The findings of this study showed that elderly stroke patients who are rehabilitating in a SNF spent just over half of the day on therapeutic activities, consequently, almost half a day they stayed alone in their own room. Of therapeutic time, most of the patients' time was spent on nursing care, followed by physical therapy, and occupational therapy. A significant association was found between the level of functioning of the patient and the time used on therapeutic activities. Contrary to expectations, patients with a better functional status spent more time on therapeutic activities than those with lower functional status.
The findings in this study need to be considered in relation to the strengths and limitations. All observational studies have the potential for bias. A limitation of the study is the small sample size and the convenience sample, which may have increased the risk of selection bias. Also, all observations took place on weekdays between 8 a.m.–4:30 p.m. Due to organizational difficulties, it was not possible to conduct observations on evenings and weekends. This may have resulted in information bias. Although observation days were randomly selected, sometimes patients did not take part in therapy every day, which may have resulted in information bias. As inherent in all observational studies, the presence of the observers could have affected behavior of patients and professionals. On the other hand, to reduce the risk of affecting behavior of the participants, a tight observation scheme was used. Moreover, the observers adhered strictly to the observation scheme and tried to secure not being intrusive when observing the participants in their daily activities. A recent study shows that patients who were discharged had a mean MMSE score of 22 point (22/30). There were no differences in MMSE score between patients who discharged to home and who stays in a nursing home (Buijck, Zuidema, Spruit-van Eijk, Geurts & Koopmans, 2011.
When considering prior studies conducted on the time use of patients with stroke, it is important to point out the difference between this group of stroke patients and the stroke patients in other studies. Similar to the study of Huijben-Schoenmakers et al. (2009), which was conducted in a nursing home, the patients in our study were about 10 years older than the patients included in other studies. These other studies were conducted in the post acute or acute phase on rehabilitation wards in rehabilitation centers and hospitals (de Wit et al., 2005; Weerdt de et al. 2000). Our study showed that age was not associated with therapeutic time. In our study, younger patients received an equal portion of therapeutic activities compared with older patients, which is in contrary to the findings of Tinson (1989), who showed that older patients spent more time on therapy. Lang et al. (2009) studied possible correlates that could influence therapy intensity but found no correlation between age and therapy intensity. It is uncertain if older patients need more therapy, if so, this raises concerns about tailoring activities in SNFs to patient needs. Furthermore insight in therapy intensity, tailored to patient needs is considered necessary. This study can help design intervention programs specifically for SNFs where patient therapeutic time is much less than for patients residing in hospitals and rehabilitation centers, and research has shown time spent in therapy is an important factor for recovery for all patients regardless of age (Kwakkel, 2006; Kwakkel et al., 2004).
In this study, less time was spent on therapeutic activities than in other studies (Huijben-Schoenmakers et al., 2009; de Wit et al., 2005), although in our study eating and drinking, communication, travel, and ADL activities were registered as therapeutic activities, which was not the case in the other studies. We considered these activities as therapeutic because the therapeutic importance of these activities is endorsed by the geriatric rehabilitation nursing model of Routasalo et al. (2004). The patients in this study received physical therapy for only 4% each day, which is equal to the findings of Huijben-Schoenmakers et al. (2009) but much less than the reported 40% found in the (rehabilitation center) study conducted by de Wit et al. (2005) in four European countries, namely Belgium, Great Britain, Germany and Switzerland. Even time spent on other therapies such as occupational therapy and speech therapy was less in our study than in earlier studies of Huijben-Schoenmakers et al. (2009) and de Wit et al. (2005). The lower therapy time we found may partly be explained by the fact that our study took place in SNFs. The patients in our study had worse functional status, were older and had more comorbidities than patients included in earlier studies in hospitals and rehabilitation centers. Furthermore, distribution of financial resources may differ between countries and healthcare facilities within countries. However, to date only one study has been conducted on time use of patients with stroke in a nursing home (comparable with SNFs), which makes it difficult to draw conclusions. The patients in this study did not have much contact with nurses during the day (8 a.m.–4:30 p.m.). Only 10% of the day patients had some kind of interaction with nurses, consecutively less than 10% of the day was spent on ADL activities with nurses. Nevertheless, many studies have described the important role that nurses have in rehabilitation of patients with stroke (Rensink et al., 2009; Routasalo et al., 2004; Pryor & Buzio, 2010; Kirkevold, 1997). Nurses can help to restore functional status, increase well-being and enhance quality of life of patients. Nurses have an important role in motivating patients to comply to their rehabilitation programs and giving emotional support to informal caregivers. Clinical Practice Guidelines (CPGs) such as the Clinical Nursing Rehabilitation Guideline Stroke (Hafsteinsdóttir & Schuurmans, 2009; Rensink et al., 2009) include recommendations focusing on the daily rehabilitation care and treatment of stroke patients. During the daily care, nurses need to stimulate patients to do simple exercises such as reach for objects (Wu, Wong, Lin & Chen, 2001), standing up from a chair several times during the day (Cheng, Wu, Liaw, Wong & Tang, 2001) and exercise walking with patients (Nilsson et al., 2001). Other studies have shown the importance of involving informal caregivers (partner or family member) in the care and training of patients with stroke (Kalra et al., 2004; Maeshima et al., 2003). Based on these studies, nurses need to supervise and encourage informal caregivers to conduct simple exercises with the patients, including walking exercises (Latham et al., 2005). This may contribute to the functional recovery and improve the psychological and social well-being of the patients as well as the informal caregiver (Kalra et al., 2004). It is important to encourage the patients to train in tasks/activities that are important and relevant for them and which the patients themselves have chosen. This improves the motivation for exercising (Wu et al., 2001). Based on the findings of this study and CPGs published (Hafsteinsdóttir & Schuurmans, 2009; Rensink et al., 2009), nurses need to select exercises and tailor these to the individual patients′ needs and thereby they may contribute in a positive way to the rehabilitation outcome of these patients. Investigation into the origin of the passive nature of patients with stroke and what the best way is to motivate them, is necessary so that nurses and other professionals are better able to encourage them to comply with rehabilitation programs. Also, further research is needed into the role of nurses in the rehabilitation care of stroke patients. Lastly, nurses need to develop intervention programs focusing on improving time use of patients and aiming to improve the functional outcome of patients with stroke. Intervention and training programs may include simple task-oriented training exercises that patients can do individually, in groups or with caregivers. Also, intervention programs may include training exercises focusing on dysphagia, communication problems, and fall prevention for patients with stroke. These training programs should occur in therapeutic climates with: 1) structured activities which are tailored to patients needs, 2) explicitly formulated goals, 3) (mostly) hands-off nursing care (using mainly verbal instructions), 4) a supportive climate created by the multidisciplinary team, and 5) interaction with other patients. All activities have the focus on discharge of the patient to an independent or assisted living situation. Although it is likely that intervention and training programs may improve various outcomes of patients with stroke, the effects of such programs would need to be investigated, preferably using randomized clinical trials, which may offer information about their effectiveness on various patient outcomes.