Benefits of Evidence Based Healthcare Practice

2995 words (12 pages) Essay

23rd Mar 2018 Health Reference this

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Evidence based practice refers to clinical practices that include best available scientific evidence (Levin and Feldman, 2006) based from expert opinion, clinical guidelines and findings from researches, combined with good clinician judgement and client’s preferences (Kim and Mallory, 2011) on issues relating to healthcare. The whole essence is to ensure the best care for patients and to be able to explain why certain clinical interventions are applied. This piece of work will briefly outline the importance of evidence based practice before analysing four pieces of evidence in the care of a stroke patient, Omar Banerjee, and its usefulness other users.

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Oman et al (2003) states that evidence based practice started to be appreciated and recommended by the National Health Services (NHS) in the UK in the early 1990s. The reason was to have effective and less costly interventions while providing high quality healthcare system. The intervention should be based on best available evidence and provided in the best interest of the patient such as Omar in this analysis.

In addition, when a particular intervention is used on a client, evidence is required to back up that particular action (Kim and Mallory, 2011). In the UK this support can come from the NICE guidelines, Care Quality Commission and the codes and practices of professional bodies like Nursing and Midwifery Council.

Evidence based practice ensures accountability. Aveyard and Sharp (2013) noted that professional health carers who belong to various professional organisations are expected to comply with their standards, codes and policies. This will be enabling them to justify their actions if required to do so.

The first analysis of Omar’s condition is based on Cross (2008)’s evidence on stroke care. This evidence was obtained from the UWE blackboard website. I have chosen this article because it has statistical information helpful to Omar and his carers. It identifies important areas of his care needs and why stroke research should continue to be an on-going process.

Sander (2013) defined stroke as a disease caused by the disturbance of the flow of blood in blood vessels in the brain which could have been necessitated by a bursting blood vessel or blood clot. Omar’s stroke was caused by a blood clot in the brain. Stroke has become a big problem and the second main cause of death and disability in developed economies after heart related diseases (Cross, 2008). Sander (2013) emphasises out that stroke is affecting about 150, 000 people in the UK yearly.

However, the article reports a decline in deaths because of improvements in stroke care, management and awareness. More resources have been put towards short to long term care of stroke patients such as admission to acute stroke units and to rehabilitation areas (Cross, 2008). The report says this evidence, among others, is being used to develop new stroke treatments and guidelines in the UK. NICE (2008) which provides tools and quick reference guide to stroke related cases could have emerged as a result of this. These developments may give hope to Omar and his distressed family.

The article cited two evidence of good practice from two hospitals. It is reported that the stroke management team at Aintree University Hospitals NHS Foundation Trust assess stroke patients on admission to the A&E, take brain scans and admit relevant patients to a stroke unit within 24 hours. The other evidence is from Salford Royal NHS Foundation Trust where patients have brain scans, swallow screens and initial dose of aspirin given to relevant patients. These practices are recommended by NICE (2008) guidelines and may reduce further risks to patients. Omar received these interventions. This shows the strength of this article to Omar’s case and how early intervention may result in positive outcome.

Although the article stressed the need for nurses to continuously monitor patients during the early stages of stroke on certain variables, it did not provide guidelines to back up the checks. Locally agreed hospital policies suggested may not meet NICE standards.

Despite the improvements noted in the research, caution should be taken when making decisions based on the findings. These are 2008 findings and a lot has happened since then. Omar may be interested in hearing recent studies such as that of Sander (2013) who points out that in addition to the swallow screen stroke patients should further be screened for malnutrition using Malnutrition Universal screening Tool (MUST) in line with the NICE (2008) guidelines.

The second analysis of Omar’s care is based on a qualitative study of Tutton et al (2012) on ten staff and ten patients’ views on the concept of hope on a British stroke unit. The evidence was obtained from EBSCO via CINAHL database and UWE library section. I chose this evidence because CINAHL is considered as one the good sources of evidence (Levin and Feldman, 2006) and the concept may be useful to Omar to learn other patients’ experiences in a similar hospital setting.

