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Nursing Interventions Within the Mauk Model of Poststroke Recovery
Stroke continues to be the third leading cause of death in the United States. According to the National Stroke Association (NSA, 2004) and the American Heart Association (AHA, 2004), there are over 750,000 new or recurrent strokes per year, with many resulting in residual disability. Stroke survivors often deal with the physical, psychosocial, and emotional consequences of stroke long after they have left the safety of professional rehabilitation. Patient instruction from nurses prior to discharge, while necessary, may be done at a point in the recovery process when the stroke survivor is not ready to learn how to deal with such consequences. Using the Mauk Model for Poststroke Recovery, nurses can identify which phase of recovery a survivor is in, and thus tailor care to his or her needs. The purpose of this article is to use the Mauk Model for Poststroke Recovery to present nursing interventions that are appropriate to each of the previously identified six phases of stroke recovery.
Stroke is a significant health problem in our society. Stroke continues to be the third leading cause of death in the United States. According to the National Stroke Association (NSA, 2004) and the American Heart Association (AHA, 2004), there are over 750,000 new or recurrent strokes per year, with 500,000 being first incidents. Up to 30% of people who suffer a stroke have some type of residual permanent disability. The cost of stroke and its aftermath is estimated at $30 billion per year (AHA, 2004). Two thirds of stroke patients are elderly, often resulting in their need for placement in a long-term care facility.
Despite these grim statistics, there is hope for stroke survivors. New and better medical treatments to diagnose and treat stroke sooner have emerged. However, survivors are often left to deal with the physical, psychosocial, and emotional consequences of stroke long after they have left the safety of professional rehabilitation.
Patients instruction from nurses prior to discharge, while necessary, is often done at a point in the recovery process when the stroke survivor and his or her family members are not ready to learn how to deal with such consequences. Survivors often remark that they would have preferred to be taught at home when they were more motivated and able to deal with the implications of their stroke (Mauk, 2004). During hospitalization, especially given the shortened length of a typical stay, stroke survivors and their family members are often just trying to cope with the fact that a stroke has occurred. Attempts to provide instruction regarding poststroke care at the time of discharge may be ineffective and frustrating to all parties. Nursing interventions are often not targeted to the needs of a stroke survivor and his or her family. The purpose of this article is to use a previously developed model for poststroke rehabilitation to present nursing interventions that are appropriate to each of the six phases of stroke recovery.
Review of the Mauk Model for Poststroke Recovery
Over a period of years, the author reviewed numerous writings and transcripts from stroke survivors to conduct concept analyses and develop an eventual theory synthesis that led to a proposed model of stroke recovery (Easton, 2001). After conducting face-to-face interviews with survivors and employing grounded theory methods and qualitative analysis, a six-phase model of stroke recovery was developed. The phases include agonizing, fantasizing, realizing, blending, framing, and owning. Although original theoretical development yielded an initial model (Easton, 1999), face-to-face interviews with stroke survivors, as well as data gleaned from stroke support groups helped to support and refine the concepts and subconcepts of the model. Stroke survivors in the study had experienced a first stroke within a range of 7 months to 37 years previous, with an average length of time from the first stroke of about 5 years.
Table 1 shows the major concepts (six phases) and subconcepts (associated characteristics) of the Mauk model. The Mauk model differs from many models based on previous stroke studies, in that it focuses on the process of stroke recovery, suggesting a framework to guide overall rehabilitation practice. For more complete information about the study on which the Mauk model is based, readers should refer to the separate article (Easton, 1999) or published dissertation (Easton, 2001). In a separate article, the author will present more complete information on the grounded theory research surrounding the development of this model of poststroke recovery.
It should be noted that the author purposefully uses the terms recovery and rehabilitation interchangeably. Stroke survivors used the term “recovery,” which may seem misleading to many healthcare professionals, but did so to indicate both a complete return to prestroke states and functioning, as well as a sense of poststroke normalcy despite the presence of lasting physical and other effects.
