursing teams to explain fidelity to and acceptability
      of the toolkit by discussing the outcomes of the audit, the BFAI and the Clinical Utility
      Questionnaire.

      Sustainability phase During the sustainability phase, the same procedure was used as in the
      implementation phase; however, no implementation strategies, such as feedback and reminders,
      were used by the opinion leaders. At the end of the sustainability phase, three explanatory
      focus group interviews (one with each team, consisting of 10, 12 and 6 participants) were
      conducted with a randomly selected group of nurses to explain the data on fidelity to and
      acceptability of the PSD toolkit. The focus group interviews were moderated by a researcher
      who was not involved in implementation. The researchers and the research assistants observed,
      took notes, and handled the recording devices.

      Data analysis

        -  the baseline data, the audit data, and the results of the BFAI and Clinical Utility
           Questionnaire: Frequencies, means, standard deviations and percentages

        -  comparison of differences in patient groups: the Chi-square test for categorical
           baseline data and t-tests

        -  BFAI: numbers with the corresponding percentage of nurses who agreed and strongly agreed
           with an item on the questionnaire.

        -  the Clinical Utility Questionnaire: a percentage of agreement with each item.

      A change of +/-10% in fidelity and acceptability was used to indicate an increase or decrease
      (McCluskey & Middleton, 2010). SPSS, version 23 (SPSS Inc., Chicago, IL, USA) was used for
      quantitative data analysis.

      The individual and focus group interviews with the nurses were analysed according to
      predefined codes based on the topics in the interview guides. All interviews, as well as the
      focus groups, were audiotaped and transcribed verbatim. The transcripts were studied, and
      initial items were identified by a researcher, and subsequently, the items were discussed
      between two researchers. Based on consensus, the final items that explained the quantitative
      results on fidelity and acceptability of the PSD toolkit were established.

      Ethical considerations This study received ethics approval from the Medical Ethics Committee
      of a University Medical Center (12-081C) and the local medical ethics committees of the
      participating hospitals. Informed consent was obtained from all participants.
    

Intervention name(s): Post-Stroke Depression toolkit
Intervention type(s): Other
Intervention description(s): The Post-Stroke Depression toolkit consists of three components: (1) two screening instruments, (2) seven evidence-based nursing interventions, and (3) an instruction manual.
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        All nurses working on the neurological wards and stroke units of the participating
        hospitals, one university hospital and two general hospitals.
      
Keywords: Complex intervention; Depression; Nursing; Stroke; Feasibility