The aim and key search terms in the article relate well to Omar’s case. Hope is defined as getting better from illness and being able to do things as before (Tutton et al, 2011). This was echoed by some of the patients in the study. An in depth analysis of key terms and the codes used in qualitative study (Aveyard and Sharp, 2013) may help carers to understand how it feel to have a stroke. Omar and his family may share the same thoughts as they are finding it hard to come to terms with sudden change of things in their family.

Despite taking long time on data collection and variations in stroke severity Omar may be encouraged to learn that some patients took less than a week in hospital. This result is echoed by Arnaert et al (2006) in a similar study based on ten patients in Canada. They reported that some clients were hoping for a quick recovery and self-healing.

The article is good evidence as it stated what is already known about this topic and nursing implications. These aspects are echoed by Arnaert et al (2006) but Tutton et al (2011) further identify what the paper has added such as the multidisciplinary team involvement in caring for stroke patients to make hope a realistic thing.

Although the article mentioned that consent was obtained from both participants, there are still some ethical issues in the article. Some of patients’ names are mentioned in the article. This is confidential information and Omar may find himself in a similar situation.

Furthermore, relatives and carers of patients were not interviewed in the study. It may be necessary to hear their views as well especially after learning from Preeti how she was struggling to come to terms with Omar’s condition. Her understanding of hope would improve our knowledge on this aspect.

It is generally accepted that qualitative evidence is ranked second from the bottom in the hierarch of evidence (Polit and Beck, 2012) and uses a small sample size for the purpose of in-depth analysis of topic under consideration (Aveyard and Sharp, 2013). Although a large sample size may be costly and time consuming, caution must be taken when making inferences on large population size like 150, 000 patients mentioned earlier.

A third analysis of Omar’s care considers service audit and evaluation evidence from Sentinel Stroke National Audit Programme (SSNAP) (2013). It is a national audit on stroke patients admitted to hospital in the first three months of 2013. The research looks at the processes of care at early stages of stroke (72 hours) from hospital arrival. I have chosen this evidence because SSNAP is a nationally recognised organisation and works with other organisations in stroke related cases. Its recent results obtainable through Google, SSNAP Audit Report (2012) and Royal College of Physicians links have strong implications on Omar’s condition.

SSNAP (2013) results show the importance of using guidelines in any intervention involving stroke cases. There is strong evidence in the article that stroke patients were immediately taken for brain scans and admitted to the stroke units, as in the case of Omar, upon arriving hospital. This is in line with NICE (2008) guidelines. Most of the trusts were able to meet this standard. However, it is worrying to learn that there is a lower chance of having scan during the weekend and night times, the time of the week when Omar experienced the stroke.

NICE (2012) guidelines stipulate that people who have had TIA should have first dose aspirin upon initial assessment. Although Omar received one, the outcome in the report is not very pleasing. It is clear from the research that this standard was not met by all trust as there are huge variations.

The research was only focused on 72 hours upon hospital arrival. It may benefit the public and give confidence to Omar if the care he received from the ambulance crew were up to standards. NICE (2012) guidelines require people suspected to have had stroke to be screened using a FAST tool. There are no statistics regarding this in the article as the research excluded time before hospital arrival and the rehabilitation. This information may enlighten the public the importance of early intervention in stroke care.

This evidence is not peer reviewed and the way data was collected is of concern. Because the SSNAP is a single source of data nationally (Paley et al, 2013) and an online web-tool was used to gather information one may wonder whether variations in results may appear if a different organisation undertakes the same research. Caution should be applied when interpreting this data.

The audit results stress the importance of early intervention by multidisciplinary stroke team in the care of stroke patients. However, there are some areas that require attention if the all standards are to be fully met.

