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Heart Disease And Stroke Atlas Health And Social Care Essay

The World Health Organisations Atlas of Heart Disease and Stroke states 15 million people worldwide suffer a stroke each year, resulting in 5 million death and 5 million cases of permanent disability (Mackay & Mensah, 2004). The European Stroke Initiative (EUSI) Guidelines noted that stroke is either the second or third highest cause of death in industrialised countries (Hacke et al, 2003). In terms of effect of stroke on society, Stroke is projected to cost around 61 million Disability Adjusted Life Years (DALYs) worldwide by 2020, compared to 38 million in 1990 which means an increase of 60% (Mackay & Mensah,2004).

According to the World Health Organisation (WHO), stroke takes the second world wide leading cause of mortality resulting in 5.5 million deaths per year. Two thirds of those deaths occur among people living in developing countries. In addition, many survivors of stroke have to adjust to a life with varying degrees of disability (World Health Organisation).

In the UK stroke is the third most common cause of death, and the most common cause of disability. More than 250.000 people live with impairments due to stroke. Almost third of the people who had a stroke are left with disabilities. (The Stroke Association,2010). Stroke coast England and Wales society nearly £7 billion per annum.

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The World Health Organisation (WHO) defines Stroke as:" rapidly developed clinical signs of focal (or global) disturbances of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin" (Edmans, 2001.P:1)

The main causes of Stroke are: 1. Ischemia leading to infraction (lack of bleed supply to a specific area leading to a poor blood supply, caused by an embolism by heart, aorta, carotid or vertebral vessels. 2. Haemorrhage (bleeding from a vessel due to hypertension or abnormal clotting it could be in subarachnoid, subdural, intracerebral or extradural areas (Edmans, 2001). 80% are due to ischemic causes and 20% due to haemorrhagic causes. (Bartel, 1998)

Stroke can cause any or all of the following neurological effects, which may or may not be transient, or even can be permanent and remain after rehabilitation (The Stroke Association, 2010):

Impairment or loss of sensation in the limbs or face.

Hemiplegia (loss) or Hemiparesis (impairment) of movement in the limbs or face.

Aphasia (loss) or Dysphasia (impairment) of the ability to produce (expressive) or to understand (receptive) speech,

Dysphagia (difficulty swallowing)

Apraxia (lack of), or Dyspraxia (impairment) in coordination of movement.

Neglect (lack of or reduction of awareness of one side of the visual fieled)

Emotional instability.


Incontinence or problems with bladder control.

Visual deficits.

The majority of Stroke survivors need Rehabilitation to improve Health and minimize disabilities (Aprile, 2008). As a result stroke survivors comprise the largest category of patient in rehabilitation (Gnocchi et al, 2008). The EUSI guidelines noted that rehabilitation needs to start as soon as the patient is stable clinically, and should continue as far as improvement in function is observed.

Within the literature many authors define Rehabilitation (Davis 2006). (Barne and Ward 2000) defined rehabilitation:" An active and dynamic process by which a disabled person is helped to acquire knowledge and skills in order to maximize physical, psychological, and social function. It is a process that maximizes functional ability and minimizes disability and handicap". (P.4)

In the recent year Client centeredness has emerged as an important principle for health delivery and rehabilitation services (picker institute, 2000) and it's considered to be a key component of good practice (Law et al, 1995). Whiteneck (1994) noted that" an individual should be viewed as the primary focus of the rehabilitation and goal setting process and subjective perception are needed to fill the gaps left by objective assessment" (P:1074) . However, the priorities between the health care professionals and clients may differ, as a result patients may not want to achieve the identified goal.

Client centred rehabilitation has been described as a programs that helps to meet individuals (people with long term disability) needs, by preparing them for life in the real world, participation in goal planning and decision making with health care professionals, and to involve the family throughout the rehabilitation process (Cott,2004). The government modernisation agenda for national health services (NHS) mentioned the need for greater partnership and involvement of service users at every level of healthcare system (Department of Health (DOH), 2005). People with stroke should have the chance when possible to take decision about their treatment and care, with partnership of healthcare professionals (NICE clinical guidelines 68-stroke, 2008). Stewart (2001) noted that "being patient centred actually means taking into account the patients' desire for information and for sharing decision making and responding appropriately" (P: 445).