Identifying Phases of Recovery
Nursing interventions could be more effective if specifically targeted to the needs of the stroke survivor at each point in the journey of recovery. By identifying the phase of recovery that a person is in, nurses could tailor care to his or her specific needs instead of providing the traditional care offered on most rehabilitation units.
Some general assumptions about the Mauk model can guide nurses as they assess the phase of stroke recovery a survivor is in (Easton, 2001). Individuals are unique and will experience the recovery process at their own pace. Some survivors moved quickly to the realizing phase, which seemed to be facilitated by certain buffering factors such as older age, expectations of illness, and less severe limitations. The majority of the sample, however, took time to traverse through each phase (Easton). In the process of working through these stages to reach the owning phase, stroke survivors make positive adaptations. The realizing phase is the pivotal stage necessary for the successful adaptation to life after a stroke. In this phase, stroke survivors realistically face their limitations and present situation. Figure 1 provides one illustration of the post-stroke journey. In this nonlinear, multi-dimensional process, stroke survivors may experience more than one phase at a time, in different proportions, for years after their stroke even though progress toward positive adjustment is evident. In addition, stroke survivors may not perceive themselves to be in the same phase that their nurse perceives them to be. Certain characteristics associated with each phase may assist the nurse in correctly assessing patient’s progress in the post-stroke journey of recovery.
Several strategies may help rehabilitation nurses identify the phase of stroke recovery that a patient is in (Mauk, 2004). Nurses should assess patient subconcepts associated with the various phases (Table 1) remembering that phases may occur simultaneously—though it is likely that one phase will be predominate. Concentrate interventions on meeting the major task for the stage that the survivor is experiencing the most.
Looking at Figure 1 and Table 1, nurses should be able to use cues given by survivors to assess the phase of stroke recovery. For example, a patient who is asking “Why did this happen to me?” or expressing shock, denial, or surprise is most likely in the agonizing phase. The patient who makes statements such as “This just doesn’t seem real” or “When this goes away and I get back to normal…” is expressing characterstics of the fantasizing phase. If the survivor is in the realizing phase, the nurse should expect to hear expressions of anger and/or complaints of fatigue and may see symptoms of depression. It will become evident that the person is realizing that the effects of his or her stroke may not all just go away. This is the pivotal point in recovery. After the person has dealt with the realizing phase, positive adaptations will occur.
The blending, framing, and owning phases may overlap somewhat though the time required for patients to reach the owning phase varies greatly. During blending, the survivor begins to meld the former life (life before the stroke) with present abilities. A sense of hope is evident, and important learning can take place during this phase. As the stroke survivor deals with many changes, frustration may occur, but this is the ideal time for nursing instruction about self-care because the person’s motivation to learn is generally high. During framing, survivors answer the question of why the stroke happened. They reflect on the stroke event in light of previous experiences that are familiar and comfortable to them. They may describe the stroke experience in their own terms based on life vocation or hobbies. If not given a reason for the stroke, they will assign one, whether related to the event or not. In the last phase, owning, the survivor exhibits a sense of control, demonstrates acceptance of the effects of the stroke, and shows new determination to make the best of the situation. The survivor will engage in self-help activities such as attending stroke support groups, trying alternative therapies, inventing ways to make life easier, pursuing other helpful resources, and demonstrating acceptance of the stroke implications for his or her present life.
The rehabilitation nurse with strong assessment skills should be able to confidantly and consistently identify survivors’ placement in the post-stroke journey. The nurse may then employ interventions that facilitate completion of the essential tasks for the phases identified, which will be discussed next.
Essential Tasks for Each Phase of Recovery
Tasks for each of the six phases of post-stroke recovery were identified. Essential tasks for stroke survivors are those that emerged as most important to the successful completion of a particular phase. Tasks for nurses are those that are most important to assisting the survivor during a certain phase. These tasks are summarized in Table 2 and have yet to be refined and tested through clinical research studies with stroke survivors.