The final analysis of Omar’s care is based on quantitative study by Beavan et al (2010) on whether looped nasogastric tube (NGT) feeding improves nutritional delivery to acute stoke patients with dysphagia. The evidence was obtained from UWE blackboard website. I chose this evidence because the intervention, tube feeding, helps to resolve Omar’s swallowing difficulties and improve nutritional needs. The research helps in answering questions on whether there are other alternatives and any effects associated with the intervention.

The research was necessitated by the poor nutrition on patients on admission to hospital and the dislodgement associated with adhesive nasal stickers. Findings from the research reported more benefits in using the loop system than the other method. Some of the benefits include fewer checks for NGT position, less supplementary feeds required, more volume of fluids and feeds and less dislodgement of NGTs. This is vital information to Omar as it highlights why the intervention is used. However, the costs were seen to be high for the two week period.

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It is important to explain to Omar that studies of this nature are useful and commonly used in clinical interventions. It is a view shared by many authors like Polit and Beck (2012) and Aveyard and Sharp (2013). They rank randomised controlled trials as second best on the hierarch of evidence after systematic reviews and meta-analysis.

There are some ethical issues regarding the funding for the research. Procare Ltd supplied the loops. The researchers stressed that it was not involved in any logistics or interpretation of the results, but one may wonder why the loops were sold at a bulk price. Could this have resulted in a discount? If the answer is yes then it is likely that the costs could be higher than the reported one.

In addition, the aspect of tolerability was mainly based on the views of nurses and family members. Although it is understandable that most of the patients were having communication problems, the number of patients unable to communicate is alarming to the extent that caution is required when using this evidence.

The study was done some years ago and the results published in 2010. A number of changes may have happened since then. Omar will be susceptible on why using such an old piece of evidence. Recent research results may be easier to convince Omar and his family than old results.

To sum up, stroke is a major disease affecting many people and causing disabilities among survivors. Any nursing intervention will require evidence to back up. Four sources of evidence have been analysed in relation to Omar, a stroke patient. The strengths and weaknesses associated with each of this evidence will enable any intervention in Omar’s care to be made in rationale way and to his best interest.

WORDS: 2 089

Reference

Aveyard, H. and Sharp, P. (2013) A Beginner’s Guide to Evidence-Based Practice in Health and Social Care, 2nd ed. Berkshire: Open University Press.

Kim, M. and Mallory, C. (2011) Statistics for Evidence-Based Practice in Nursing, Burlington: Jones and Bartlett Learning.

Oman, K.S., Krugman, M.E. and Fink, R. M. (2003) Nursing Research Secrets, Philadelphia, Pennsylvania: Hanley and Belfus.

Pilot, D. F. and Beck, C.T. (2012) Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Levin, R. F. and Feldman, H. R. (2006) Teaching Evidence-Based Practice in Nursing: A Guide for Academic and Clinical Settings, New York: Springer Publishing Company.

Arnaert, A., Filteau, N. and Sourial, R. (2006) Stroke Patients in the Acute Care Phase: Role of Hope in Self-healing [online]. 20 (3), pp137-146. [Accessed 14 November 2013]

Beavan, J., Conroy, S.P., Harwood, R., Gladman, J.R.F., Leonardi-Bee, J., Sach, T., Bowling, T., Sunman, W. and Gaynor, C. (2010) Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Available from: https://blackboard.uwe.ac.uk/bbcswebdav/pid-3425495-dt-content-rid-4569416_2/courses/UZWSN3-15-1_13oct_gl_feb14_1/Tube%20feeding%20after%20stroke%20RCT.pdf [Accessed on 19 November 2013]

Cross, S. (2008) Stroke care: a nursing perspective. Nursing Standard. 22 (23), pp 47-56. Available from: https://blackboard.uwe.ac.uk/bbcswebdav/pid-3473085-dt-content-rid-4709333_2/xid-4709333-2 [Accessed on 29 October 2013]

