Journal of Rehabilitation Medicine 51-10 | Page 22

742
G. Gard et al.
In Sweden, acute stroke care is provided in stroke
units and the majority of patients are discharged directly
to their home. Primary care is the basis for long-term
follow-up. The RTW organization of stroke patients in
Sweden varies between hospitals, municipalities and
County Councils. The new guidelines of the Swedish
National Board of Health and Welfare advocate that
all stroke patients should be followed-up by stroke
professionals in a structured manner (9). In Sweden,
the healthcare organization supporting patients after a
stroke includes the whole rehabilitation chain from the
hospital to the community. Four rehabilitation actors
provide support for RTW in vocational rehabilitation
(VR) in Sweden; the healthcare organization, the Social
Insurance Office (SIO), the Employment Agency (EA)
and employers (10). A labour union and an occupatio-
nal health service may also be active in VR (10). The
SIO determines whether an individual has the right to
sick-leave and to coordinate resources for RTW. The
employer has the responsibility to facilitate RTW accor-
ding to the Swedish Working Environment Act. During
this process, all stakeholders are involved, but do not
always adequately cooperate with each other (10).
A review of qualitative studies regarding stroke
patients’ perspectives concerning healthcare factors
has shown that healthcare is fragmented, discharge
services are poorly coordinated, and accessing health
and social care in the community is difficult. The health­
care systems with which the patients interface and the
interpersonal complexities they encounter must be im-
proved in order to facilitate RTW (11). There is a need to
transform the RTW approach so that services prioritize
patients’ needs (12). Therefore, in-depth knowledge
of stroke survivors’ experiences of healthcare-related
facilitators and barriers to improve RTW is needed.
Aim
The aim of this study was to explore stroke survivors’
experiences of healthcare-related facilitators and bar-
riers concerning RTW after stroke.
METHODS
Patients discharged from the stroke unit at Skåne University
hospital (SUS), who were on sick-leave due to the stroke onset,
were referred to an outpatient stroke rehabilitation unit. Some
patients underwent a multidisciplinary team assessment 4–8
weeks after stroke and, if needed, a multidisciplinary outpa-
tient rehabilitation. Thereafter, they were referred to primary
healthcare.
nants for RTW after stroke. Participants fulfilling the following
criteria were included in the questionnaire study: admitted to
SUS for acute stroke care; aged 18–64 years at stroke onset;
referred to outpatient stroke rehabilitation within 180 days
after stroke onset, and were in employment for at least 10 h
per week prior to the stroke. Persons not fluent in Swedish or
with cognitive and/or language deficits that made them unable
to answer the questionnaire were excluded. An invitation letter
to take part in this interview study was sent to 39 persons who
had answered the questionnaire between March and September
2017. Thereafter, they were contacted by telephone to confirm
participation. Twenty-two persons agreed to participate and 17
declined or were unreachable. Two of the persons who initially
agreed were unable to attend on the day of interview. A final
total of 20 persons provided informed consent.
Table I describes the participants’ characteristics. Of the 20
participants, 15 had had a cerebral infarction while 5 had had
an intracerebral haemorrhage. At the time of the interview, 16
persons had returned to their previous work. One participant
returned to work for a few months and then retired shortly
before the interview. Three persons were in work training, 2
of them had changed work due to the sequelae of the stroke,
while the third person was in work training at the previous
workplace. The participants perceived overall a good recovery
from stroke, measured with the Stroke Impact Scale (SIS) (13).
Fatigue, measured with the Mental Fatigue Scale (MFS) (14)
was present in some participants.
Qualitative interviews
The interviews were performed a median of 14 months post-
stroke in focus groups to facilitate a group dynamic process
with discussion between the participants (15, 16). By using
focus group interviews, new research areas can be explored
from the participants’ perspective (16). The study was designed
in accordance with the COnsolidated criteria for REporting
Qualitative research (COREQ) (17).
Procedure
In the interview guide, open questions were formulated based
on earlier research and clinical experience. The main question
was to describe various experienced facilitators and barriers to
RTW related to healthcare. Follow-up questions were also used,
Table I. Characteristics of the 20 participants
Sex, female, n
Age, years at stroke onset, median (range)
Type of stroke, n
Ischaemic stroke
Intracerebral haemorrhage
Employed in, n
Private sector
Public sector
Working hours per week after stroke, n
30–40 hours
20–29 hours
10–19 hours
Work training
Perceived recovery from stroke a , median % (range)
Fatigue b , median (range)
Participants
A convenient sample of 20 persons was selected from an on-
going questionnaire study with the aim of identifying determi-
www.medicaljournals.se/jrm
a
7
52 (39–62)
15
5
14
6
12
3
2
3
90 (54–100)
9 (0–20)
Assessed with the Stroke Impact Scale (13), item 9, at the time of the
questionnaire study. The scale ranges from 0–100%.
b
Assessed with the Mental Fatigue Scale (MFS) (14) at the time of the
questionnaire study. The scale ranges from 0 to 42 points.