During the agonizing phase, patients are simply trying to survive the initial onslaught of the stroke. Nurses should provide physical care and protection to help the new stroke patient survive the effects. In the fantasizing phase, patients are trying to protect themselves from the reality of the effects of the stroke. Because survivors may experience a sense of unreality and conceptualize time differently, realizing may be a difficult phase as the survivor faces the reality of the aftermath of their stroke. Nurses must provide emotional and psychosocial support as survivors deal with the various effects of the stroke, whether physical, emotional, spiritual, or other.
During the final three phases, rehabilitation nurses may make the most lasting impact on a survivor’s ability to adapt to life after a stroke. Adaptation begins during the blending phase, and this is the time when nurses should be doing the most teaching. The stroke survivor has the greatest readiness to learn and wants to blend his or her past with the present. During framing, the stroke survivor is reflecting on the stroke experience and trying to put it into perspective. One of the most important tasks the nurse can assist with during this phase is providing an accurate medical reason for the stroke. Therapeutic listening is also essential. In addition, it is important to realize that this phase may be ongoing and is unique for each person. In the last phase, owning, the stroke survivor begins to move on with life. The nurses should enhance the person’s inner resources, as well as help link the stroke survivor and his or her family to appropriate community resources during this stage.
Nursing Interventions Within Each Phase
When using the Mauk Model of Poststroke Recovery, rehabilitation nurses may recognize that much of the teaching done in acute care hospitals or rehabilitation units is not tailored to stroke survivor’s immediate needs. Survivors may not even be at the realizing phase upon discharge, so they are less likely to be motivated to learn needed skills and less likely to retain the information they are taught. Patients may not have yet realized what the lasting effects of their stroke will be, nor be prepared to adapt to a new body image. The Mauk Model suggests that nursing teaching would often be better received during the latter phases when a person is ready to learn adaptive skills.
Some practical suggestions of appropriate interventions for each phase of the post-stroke journey follow. Agonizing Phase: Promote the will to live; Focus nursing care on the physical, providing comfort and protection; Make time to listen to the stroke survivor and family members; Help the stroke survivor and family members distinguish between real and imagined fears; Answer questions as needed; Provide basic information about procedures and tests; Accept denial as an appropriate coping mechanism at this time; Encourage family involvement in the recovery process; Strengthen support systems, including family, church, and friends; Involve the stroke survivor’s spiritual leader in the rehabilitation team; Identify coping mechanisms and support systems available to the stroke survivor; Acknowledge feelings of loss; Encourage expression of feelings.
Fantasizing Phase: Provide consistent reality orientation; Provide essential, research-based information related to recovery and rehabilitation after stroke; Directly answer any and all questions from the stroke survivor and family members; Be encouraging without offering false hope or fostering unrealistic expectations regarding recovery; Acknowledge that time may have taken on a different meaning to the stroke survivor during this phase; Promote a positive self-image through good hygiene, grooming, and personal clothing; Encourage activities that enhance self-esteem; Be available to listen; Encourage verbalization of feelings; Initiate social support interventions (prior to potential onset of depression).
Realizing Phase: Encourage verbalization of feelings; Be alert to verbalizations of suicidal intent and take appropriate actions; Keep the environment safe; Screen the stroke survivor for depression and make appropriate referrals; Strengthen social supports; Provide information to family members and be watchful for signs of readiness to learn among the stroke survivor and family members; Recognize that while depression is common in this phase, continued depressive symptoms may require medical intervention but may also indicate lack of adaptation; Involve the the stroke survivor’s spiritual leader if faith has been identified as a coping mechanism or source of social support; Recognize that anger is a part of the grieving process (do not take displays of anger personally); Acknowledge fatigue as a common and significant problem post-stroke; Pace the stroke survivor’s activities and therapies, alternating work and rest; Maximize available energy through teaching energy conservation techniques, organization of tasks, and good body mechanics; Inform family members and the stroke survivor that fatigue may continue for years after the stroke and that they may need to make lifestyle changes to adjust; Assure family members that feelings of anger are normal for stroke survivors and not to be taken personally; Help survivor to identify additional coping strategies to manage anger.