National Institute for Health and Clinical Excellence (NICE) (2008) Audit support (NICE clinical guideline 68 – Stroke) Available from: https://blackboard.uwe.ac.uk/bbcwebdav/pid-3461610-dt-content-rid-4659555_2/xid-4659555_2 [Accessed 12 November 2013]

NICE (2008) Understanding NICE guidance: Early assessment and treatment of people who have had a stroke or transient ischaemic attack (TIA) Available from: www.nice.org.uk/nicemedia/pdf/cg68publicinfo.pdf [Accessed on 01 December 2013]

Paley, L., Campbell, J., Hoffman, A. and Rudd, (2013) Sentinel Stroke National Audit Programme (SSNAP): Clinical audit first pilot public report, National results. Available from: www.rcplondon.ac.uk/sites/default/files/ssnap_pilot_national_report_january_-_march_2013_admissions_with_appendices_.pdf [Accessed on 11 December 2013]

Pale, L., Campbell, J., Hoffman, A. and Rudd, (2013) Sentinel Stroke National Audit Programme (SSNAP): Clinical audit first pilot public report, National results. Available from: www.rcplondon.ac.uk/sites/default/files/ssnap_pilot_national_report_january_-_march_2013_admissions_with_appendices_.pdf [Accessed on 11 December 2013]

Sander, R. (2013) Prevention and treatment of acute ischaemic stroke. Nursing Older People [online]. 25 (8), pp 34-38. [Accessed on 4 December 2013].

Sentinel Stroke National Audit Programme (SSNAP) (2012) Acute organisational audit report: Public Report for England, Wales and Northern Ireland. Available from: http://www.rcplondon.ac.uk/sites/default/files/ssnap_acute_organisational_audit_-_public_report_2012_0.pdf [Accessed 12 November 2013]

Tutton, E., Seers, K., Langstaff, D. and Westwood, M. (2011) Staff and patient views of the concept of hope on a stroke unit: a qualitative study [online]. 68 (9), pp 2061-2069. [Accessed 14 November 2013]

1

Evidence based practice refers to clinical practices that include best available scientific evidence (Levin and Feldman, 2006) based from expert opinion, clinical guidelines and findings from researches, combined with good clinician judgement and client’s preferences (Kim and Mallory, 2011) on issues relating to healthcare. The whole essence is to ensure the best care for patients and to be able to explain why certain clinical interventions are applied. This piece of work will briefly outline the importance of evidence based practice before analysing four pieces of evidence in the care of a stroke patient, Omar Banerjee, and its usefulness other users.

Oman et al (2003) states that evidence based practice started to be appreciated and recommended by the National Health Services (NHS) in the UK in the early 1990s. The reason was to have effective and less costly interventions while providing high quality healthcare system. The intervention should be based on best available evidence and provided in the best interest of the patient such as Omar in this analysis.

In addition, when a particular intervention is used on a client, evidence is required to back up that particular action (Kim and Mallory, 2011). In the UK this support can come from the NICE guidelines, Care Quality Commission and the codes and practices of professional bodies like Nursing and Midwifery Council.

Evidence based practice ensures accountability. Aveyard and Sharp (2013) noted that professional health carers who belong to various professional organisations are expected to comply with their standards, codes and policies. This will be enabling them to justify their actions if required to do so.

The first analysis of Omar’s condition is based on Cross (2008)’s evidence on stroke care. This evidence was obtained from the UWE blackboard website. I have chosen this article because it has statistical information helpful to Omar and his carers. It identifies important areas of his care needs and why stroke research should continue to be an on-going process.

Sander (2013) defined stroke as a disease caused by the disturbance of the flow of blood in blood vessels in the brain which could have been necessitated by a bursting blood vessel or blood clot. Omar’s stroke was caused by a blood clot in the brain. Stroke has become a big problem and the second main cause of death and disability in developed economies after heart related diseases (Cross, 2008). Sander (2013) emphasises out that stroke is affecting about 150, 000 people in the UK yearly.