Client centred approach has been defined as one that is" based on the belief that the client is the important person in the relationship and that he has the recourses and ability to help himself given the opportunity to do so" (Dexter & Wash 1986, P (17) cited in Sumison T ,2006 P (5)). Client centred practice can be described as an approach that embraces partnership with people using services (Restall et al,2003) , it also offers a shift from the traditional medical model provided by the health care practitioners( Wright & Rowe,2005). The medical model embarrasses the view that the health care professionals are the experts, who have all the power and authority to control others. In other words clients are defined through their medical conditions (illness) and treated as dependant on the health care professionals (Barbore, 1995). Hunt (1993) noted that, the medical model was the dominant view for a long time where health care professionals held the view that " rehabilitation can be used to reduce disability be helping people relearn skills and adapt themselves to a world in which able bodiedness is the norm" (P: 130). On the other hand the social model argues that it is the society that disabled the person. How the society treats disability (Barnes & Mercer, 2003). Client centred can be applied in both the social/medical model environment as it creates a natural balance between them (Falardeau & Durand, 2002).

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Pollock(1993) noted that client centred approach takes into consideration goals that are set by the client according to his/her own view of the problem, as a result it encourages and increases the persons potential and participation during rehabilitation. In addition setting goals may help individuals to solve his/her problems and the feeling of control over their health increase.

According to the stroke statistic mentioned previously, and the highly cost of treatment and rehabilitation for stroke survivor. Therefore, to determine an effective and efficient rehabilitation program, might improve or determine efficient and effective overall outcomes for these growing survivors.

This dissertation will comprise the following chapters: the preliminary literature review where the body of knowledge will be discussed in depth. This chapter sets to discover what is already known about client centred care, its definitions, core elements, barriers and limitations, and client centred goal setting, ending with a clear statement of the research question for this study. The Methodology chapter will discuss and justify the paradigm and methodology used for this dissertation and why is it appropriate for this study. Then it will move to the Methods chapter where the process of searching the literature will be demonstrated, search term, inclusion and exclusion criteria, and the chosen tools used to critically analysed, synthesize and analyse the key articles. The results chapter will set to critically appraise the key articles using "step by step" framework to compare their strength and weakness to be able to judge the results and findings of these studies. In the Analysis chapter themes and codes that emerged from the key papers will be presented, and compared according to the strength of the evidence. The discussion chapter will link the findings and results from the analysis chapter (themes) with what is already known about the topic from the literature review. Moreover, limitation and recommendation for the current study will be mentioned in this chapter. Finally, the in conclusion chapter the author will summarise the findings, and make a recommendation for future academic work.


Working in the UK in a neuro rehabilitation environment had been an eye opening experience. This experience has uniquely directed the author towards the field of rehabilitation. What appeals to the author the most about rehabilitation is the client centred approach to patients care. The aim of this study is to review the literature about client cantered care, aiming to discover the benefits of implementing client centred care in stroke rehabilitation practice, and what attitude should both health care professionals and clients need to go through to embrace client centred practice. After gaining this Msc degree the author is planning to go back home and try to implement and use the evidence gathered in this project to educate health care professional's student. As in my country (Jordan) Client centred approach is not yet practised by both the individuals and the professionals too in rehabilitation units. That means that while treating or even setting goals of a patient, family are the ones involved mainly in planning everything for the patient not the patient himself, in another words Professionals have to treat the whole family not the individuals.



This chapter aims to set the ground for the study to be taking, by examine the exciting knowledge in client centred approach. Shadowing an overview of client centred practice, a variety of definition for Client centred will be discussed from medical, nursing and occupational therapy perspective. Later on, the core elements of client centred will be discussed in depth .The chapter will also discuss the challenges to implement client centred practise and how to overcome them. Finally, client centred goal setting will be defined and explained. By the end of this chapter the research question will be demonstrated.

Rogers theory of therapy

Carl Rogers was the first to describe client centred, Rogers stated that the focus of any intervention should be based on the clients concern "The role of the therapist according to Rogers is to facilitate problem solving through stimulating the persons desire and ability to understand problems and propose solution that are appropriate for his/her life" (law & Mills, 1998: Cited in Richared & Lauri ,2010). Client centred therapy describes Carl Rogers way of working with people experiencing problems in living due to personal disturbances (Rogers,1980 Cited in Kazantzis & Labate,2007). In 1939, Rogers developed his own theory of psychotherapy with troubled children, then after that he tried to expand this theory by including families, couples and groups. In 1959 his theory of group interaction and interpersonal relationship, as well as theory of motivation and personality development was published. The theory of motivation came up from Rogers observation to clients development within the therapeutic relation (Kazantzis & Labate, 2007). Based on his experience as a psychotherapist, Rogers noted that "persons possess resources of self-knowledge and self healing, and that personality change and developments are possible if a definable climate of facilitative conditions is present" (Rogers, 1980 P: 115). Ryan & Deci (2000) also noted that a self directed/driven process might lead to a better self understanding and acceptance. Witty (2007) demonstrated that "Rogers felt that all living organisms are continually actualizing their potential, even under unfavourable circumstances" (P: 36). Rogers (1980) did write about a potato in his boy hood home:

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"The actualizing tendency can, offcourse, be thwarted or warped, but it cannot be destroyed without destroying the organism. I remember that in m boyhood, the bin in which we stored our winter's supply of potatoes was in the basement, several feet below a small window. The conditions were unfavourable, but the potatoes would begin to sprout pale white sprouts, so unlike the healthy green shoots they sent up when planted in the soil in the spring. But theses sad, spindly sprouts would grow 2 or 3 feet in length as they reached towards the distant light of the window. The sprouts were in their bizarre, futile growth, a sort of desperate expression of the directional tendency I have been describing. They would never become plants, never mature, never fulfil their real potential. But under the most adverse circumstances, they were stiving to become. Life would not give up, even if it could not flourish..... This potent constructive tendency is an underlying basis of the person-centred approach (Rogers,1980 P:118-119)

Overview of the client centred care concept

In 1980 Health promotion was established, it was based on, that the clients should be involved in health care and to be responsible of their own health, in addition consumers right, technological revolution and human rights all of which helped to develop the concept of client centred practice (Gage, 1994, law et al,1995 cited in Sumsion,2006). Moreover, the Canadian Association of Occupational Therapists (CAOT) has embraced the concept of client centred, as in 1980 (CAOT) and the Department on National Health and Welfare the Guidelines for Client Centred Practice of Occupational Therapy been produced (Richared L & Lauri K, 2010), in addition The American Occupational Therapy Association(AOTA,1998), the Commission on Accreditation of Rehabilitation Facilities (CARF,1989), and the Joint Commission on Accreditation of Healthcare Organization (JCAHO,1992) all of those organisations did emphasized on the need for client centred practice. The main goal and aim of The National Service Framework for Long Term Condition for people with long term conditions to fully support individuals to be able to manage themselves, maintain independence to get to the best possible quality of life. Universities are also acknowledging the need to change the way future therapist and doctors are educated, for instant, the medical school at a Canadian university adapted a patient-centred method as the focus of the curriculum, as it recognize and belief that, a patient has a disease but also an illness experience that differs from one to another ( Western Alumni,1997). The above examples may lead to a conclusion that client centred practice is supported and recognised by health care professionals and the health care system.

What is client centred practice?

Client centred care has many definition within the literature, however, a universal definition does not exist (Stewart, 2001). Client centred practice within occupational therapy is has been defined as "an approach to providing occupational therapy which embraces a philosophy of respect for and partnership with people receiving services. It recognises the autonomy of individuals, the need for client choice in making decision about occupational need, the strength clients bring to an occupational therapy encounter and the benefits of the client therapist partnership and the need to partnership and the need to ensure that services are accessible and fit the context in which a client lives" P: 253 (Law et al, 1995 cited Sumsion, 2006 P: 5). In addition Sumsions (2000) conducted a interviews to determine how client centred was define by occupational therapist, and concluded the following definition of client centred practice is "a partnership between the client and the therapist the empowers the client to engage in functional performance to fulfil his or her occupational rules in a variety of environments, the clients participates actively in negotiating goals which are given priority and are at the centre of assessment, intervention and evaluation. Throughout the process the therapist listen to and respect the clients value, adapt the interventions to meet the client's needs and enables the client to make informed decision" (Sumsion, 2000 cited in Sumsion & Law, 2006) (P:308) .The British Association of Occupational therapist(1994) definition of client centred practice is" the re-design of patient care so that hospital recourses and personal care are organised around patients rather than around various specialised department" (P:1). The College of Occupational Therapist supports the client-centred approach to intervention by stating within the code of ethics and professional conduct that service should be client-centred and needs led (College of Occupational therapists 2000).