Blending Phase: Emphasize the stroke survivor’s strengths in the light of fostering hope; Foster hope for improvement and never take away hope; Encourage persistence and perseverance with rehabilitation; Promote family involvement; Focus on nursing teaching and include all the skills that are needed to adjust to life at home after stroke; Connect with educational support groups; Provide discharge follow-up; Cultivate readiness and motivation to learn; Give positive feedback for attempts to learn new skills; Promote relaxation and stress management; Encourage good grooming to continue to promote a positive body image; Explain the purpose of adaptive equipment; Use only those adaptive devices that are necessary, and work towards minimizing the use of adaptive equipment as recovery progresses; Assist in setting both long- and short-term goals; Set up a periodic evaluation plan to see how well goals are being met; Explain complications of stroke; Assess the stroke survivor for potential complications of stroke and risk factors for recurring stroke; Provide specific teaching regarding prevention of recurring stroke; Provide a realistic picture of functional return; Help families avoid wasting funds on therapy that will not correct deficits, and address unrealistic expectations for recovery.
Framing Phase: Listen attentively as the stroke survivor attempts to make sense of the stroke experience; Get support for self as a nurse from other nurses who have experience in stroke rehabilitation; Provide a medical reason via the physician for why the stroke occurred; If the cause of stroke remains unclear, inform the stroke survivor of this, but provide a short list of the most likely causes as confirmed by the physician; Help the stroke survivor relate or reflect upon the stroke experience in light of previous experiences; Arrange for peer counseling if desired.
Owning Phase: Return control of even simple tasks to the stroke survivor; Enhance all available support systems and resources to promote self-help and independence at home; Promote community re-entry activities; Link the stroke survivor and family to community resources; Encourage participation in stroke support groups both as an inpatient and after discharge; Provide information to the stroke survivor and family, including phone numbers and addresses of local and national organizations; Encourage regular exercise and a gradual return to former activities as able; Evaluate the feasibility of travel and other former activities; Evaluate insurance coverage for ongoing help with problems related to the stroke; Provide realistic, accurate information about challenges that may be encountered at home, even for years after the stroke event (grieving, complications, fatigue).
Oral and written statements from stroke survivors about their stroke experience provided additional guidance and insight into what might most benefit patients during each of the six phases of recovery. The aforementioned is not meant to provide an all-inclusive list of interventions, but merely to suggest some strategies for facilitating survivors’ positive adaptation to stroke based on traditional and accepted practices that nurses already employ in stroke rehabilitation. These interventions have been logically grouped to help nurses meet their basic tasks for each phase of recovery within the Mauk model.
Case Example: Application of the Mauk Model
George was a 69-year-old male admitted to the acute rehabilitation unit after surviving an ischemic stroke 7 days before that resulted in left hemiparesis, minor cognitive-perceptual deficits, and some treatable bowel and bladder dysfunction. The admitting nurse noted that George expressed shock that he had suffered a stroke because he had always diligently maintained a low-fat diet, was not overweight, and had never smoked cigarettes—unlike other people he knew who “never had a stroke.” He wondered aloud why this had happened to him and told the nurse that when he got things “back to normal,” he was going to play in the golf tournament in 2 weeks. He cried once or twice during the nurse’s interview with him.
The admitting nurse assessed that George was in the first phases of poststroke recovery, showing signs of agonizing and fantasizing. She implemented the aforementioned interventions for those phases, providing physical care, emotional support, and needed information to George and his family. After the first week of participation in rehabilitation therapies, George began to show signs of anger and frustration because, though he was walking better than before, the feeling in his arm had not returned. He noticed that other patients had similar problems and told the nurse that “Maybe I’m not going to regain the use of my arm after all.” George began to ask to go to bed earlier and did not seem to want to participate in therapies as often. His wife told the nurse he seemed depressed.