However, the article reports a decline in deaths because of improvements in stroke care, management and awareness. More resources have been put towards short to long term care of stroke patients such as admission to acute stroke units and to rehabilitation areas (Cross, 2008). The report says this evidence, among others, is being used to develop new stroke treatments and guidelines in the UK. NICE (2008) which provides tools and quick reference guide to stroke related cases could have emerged as a result of this. These developments may give hope to Omar and his distressed family.

The article cited two evidence of good practice from two hospitals. It is reported that the stroke management team at Aintree University Hospitals NHS Foundation Trust assess stroke patients on admission to the A&E, take brain scans and admit relevant patients to a stroke unit within 24 hours. The other evidence is from Salford Royal NHS Foundation Trust where patients have brain scans, swallow screens and initial dose of aspirin given to relevant patients. These practices are recommended by NICE (2008) guidelines and may reduce further risks to patients. Omar received these interventions. This shows the strength of this article to Omar’s case and how early intervention may result in positive outcome.

Although the article stressed the need for nurses to continuously monitor patients during the early stages of stroke on certain variables, it did not provide guidelines to back up the checks. Locally agreed hospital policies suggested may not meet NICE standards.

Despite the improvements noted in the research, caution should be taken when making decisions based on the findings. These are 2008 findings and a lot has happened since then. Omar may be interested in hearing recent studies such as that of Sander (2013) who points out that in addition to the swallow screen stroke patients should further be screened for malnutrition using Malnutrition Universal screening Tool (MUST) in line with the NICE (2008) guidelines.

The second analysis of Omar’s care is based on a qualitative study of Tutton et al (2012) on ten staff and ten patients’ views on the concept of hope on a British stroke unit. The evidence was obtained from EBSCO via CINAHL database and UWE library section. I chose this evidence because CINAHL is considered as one the good sources of evidence (Levin and Feldman, 2006) and the concept may be useful to Omar to learn other patients’ experiences in a similar hospital setting.

The aim and key search terms in the article relate well to Omar’s case. Hope is defined as getting better from illness and being able to do things as before (Tutton et al, 2011). This was echoed by some of the patients in the study. An in depth analysis of key terms and the codes used in qualitative study (Aveyard and Sharp, 2013) may help carers to understand how it feel to have a stroke. Omar and his family may share the same thoughts as they are finding it hard to come to terms with sudden change of things in their family.

Despite taking long time on data collection and variations in stroke severity Omar may be encouraged to learn that some patients took less than a week in hospital. This result is echoed by Arnaert et al (2006) in a similar study based on ten patients in Canada. They reported that some clients were hoping for a quick recovery and self-healing.

The article is good evidence as it stated what is already known about this topic and nursing implications. These aspects are echoed by Arnaert et al (2006) but Tutton et al (2011) further identify what the paper has added such as the multidisciplinary team involvement in caring for stroke patients to make hope a realistic thing.

Although the article mentioned that consent was obtained from both participants, there are still some ethical issues in the article. Some of patients’ names are mentioned in the article. This is confidential information and Omar may find himself in a similar situation.

Furthermore, relatives and carers of patients were not interviewed in the study. It may be necessary to hear their views as well especially after learning from Preeti how she was struggling to come to terms with Omar’s condition. Her understanding of hope would improve our knowledge on this aspect.

It is generally accepted that qualitative evidence is ranked second from the bottom in the hierarch of evidence (Polit and Beck, 2012) and uses a small sample size for the purpose of in-depth analysis of topic under consideration (Aveyard and Sharp, 2013). Although a large sample size may be costly and time consuming, caution must be taken when making inferences on large population size like 150, 000 patients mentioned earlier.

