Exploring the care needs of stroke dyads in hospital-to-home transition from perspectives of stroke dyads and health professionals

Author: Langduo Chen

Chen, Langduo, 2023 Exploring the care needs of stroke dyads in hospital-to-home transition from perspectives of stroke dyads and health professionals, Flinders University, College of Nursing and Health Sciences

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Stroke occurs when cerebral blood flow is disrupted by vascular occlusion or rupture, causing brain tissue damage. It is a leading cause of adult disability worldwide. Hospital-to-home transition is a challenging period for stroke dyads (people with stroke and their caregivers) due to shortened hospital stays and complex care needs, as they must now take charge of care. Although stroke dyads demonstrate dyadic interdependence in the transition, few studies have explored their individual and dyadic care needs and expectations during the transition.


The aim of the study was to understand the care needs and expectations of stroke dyads during the hospital-to-home transition from the perspectives of stroke dyads and health professionals in South Australia.


Gadamer’s philosophical hermeneutics guided the study. Thirty stroke dyads and 31 stroke care clinicians, including two general practitioners, participated in the study. Data were collected through interviews with stroke dyads before hospital discharge and at 3 and 6 months after discharge. Focus groups and interviews were used to collect data with stroke care clinicians.


Stroke dyads’ perceived preparedness in managing post-discharge care was influenced by psychological and emotional state, resilience, and level of engagement in discharge planning. Returning home was seen as a significant milestone in the post-stroke trajectory. However, compared with people with stroke, caregivers perceived profound uncertainties about their role and how to take over care after discharge as a result of inconsistent engagement in discharge planning.

After discharge, stroke dyads experienced a sense of setbacks due to physical and psychosocial factors. They perceived a dyadic interdependence, which generated positive impacts on their adaptation to challenging situations. Caregivers played a key role in providing psychological support for people with stroke, but such a role was not fully recognised nor supported in the healthcare system. Moreover, stroke dyads expected enhanced communication, engagement in discharge planning and needs-driven service provision. Additionally, health professionals believed that prioritising the safety and continuity of care enhanced the transition and helped health professionals to cope with work-related challenges.


Findings support previous studies that found that equal attention to stroke dyads’ psychological and physical recovery facilitates the development of their self-management ability during the transition. The findings also add new understandings that people with stroke mainly rely on caregivers to provide psychological support, while caregivers also show vulnerability in their role and unmet self-care needs. Such situations underscore the significance of dyad-centredness in care needs assessment and discharge planning. Additionally, findings suggest an innovative nurse-led, stroke-specific hospital-to-home transition care framework. This framework emphasises the partnership between the healthcare organisation, health professional and stroke dyad as the foundation for stroke-dyad-centred transition care at three key time points—during the hospital stay, arriving home and during formal rehabilitation programs, and after separation from formal rehabilitation programs and during community dwelling.


Findings support a dyad-centred and interdisciplinary care approach to hospital-to-home transition care that emphasises collaboration, communication and continuity of care across different care settings and service providers. Findings also support the need for further studies on the feasibility, acceptability and effectiveness of the nurse-led, stroke-specific hospital-to-home transition care framework.

Keywords: people with stroke, caregivers, stroke dyads, transition care, discharge planning

Subject: Nursing thesis

Thesis type: Doctor of Philosophy
Completed: 2023
School: College of Nursing and Health Sciences
Supervisor: Lily Dongxia Xiao