At this point, the nurse determined that George might be in the realizing phase. The nurse recognized that this phase was the most essential for George to work through to positively adapt to life after his stroke. She implemented the interventions appropriate for this phase and provided additional support and resources to the family. This included written information about the stroke service and support groups offered by the hospital. The nurse also stated that she would call George the week after he went home to see how things were going. She assured George’s wife that any displays of anger were not to be taken personally and wrote a referral for George to be seen by the unit psychologist. The nurse continued to provide emotional support for George and encouraged him to verbalize his feelings. She also connected with George’s pastor, who visited him and provided additional spiritual support.
George remained in the unit another week and continued to seem depressed. Although he did not display a readiness to learn, the nurse instructed him and his wife in necessary discharge teaching regarding the use and purpose of medications, lifestyle modifications to reduce the risk of another stroke, the importance of follow-up visits with his physician, and the feelings he might have have after he returned home. Although George was not in the ideal phase for learning, he and his wife were nevertheless provided with necessary information and reminded to call the unit with any questions that might arise later. The nurse also encouraged George to attend the unit’s stroke survivor support group after discharge. In addition she discussed the process of stroke recovery with George’s wife and emphasized that helpful resources would be available whenever George was ready to learn and continue his recovery through the last three phases.
One month after discharge, George had adjusted to being home. He had questions about his stroke and wanted to learn more about preventing a recurrence. He was feeling better about himself and had found some ways to make life easier by using adaptive equipment and modifying his home environment. He also attended the stroke survivor support group along with his wife and told the group leader that he had been thinking about what could have caused his stroke. George seemed more cheerful and had a more positive outlook on life, though he still tired easily and at times became frustrated.
The nurse leading the stroke support group determined that George was in the blending and framing stages, because he showed some positive adaptations. The last three phases are the ideal time for survivors to acquire additional knowledge and gain a sense of control over their recovery and life. Nurses can assist survivors in setting goals and making decisions about additional treatment options. In order to foster the recovery process, the nurse helped George consider a medical reason for his stroke and encouraged him to take control over what had happened to him by using the available community resources on the list provided. The nurse also helped George and his wife evaluate their coping skills and assess whether there were additional things George could do to gain a greater sense of control over his life. She encouraged George to resume some of his former hobbies and put him in touch with a personal trainer, as well as a golf coach who specialized in helping stroke survivors return to their game.
The nurse leading the support group also scheduled an appointment for George and his wife to meet with a clinical nurse specialist (CNS) to discuss issues related to sexuality after stroke, as well as the feasibility of returning to some of his other former activities. The CNS was able to speak with George about his desire to pursue other forms of treatment that might increase the physical function of his arm. She provided him with information regarding current research and likely outcomes, as well as costs of different types of therapy. The CNS also connected George and his wife with another couple who had successfully adapted to life after a stroke and who had experiences similar to George’s. The information provided by the CNS did not offer George false hope, but allowed him to set realistic goals for the future that were supported by evidence-based practice. At this point in his recovery, George was now ready to take the needed steps to improve his quality of life and to use the help of professionals to guide him on that quest.
In the previous scenario, nurses used their assessment skills to determine a stroke patient’s phase of recovery. When patients do not complete the recovery process within a hospital or rehabilitation unit, nurses should advocate services that will allow them to follow survivors and their families until full recovery is achieved. Using the Mauk model should ensure that nursing care is appropriately focused, in whatever setting the interventions take place.
Frameworks such as chronic illness trajectory or Kubler-Ross’s stages of grieving have often been used to understand stroke recovery, yet they are not as applicable to the stroke experience as is the Mauk model. Stroke itself is not a chronic illness and does not necessarily follow a downward trajectory over time. Furthermore, although grieving does occur, the Kubler-Ross model does not capture the adaptation process that is inherent in stroke recovery. An advantage of using the Mauk model for care of stroke survivors is that it emerged from the experience of survivors themselves. One disadvantage of the Mauk model is that nurses are not always caring for survivors when they are most ready to learn, so nurses will need to actively advocate that survivors receive care at the time they truly need it. This will likely mean that some type of follow-up program will need to be implemented.