A third analysis of Omar’s care considers service audit and evaluation evidence from Sentinel Stroke National Audit Programme (SSNAP) (2013). It is a national audit on stroke patients admitted to hospital in the first three months of 2013. The research looks at the processes of care at early stages of stroke (72 hours) from hospital arrival. I have chosen this evidence because SSNAP is a nationally recognised organisation and works with other organisations in stroke related cases. Its recent results obtainable through Google, SSNAP Audit Report (2012) and Royal College of Physicians links have strong implications on Omar’s condition.

SSNAP (2013) results show the importance of using guidelines in any intervention involving stroke cases. There is strong evidence in the article that stroke patients were immediately taken for brain scans and admitted to the stroke units, as in the case of Omar, upon arriving hospital. This is in line with NICE (2008) guidelines. Most of the trusts were able to meet this standard. However, it is worrying to learn that there is a lower chance of having scan during the weekend and night times, the time of the week when Omar experienced the stroke.

NICE (2012) guidelines stipulate that people who have had TIA should have first dose aspirin upon initial assessment. Although Omar received one, the outcome in the report is not very pleasing. It is clear from the research that this standard was not met by all trust as there are huge variations.

The research was only focused on 72 hours upon hospital arrival. It may benefit the public and give confidence to Omar if the care he received from the ambulance crew were up to standards. NICE (2012) guidelines require people suspected to have had stroke to be screened using a FAST tool. There are no statistics regarding this in the article as the research excluded time before hospital arrival and the rehabilitation. This information may enlighten the public the importance of early intervention in stroke care.

This evidence is not peer reviewed and the way data was collected is of concern. Because the SSNAP is a single source of data nationally (Paley et al, 2013) and an online web-tool was used to gather information one may wonder whether variations in results may appear if a different organisation undertakes the same research. Caution should be applied when interpreting this data.

The audit results stress the importance of early intervention by multidisciplinary stroke team in the care of stroke patients. However, there are some areas that require attention if the all standards are to be fully met.

The final analysis of Omar’s care is based on quantitative study by Beavan et al (2010) on whether looped nasogastric tube (NGT) feeding improves nutritional delivery to acute stoke patients with dysphagia. The evidence was obtained from UWE blackboard website. I chose this evidence because the intervention, tube feeding, helps to resolve Omar’s swallowing difficulties and improve nutritional needs. The research helps in answering questions on whether there are other alternatives and any effects associated with the intervention.

The research was necessitated by the poor nutrition on patients on admission to hospital and the dislodgement associated with adhesive nasal stickers. Findings from the research reported more benefits in using the loop system than the other method. Some of the benefits include fewer checks for NGT position, less supplementary feeds required, more volume of fluids and feeds and less dislodgement of NGTs. This is vital information to Omar as it highlights why the intervention is used. However, the costs were seen to be high for the two week period.

It is important to explain to Omar that studies of this nature are useful and commonly used in clinical interventions. It is a view shared by many authors like Polit and Beck (2012) and Aveyard and Sharp (2013). They rank randomised controlled trials as second best on the hierarch of evidence after systematic reviews and meta-analysis.

There are some ethical issues regarding the funding for the research. Procare Ltd supplied the loops. The researchers stressed that it was not involved in any logistics or interpretation of the results, but one may wonder why the loops were sold at a bulk price. Could this have resulted in a discount? If the answer is yes then it is likely that the costs could be higher than the reported one.

In addition, the aspect of tolerability was mainly based on the views of nurses and family members. Although it is understandable that most of the patients were having communication problems, the number of patients unable to communicate is alarming to the extent that caution is required when using this evidence.

The study was done some years ago and the results published in 2010. A number of changes may have happened since then. Omar will be susceptible on why using such an old piece of evidence. Recent research results may be easier to convince Omar and his family than old results.

To sum up, stroke is a major disease affecting many people and causing disabilities among survivors. Any nursing intervention will require evidence to back up. Four sources of evidence have been analysed in relation to Omar, a stroke patient. The strengths and weaknesses associated with each of this evidence will enable any intervention in Omar’s care to be made in rationale way and to his best interest.

