Rhetoric and reality in stroke patient care.

The aim of this study was to identify aspects of the process of care that might help explain the improved outcomes associated with stroke units. Three different care settings for stroke patients, an elderly care unit and general medical ward in an inner-city teaching hospital and a stroke unit in another teaching hospital in the same city, were compared using non-participant observational methods. Nurses on the stroke unit and general medical ward usually engaged in standardised and functional interaction with patients, while nurses on the elderly care unit were observed to adopt a more personal and attentive approach with patients. Rehabilitation nursing was rarely observed on the stroke unit, never on the general medical ward but always on the elderly care unit. There was evidence of effective communication between nurses and therapists on the elderly care unit but this was not observed on the stroke unit. On the elderly care unit the team appeared divided, with therapists and nurses on one side and medicine on the other, while on the stroke unit the divide was between doctors and therapists on one hand and nurses the other. On the general medical ward there was no team working. The observed lack of rehabilitation nursing, nurses' disengagement from the team and nurses' observed lack of warmth towards patients on the stroke unit were all surprising findings. Further research needs to examine whether such findings would be reproduced in stroke units elsewhere. If so, it might be that the better outcomes achieved on stroke units are despite rather than because of the nursing they receive there.