In medicine, patient centred approach was seen as "the physician tries to inter the patients world to see the illness through the patients eyes" (Mcwhinney,1989 cited in Mead & Bower, 2000). In the medical literature client centred practice focuses on the issues of communication between the health care professionals (Doctors) and clients which is one component of client centeredness. Finally, in nursing literature client centred care is a philosophy of care, which includes the emotional, spiritual, social and the physical needs of the client, and a mutual collaboration between the client and health care professionals (Nurses) (Millers & Koop, 1984)

The above definitions might lead to a conclusion that communication, partnership and respect for patients is a core requirement for client centred care.

The goal of client-centred practice is to formulate a tender, caring, and empowering environment in which clients direct all of the process care to speed the healing outcomes ( Matheis-Kraft et al, 1990). In order for this to happen a repositioning in power should transfer from the therapist to the client, with individual empowerment as key (Gage and Polatajko, 1995).

Larsson Lund et al (2001) mentioned that the client should be the one in charged over their health because the quality of life is more essential than therapeutic problems. Clients can participate in client centred practice by being involved actively in discussion (Degnen, 2002) ,treatment planes and goal settings.(Gage,1994). Stewart (2001) noted that "being patient centred actually means taking into account the patients desire for information and for sharing decision making and responding appropriately" (P:445)

One of the key values of client-centred approach is for health care professionals to inter patients world through seeing their illness from the patients eyes (Brown et al, 1989), McCracken et al (1983) also agree with this value, by stating that client-centred approach is based on, that health care professionals have to understand the illness from the patients perspective, not just interpreting the illness from the medical point of view. Health care professionals should try to expand the illness experience of patients by having a clear idea about the patient's feelings, fears and ideas about what is wrong, expectations from health care professionals and how did their illness affect on their functioning (Watson et al, 1989).

Core elements of client centred practice

Sumsion & Law (2006) where the once who delineated the five core concepts of client centred practice: a number of previous studies came out with the same ideas

This is also referred in the literature review where it had been stated that ..


To understand the influence of power is a key value to implementing and understanding of client centred practice. Control, strength and competitiveness are central concepts within the idea of power. To implement a client centred practice health care professionals needs to understand the balance of power between clients and therapist (Honey,1999), the balance of power within client centred practice means a shift in power from the strict traditional medical paradigm to one the concentrates on the clients need ( Falardeau & Durand,2002). however, Corring(1996) cited in sumsion & law (2006) found that health care professionals might have the power over the clients and that clients are disempowered by the health care system, French (1994) agreed with Corring (1996) and did described the relationship between therapist and clients as " is an unequal relationship with the professionals holding most of the power. Traditionally professional workers have defined, planed and delivered services, while disabled people have been passive recipients with little if any opportunity to exercise control" .(p103). Once this power is accepted and understood from both the clients and health care professionals, both can work collaboratively and clients can control their own health and become equal partner in health care instead of always seeking help from professionals (Sumsion, 1999).

Listening and communicating

Effective communication by using the appropriate language is a key element to insure an effective collaboration and partnership between health care professionals and clients (Townsend,1998), this communication includes clients, his/her family and all of the team member ( Kraft M et al,1990), listening is an important aspect of communication (Webster,2001), which can be addressed by allowing the client to express his/her values, beliefs and issues they are facing, regarding his/her experience with impairment (Harrison,2001), in order for this to happen therapist should be patient and take time to listen even though if what is expressed does not make sense to therapist. Otherwise, clients might feel not valued or respected (Hanman, 2001),as result, therapist may feel pressured as they might find it difficult to give clients sufficient time, ( Fondiller, Rosage & Neuhaus, 1990 ( P:51) stated this comment " When time is measured in 15 units how can there be patient centred treatment?"

Therefore, the health care professionals might face the challenge to change the traditional relation with clients and shift it towards partnership (Rosenbaum et al, 1998) which is going to be discussed next.