WORDS: 2 089

Reference

Aveyard, H. and Sharp, P. (2013) A Beginner’s Guide to Evidence-Based Practice in Health and Social Care, 2nd ed. Berkshire: Open University Press.

Kim, M. and Mallory, C. (2011) Statistics for Evidence-Based Practice in Nursing, Burlington: Jones and Bartlett Learning.

Oman, K.S., Krugman, M.E. and Fink, R. M. (2003) Nursing Research Secrets, Philadelphia, Pennsylvania: Hanley and Belfus.

Pilot, D. F. and Beck, C.T. (2012) Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Levin, R. F. and Feldman, H. R. (2006) Teaching Evidence-Based Practice in Nursing: A Guide for Academic and Clinical Settings, New York: Springer Publishing Company.

Arnaert, A., Filteau, N. and Sourial, R. (2006) Stroke Patients in the Acute Care Phase: Role of Hope in Self-healing [online]. 20 (3), pp137-146. [Accessed 14 November 2013]

Beavan, J., Conroy, S.P., Harwood, R., Gladman, J.R.F., Leonardi-Bee, J., Sach, T., Bowling, T., Sunman, W. and Gaynor, C. (2010) Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Available from: https://blackboard.uwe.ac.uk/bbcswebdav/pid-3425495-dt-content-rid-4569416_2/courses/UZWSN3-15-1_13oct_gl_feb14_1/Tube%20feeding%20after%20stroke%20RCT.pdf [Accessed on 19 November 2013]

Cross, S. (2008) Stroke care: a nursing perspective. Nursing Standard. 22 (23), pp 47-56. Available from: https://blackboard.uwe.ac.uk/bbcswebdav/pid-3473085-dt-content-rid-4709333_2/xid-4709333-2 [Accessed on 29 October 2013]

National Institute for Health and Clinical Excellence (NICE) (2008) Audit support (NICE clinical guideline 68 – Stroke) Available from: https://blackboard.uwe.ac.uk/bbcwebdav/pid-3461610-dt-content-rid-4659555_2/xid-4659555_2 [Accessed 12 November 2013]

NICE (2008) Understanding NICE guidance: Early assessment and treatment of people who have had a stroke or transient ischaemic attack (TIA) Available from: www.nice.org.uk/nicemedia/pdf/cg68publicinfo.pdf [Accessed on 01 December 2013]

Paley, L., Campbell, J., Hoffman, A. and Rudd, (2013) Sentinel Stroke National Audit Programme (SSNAP): Clinical audit first pilot public report, National results. Available from: www.rcplondon.ac.uk/sites/default/files/ssnap_pilot_national_report_january_-_march_2013_admissions_with_appendices_.pdf [Accessed on 11 December 2013]

Pale, L., Campbell, J., Hoffman, A. and Rudd, (2013) Sentinel Stroke National Audit Programme (SSNAP): Clinical audit first pilot public report, National results. Available from: www.rcplondon.ac.uk/sites/default/files/ssnap_pilot_national_report_january_-_march_2013_admissions_with_appendices_.pdf [Accessed on 11 December 2013]

Sander, R. (2013) Prevention and treatment of acute ischaemic stroke. Nursing Older People [online]. 25 (8), pp 34-38. [Accessed on 4 December 2013].

Sentinel Stroke National Audit Programme (SSNAP) (2012) Acute organisational audit report: Public Report for England, Wales and Northern Ireland. Available from: http://www.rcplondon.ac.uk/sites/default/files/ssnap_acute_organisational_audit_-_public_report_2012_0.pdf [Accessed 12 November 2013]

Tutton, E., Seers, K., Langstaff, D. and Westwood, M. (2011) Staff and patient views of the concept of hope on a stroke unit: a qualitative study [online]. 68 (9), pp 2061-2069. [Accessed 14 November 2013]

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