The continuum of care: the process and development of a nursing model for stroke education.

A recent focus in health care is to develop a seamless transition for patients between the variety of health care agencies with whom they interact. The continuum of care for patients with stroke is complex and many levels of care are required, from acute intervention through to rehabilitation and reintegration into the community. A group of nurses from a variety of agencies in Southwestern Ontario received funding from the Ontario province Wide Nursing Project to effect a desirable change in the way nurses care for the stroke patient. This article describes the Ontario Province Wide Nursing project and the process of and challenges in developing a nursing model for stroke. The development of a nursing model for stroke patients and their families involved conducting nursing, and patient and family focus groups to identify key issues. Thirty-eight nurses participated in the nursing focus groups, and 8 patients and 18 family members participated in the patient and family focus groups. The common themes were the need for improved communication and the need to better prepare patients and families for the many transitions they experience during their recovery from stroke. A Stroke Education Record, which identifies a comprehensive list of potential learning needs of stroke patients and their families, and a Stroke Education and Resource Guide, which provides a reference for nurses, were developed and will be implemented in September 1998. Implementation of the model included a workshop, staff inservices, a self-learning package, and unit displays. Evaluation of the model will include nursing and patient and family focus groups, a chart review, written nursing evaluations, and patient and family telephone interviews.