Predicting the functional independence during the recovery phase for poststroke patients

Abstract Background Successful recovery of stroke survivors can be challenging. However, when targeted functional capacities are predicted early in the recovery phase, necessary nursing intervention can be initiated aiming at supporting the client moving forward in the rehabilitation journey. Aim(s) This study aimed to evaluate stroke self‐efficacy of poststroke patients and identify the differences in stroke self‐efficacy level among some relevant variables. Design A descriptive cross‐sectional design was employed to achieve the aforementioned objectives. Methods A purposive sample of 207 poststroke patients who were recovering from stroke in three major teaching hospitals at Baghdad city were recruited to participate in the study. Data collection process started 3 November 2016 –15 May 2017. Inclusion criteria embraced stroke patients who were adult, have Glasgow Coma Scale score 14–15, capable of giving written or verbal consent. The modified version of the stroke self‐efficacy questionnaire was used for data collection. Results A significant statistical difference at the p‐value ≤ 0.05 level, in stroke self‐efficacy, was verified among subjects’ age, residency, stroke incidence and patient's knowledge about his/her stroke medical diagnosis.

This necessitates an active engagement in fulfilling the planned rehabilitation goals of all the involved parties, particularly the patient him or herself. High stroke self-efficacy is connected with better clinical outcome (Korpershoek, van der Bijl, & Hafsteinsdóttir, 2011). Therefore, this research was designed to assess the levels of stroke survivor's self-efficacy in terms of its major pillars, functional capacity and self-management. The main research questions that the study was developed to answer were as follows: What is the level of stroke self-efficacy of poststroke patients? and What are the differences in stroke self-efficacy level among some demographic and clinical variables of patients recovering from stroke?

| BACKG ROU N D
The unprecedented increase of ageing population percentage can and will aggravate the situation at the level of the global public health arena. This necessitates both an effective and urgent intervention to help the huge numbers of stroke patients dealing with their multi-dimensional health problem by facilitating a planned recovery under the umbrella of healthy transition. Therefore, extending a helping hand to stroke patients aiming at improving their functional independency is vital during the early stages of their acute illness. The literature suggested that functional independence of patients with chronic conditions such as stroke can be predicted by assessing patient's self-efficacy (Torkia, 2014). Unfortunately, scientific inquiries that have explored self-efficacy in a Middle Eastern stroke population are scarce, which justifies this research endeavour, aiming basically at attaining a more inclusive, clinically pertinent comprehension of self-efficacy during the recovery phase in the aforementioned population. Self-efficacy has been defined as person's belief in his/ her ability in organizing, managing and executing the steps that are necessary to achieve the targeted goal(s) (Jones, Partridge, & Reid, 2008). Based on the aforementioned definition, it is crucial to assess stroke self-efficacy to predict the independence level in terms of functional capacities and self-management dimensions in poststroke patients. This would be helpful to them in terms of moving forward in the rehabilitation program. Assessing stroke patient's self-efficacy level is the starting point of applying nursing therapeutics. As a result, it is mandatory to assess stroke patient's self-efficacy level as an infrastructure of the rehabilitation journey. The outcome of the planned assessment would be essential in designing and implanting tailored nursing therapeutics (Tables 1, 2 and 3).

| Study design, sample and setting
A descriptive cross-sectional design study was conducted on 207 patients who were recovering from stroke in three major teaching hospitals at Baghdad city from 3 November 2016-15 May 2017. As it consistent with nursing studies, the study targeted an alpha level of 0.05, an effect size of 0.891, a power of 80 and a sample size of 207

| Data collection and tool(s)
The modified version of the stroke self-efficacy scale (Riazi, Aspden, & Jones, 2014) was selected to achieve the study objectives. The 13-item stroke self-efficacy scale was found to have satisfactory feasibility and face validity to be used during the stroke recovery phase. Cronbach alpha is 0.90 signifying a satisfactory internal consistency and criterion validity is good, r = 0.803, p < 0.001. The stroke self-efficacy questionnaire consisted of two sections: the first section focused on socio-demographic characteristics and stroke-related clinical variables. The second section included the stroke self-efficacy scale, where 13 items focused on functional independency of stroke clients. This scale was rated based on the following numerical range (0-3). subjects in this study were given an opportunity to rate their own confidence "self-efficacy" level based on the aforementioned scale continuum. Whereas "0" stands for "not at all confident in his or her functional independence," "3" stands for "very confident in his or her functional independence." The questions focused on examining patients' confidence about their physical ability doing some tasks that maybe challenging since their most recent stroke attack. Subjects were asked to encircle the numerical value on the scale form that shows how certain they were in doing the tasks despite stroke. The level of stroke self-efficacy was assessed and consequently classified in to three levels, which are low, moderate and high.