Professional and affective partnership between the client and health care professional is needed to insure that maximum care is provided ( Levitan,1997), in client centred practice clients should play the major and active role in settings goals and outcomes, on the other hand health care professionals are the expert that provides information, knowledge and treatment to help clients to move on ( Rosenbaum et al,1998), being client centred is time consuming, however the time spent will enhance the relationship between clients and health care professionals, which will lead to a long term benefits ( jones et al,2004). The concept of client centred requires a partnership between healthcare professionals and the client, this partnership is mainly based on therapist willingness to listen to the clients point o view and perspective about disability/impairment and what is his/her experience of being disabled/impaired like (Sumsion & law,2006)


Choice is an important and a key element in client centred practice, however choice element depends on the level of illness or disability, and the capability/ability of client to make decision. Health care professional should include a range of choices for the client to choose from throughout the intervention process (Sumsion & Law,2006),and to bare on mind that each client is a unique individual who should be provided with the information in a understandable, and afford the client the chance and opportunity to choose the best course of action according to his/her values and wishes( Law, Baptiste & Mills,1995)


"Hope is the expectation that something good will happen in the future and that the client can't live without it "(Von gunten, 2002 P: 1421). Throughout client centred practice, it is important for clients to maintain hope. Health care professionals should understand the importance of spirituality in each client, and to demonstrate respect for client's personal definition of hope and perspective on each client's journey towards wellness (Sumsion & law, 2006). Bays (2001) see spiritual strength as a central component o hope. Spirit is recognised as "the driven force and motivation for a person to find meaning and purpose in life" (Engquist et al, 1997). Moreover," Each individuals spirit is expressed through his or her engagement in everyday life, that is, his/her occupational performance in work, self-care and leisure" ( Egan & Delaat,1994(P:100). Hope is a important issue for clients, (Bays 2001, P: 26) stated "if you don't have the hope then you will be totally lost "

Client centred goal setting

Barnes & Ward (2000) did describe goal setting as "the essence of rehabilitation" (P: 8). Goal settings helps to facilitate a client centred approach in rehabilitation, as it could be adapted to the client according to his/her impairment (Malec, 1999), it also provides a way to measure the progress in rehabilitation, and the effectiveness of the chosen rehabilitation programs (Lannin, 2003). A successful rehabilitation is the one that is based on team collaboration, client oriented, and aiming to target the goal rather than finding a solution for the problem (Gage, 1994).

Goals are a major component of the rehabilitation process. The rehabilitation team usually have a common goal to the patient, that's why it is important to include the patient in the goal-setting process (Wade, 1998). Pollock (1993) noted that, patients should be the one to set the goals so he/she could solve their own problems, otherwise the patient will start feeling that they are not controlling their health. Moreover, claims that, there might be an increase in patient participation in the rehabilitation process, if patients did participate to set their own goals and decision making.

Barriers to implementing client centred practice

Knowledge about implementing client centred over the past two decades has grown considerably (Sumsion & Law, 2006), there are many issues that health care professional must address before trying to implement client centred practice (Sumsion,2006), these issues and barriers may be due to the client, the therapist and the working environment (Law & Britten,1995) .

Sumsion T (2006) noted that the barriers to client centred practice were found when the health care professionals and clients had different goals, when the health care professional don't accept the clients goal, Lack of time and ability to build rapport with clients, health care professionals lack the knowledge about client centred practice, and when the healthcare professional feels unhappy and uncomfortable to let the clients set their own goals. To overcome these barriers he recommended the need of management, education, support, training in client centred practice, and having a structured philosophy.

A study done by Sumison & Smyth (2000) among 60 occupational therapists using a postal questionnaire in the United Kingdom, in which therapist ranked 16 barriers to client centred practice identified from the literature, the three highest barriers were:

health care professional and the client have different goal

heath care professionals beliefs and value prevent them from accepting the client goal

Health care professionals feel uncomfortable letting clients to decide in their own about his/her goals.

Moats (2007) noted that clients with cognitive impairments might make unrealistic and unsafe choices, causing a limitation while trying to implement client centred care. A expolarity study was conducted by Wressle & Henriksson (1999) with geriatric stroke patient during rehabilitation program suggest that, clients usually don't participate in goal formulation and treatment plan, they also put forward the need of having a structure model and philosophy to engage clients in the rehabilitation program.

At the organisation level, Gage (1994) noted that a lack of interdisciplinary care serving is considered to be a barrier of implementing client centred practice, moreover Wressler & Samuelsson (2004) highlights that the lack of understanding about what is client centred practice in general also considered to be a barrier. In addition, time pressure placed on health care professional might also be a significant factor that holds client centred practice back (Stewart et al, 2003).

From the previous discussion it may not be easy nor simple to implement a client centred approach (Sumsion,2006).


This chapter has provided an insight into the different aspect of client centred practice, which will serve as a base to guide the rest of the study. This study will take a close look at the benefits of client centred approach in practice, this will be done by trying to answer the following question: how does research underpin the use of client centred approach?

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