The Mauk Model for Poststroke Recovery, enables nurses to tailor their interventions to better meet the needs of stroke survivors as they journey through the recovery process. Rehabilitation nurses are uniquely positioned to identify the various phases of stroke and take appropriate and meaningful action to provide a higher quality of care according to patients’ needs. Nurses may use the Mauk model to guide practice by focusing on the interventions suggested for each phase. Nurses using this model will need to become proficient in assessing the stage of recovery a patient is in to properly tailor interventions.
The model suggests the need for more community-based educational stroke support groups and especially underscores the importance of individualized home nursing instruction for stroke survivors and their families to address concerns that arise following discharge from the healthcare facility. For survivors completing the recovery process at home without the assistance of the healthcare system, nurses may teach the concepts of stroke recovery in the model prior to discharge and make suggestions for home activities that are similar to nursing interventions as suggested in this article.
Existing and recent clinical practice and research supports the interventions suggested by the Mauk model. A classic study by Mumma (1986) revealed that long after stroke, patients and spouses still struggled to adapt to changes such as loss of mobility and decreased independence. Pierce, Finn, and Steiner (2004) found that the top five self-care needs for which patients and their families desired information about were (a) preventing falls, (b) proper nutrition, (c) staying active, (d) stress management, and (e) coping with mood changes. Pierce and colleagues have conducted ongoing research on the benefits of Internet-based support for rural caregivers of stroke survivors (Pierce et al., 2004). Castellucci’s research on patients’ perceptions of autonomy after stroke (2004) suggested that increasing a survivor’s sense of choice in decision-making may decrease feelings of loss and subsequently decrease the depression from which stroke survivors commonly suffer. Certainly these findings suggest that the stroke recovery process continues long after discharge from the healthcare facility and that survivors and their family members could greatly benefit from nursing interventions within the home and community.
The Mauk Model and its interventions need to be examined, refined, and tested. Many questions remain to be explored such as: How accurately and consistently can nurses identify in which phase a patient is? Could a checklist be developed to assist nurses to identify a stroke patients’ phase of recovery? How do survivors progress within and through each phase? How effective are the suggested interventions for facilitating stroke recovery? Will the interventions result in better outcomes for stroke? If so, which outcomes would be improved? Could this model be used with other populations?
A pilot study with nursing students and registered nurses is being conducted by the author to determine whether case studies may be used to correctly assess a survivor’s phase of stroke recovery. All of the case studies are being investigated to further refine the model.
Preliminary discussions suggest that the model is applicable for most stroke events. However, the author notes that in cases where stroke survivors have other complicating medical problems, such as traumatic brain injury or severe cognitive deficits, the applicability of the model may be challenged. Further testing and refinement might be required to enhance the model’s usefulness for such patients. In addition, the rare negative case example involved a survivor being “stuck” in one phase so he or she cannot progress through the realizing phase and move on to the positive adaptations associated with the last three phases. However, even such negative cases demonstrate that stroke survivors may remain angry and depressed, characteristics associated with the realizing phase, and thus still provides support for the idea that people who adapt well to life after stroke must continue to progress through all of the phases of recovery outlined in the Mauk model.
The author acknowledges that much more research and clinical data are needed to evaluate the many aspects of the Mauk model and to determine the most appropriate interventions for each phase of stroke recovery. In addition, more concrete ways of assessing which phase a survivor is in at any given time need to be developed. Ultimately, an experimental study will be designed in which survivors are randomly assigned into groups who receive care based on either the Mauk model or a more typical approach to nursing. Such a study will better determine the success or failure of outcomes, as well as provide additional data for continued development of the model. This grounded theory model will better educate nurses to assess stroke survivors’ recovery progress so that they may offer proper interventions in the poststroke journey.
About the Author
Kristen L. Mauk, Phd RN CRRN-A APRN BC is an associate professor of nursing at Valparaiso University. Address correspondence to her at Valparaiso University, 116 Le Bien Hall Valparaiso, IN 46363 or firstname.lastname@example.org
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