| Ethical considerations
The research ethics committee at the University of Baghdad, College of Nursing consented the study proposal. All the collected data during the study course were recorded in such an approach that subject's identities remain confidential. A password-protected file was used to store the study related-electronic data. The collective form of the study findings is the only part that is disseminated in the study report. All the informed consents were signed by the subjects, where they had been informed that their participation is completely voluntary and they have the right to read, discuss and question the study protocol, the benefits and risks of participation with the researcher.

| Statistical analysis
SPSS® version 20.0 was used to conduct the statistical analysis.
Both descriptive and non-parametric tests were employed to conduct the statistical analysis through the computation of the frequencies, percentages, Mann-Whitney test and Kruskal-Wallis test. The advantages of using non-parametric tests can explain choosing them to be used in this study. Examples are however not limited to: their statistical potential to give meaningful results even when having a small sample size. Of equal importance, when compared with parametric tests, the non-parametric tests constitute less strict assumptions, which make them more feasible option. Furthermore, their fixability to be used in many kinds of categorical, as well as interval data can make them a valid choice for fulfilling research endeavours.
Finally, their ability to show the mean rank gives a very clear idea about the processed data in terms of their contribution in explaining the phenomenon under statistical investigation, as well as highlighting the significant statistical difference among the studied variables.

| D ISCUSS I ON
It is crucial to recognize that the transition from partial or complete dependence to full independence is a process that progresses gradually over time (Buscherhof, 1998). The quality and the speed of this progress depend on many factors. Examples are as follows: the condition's severity, availability of resources and most importantly the client's attitude in terms of adaption to neurologic deficits. Therefore, it is helpful to concede that complex situations which are related to stroke clients "vulnerability in terms of health-illness TA B L E 2 Differences in Stroke Self-Efficacy among two-level variables Note: Mann-Whitney test indicates that female patients have a better stroke self-efficacy than that of male patients. However, there is no a statistically significant difference in patients' stroke self-efficacy between the gender groups (U = 4,911.5, p-value = 0.391). On the other hand, stroke patients who live in urban areas have a better stroke self-efficacy than that of patients who live in rural areas. A statistically significant difference in patients' stroke self-efficacy between the residency groups (U = 3,305.5, p-value = 0.000) was verified. Moreover, patients who were diagnosed with haemorrhagic stroke have a better stroke self-efficacy than that of patients who were diagnosed with ischaemic stroke. However, there is no a statistically significant difference in patients' stroke self-efficacy between the stroke type groups (U = 2,981.0, p-value = 0.386).
TA B L E 3 Differences in Stroke Self-Efficacy among three or more levels variables Note: Kruskal-Wallis Test reveals that stroke patients who are within 40-49 years age group, with Bachelor degree, and have been affected by stroke for more than a year, have a better stroke self-efficacy than that of other groups. Table 3 also shows that there is a statistically significant difference in patients' stroke self-efficacy among the age groups (χ 2 = 12.914, df = 4, p-value = 0.012). However, there is no a statistically significant difference in patients' stroke self-efficacy among the educational level groups (χ 2 = 3.652, df = 5, p-value = 0.601), and stroke duration groups (χ 2 = 0.648, df = 2, p-value = 0.723). Of equal importance, knowledgeable patients about their stroke type and patients who are affected by stroke for the first time in their life have a better stroke self-efficacy than that of other groups. A statistically significant difference was detected in patients' stroke self-efficacy among the knowledge about stroke specific type groups (χ 2 = 7.845, df = 2, p-value = 0.020) and stroke incidence groups (χ 2 = 6.945, df = 2, p-value = 0.031).
transition, can be best explored through the lenses of nursing theories" (Meleis, 2010). For that reason, a directing theoretical framework is mandatory to understand stroke patient's response to their acute illness and guiding a tailored efficacious intervention based on their self-efficacy level assessment. The transitions theory of Meleis's (2010) perfectly suits the study objectives. Meleis's definition of nursing is "the art and science of facilitating the transition of populations' health and well-being" (Meleis, 2010, p.5 It is well documented in the relevant rehabilitation nursing literature that high-level self-efficacy of patients with stroke is connected with high-quality ADL functioning (Korpershoek et al., 2011;Pang, Eng, & Miller, 2007;Robinson-Smith, & Pizzi, 2003).
Conversely, low self-efficacy in stroke patients may decrease quality of life (Korpershoe et al., 2011). An unfortunate finding presented in Figure 1 shows the highest percentage of this research subjects were classified under the category of lowest stroke self-efficacy, reflecting low functional independence. One way to explain this unfortunate finding is lack of holistic nursing care intervention, where nurses overlock the psycho-social aspects of care plan. To address this defect, nurses need to value the self-efficacy-based The highest percentage of the study subjects were classified under the category of lowest stroke-related self-efficacy, reflecting low functional independency. This was calculated based on the cut of point (0-39) whereas 0 represents the lowest possible score, 39 is the highest possible score. Accordingly, Levels of self-efficacy were classified in to the following: low = 0 -13, moderate = 13.1-26, and high = 26.1-39. The percentages of each level were represented by the pie chart to help readers seeing the whole picture of the study population in terms of their confidence level. Of equal importance, the mean score for level of subjects' confidence of doing the tasks in spite of being affected by stroke was 10.48 signifying low overall self-efficacy level Low Stroke-related self-efficacy = 72.0%

Stroke-related self-efficacy levels
Moderate Stroke-related self-efficacy = 27.1% High Stroke-related self-efficacy = 1% intervention and its positive impact on improving stroke patient's functional capacity in terms of ADL and health-related quality of life (Kvigne, Kirkevold, & Gjengedal, 2005).
Aiming basically at judging particular realms of poststroke independent functioning, such as Activities of Daily Living (ADL) and self-management tasks. The study unidimensional tool was used to highlight the aforementioned realms. Reflecting on ADL, which are among the most basic and independent functions for human beings.
However, they may pose a significant challenge to stroke patients. Payne, Stagnitti, Hooke, and Hitch (2015) reported that more than tree quartets of stroke patients may suffer from varying degrees of eating difficulties, which may jeopardize their independence of performing these basic activities. Despite this fact, persons are more likely to engage in a rigorous attempt to satisfy the luck of basic needs, such as hunger or thirst, aiming at achieving homoeostasis (Timmerman & Acton, 2001). Of equal importance, coping with stroke as an incapac- One principle objective of this study was to identify the differences in stroke self-efficacy among some relevant variables.
Highlighting theses statistical differences would be of great clinical value when designing stroke-related self-efficacy interventions.
A significant statistical difference in stroke self-efficacy was verified among subjects' age, residency, stroke incidence and patient's knowledge about his/her stroke medical diagnosis. The literature showed that the dominant age group of clients with low self-efficacy was less than 75 years (Andersson, Kamwendo, & Appelros, 2008). This comes along with the current study findings. Such findings can be best explained by the clinical fact that even minor strokes in senior person may lead to significant multisystem deficits, including cognitive, locomotive and sensory deficits. Which may influenced stroke patients goal attainment, outcome expectations and most importantly their self-efficacy (Ireland & Arthur, 2006). This should not discourage healthcare providers to enhance older adult's self-efficacy considering the fact that ageing is not a synonym of a disease. Instead, healthcare providers should deal with ageing as a biological process where they should support self-efficacy aiming at achieving full independence (Rattan, 2014 (2005) explained that because self-efficacy is modifiable in nature, thus knowledge may positively affect it in a way that can be reflected on stroke patient's clinical outcome. Therefore, they recommended that patient's literacy about their chronic conditions such as stroke must be enhanced in a way that boosts their self-efficacy.

| CON CLUS ION
Low stroke self-efficacy was evident predicting low level of autonomous functional capacities among the study sample. Subjects' age, residency, knowledge about stroke specific medical diagnosis and stroke incidence were the most influential factors on the stroke patients related self-efficacy, consequently on their functional independence during the recovery phase. Therefore, it is highly recommended that comprehensive rehabilitative programs should be tailored according to stroke patient's self-efficacy, which reflects the accurate level of physical independence. Additionally, both self-efficacy and its related functional independence are complex constructs that cannot explained by the contribution of single or mutable variables. In fact, they are the outcome of the interaction among the physical, psychosocial, demographic and clinical characteristics. Therefore, a mixed methods study is mandate considering its ability to highlight other variables that may contribute in explaining stroke self-efficacy.
Being the patients official advocate, nurses can play a pivotal role with stroke patients by facilitating personal readjustment aiming at regaining full independence. However, under the current critical circumstances of Iraq, this would be challenging. Therefore, the WHO is invited to boost its valuable support to Iraqi nurses through mentoring and advocating nursing role in the multidisciplinary team of stroke patient care.

ACK N OWLED G EM ENTS
The author would like to appreciate all the genuine efforts that had been made by the hospitalized stroke patients, senior students at the School of Nursing, University of Baghdad, and the nursing staff in the Medical City Complex. This research work would not be possible without your support!