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ORIGINAL RESEARCH
Understanding nursing on an acute stroke unit: perceptions of space,
time and interprofessional practice
Cydnee C. Seneviratne, Charles M. Mather & Karen L. Then
Accepted for publication 17 April 2009
Correspondence to C.C. Seneviratne:
e-mail: ccsenevi@ucalgary.ca
Cydnee C. Seneviratne PhD RN
Post-Doctoral Fellow and Instructor
Faculty of Nursing
University of Calgary
Calgary, Alberta, Canada
Charles M. Mather PhD
Assistant Professor
Department of Anthropology
University of Calgary
Alberta, Canada
Karen L. Then PhD RN ACNP
Professor
Faculty of Nursing
University of Calgary
Alberta, Canada
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JOURNAL OF ADVANCED NURSING
S E N E V I R A T N E C . C . , M A T H E R C . M . & T H E N K . L . ( 2 0 0 9 ) Understanding nursing
on an acute stroke unit: perceptions of space, time and interprofessional practice.
Journal of Advanced Nursing 65(9), 1872–1881.
doi: 10.1111/j.1365-2648.2009.05053.x
Abstract
Title. Understanding nursing on an acute stroke unit: perceptions of space, time and
interprofessional practice.
Aim. This paper is a report of a study conducted to uncover nurses’ perceptions of
the contexts of caring for acute stroke survivors.
Background. Nurses coordinate and organize care and continue the rehabilitative
role of physiotherapists, occupational therapists and social workers during evenings
and at weekends. Healthcare professionals view the nursing role as essential, but are
uncertain about its nature.
Method. Ethnographic fieldwork was carried out in 2006 on a stroke unit in Can-
ada. Interviews with nine healthcare professionals, including nurses, complemented
observations of 20 healthcare professionals during patient care, team meetings and
daily interactions. Analysis methods included ethnographic coding of field notes and
interview transcripts.
Findings. Three local domains frame how nurses understand challenges in orga-
nizing stroke care: 1) space, 2) time and 3) interprofessional practice. Structural
factors force nurses to work in exceptionally close quarters. Time constraints compel
them to find novel ways of providing care. Moreover, sharing of information with
other members of the team enhances relationships and improves ‘interprofessional
collaboration’. The nurses believed that an interprofessional atmosphere is funda-
mental for collaborative stroke practice, despite working in a multiprofessional
environment.
Conclusion. Understanding how care providers conceive of and respond to space,
time and interprofessionalism has the potential to improve acute stroke care. Future
research focusing on nurses and other professionals as members of interprofessional
teams could help inform stroke care to enhance poststroke outcomes.
Keywords: acute stroke unit, ethnography, interprofessional practice, nursing, per-
ceptions, space, time
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH
Introduction
Stroke can be a devastating and physically debilitating cardio/
neurovascular disease (Hickey 2003). It interrupts life, arrests
previously-cherished activities, and decreases overall quality
of life for survivors and their families (Canadian Stroke
Network, 2007). According to the World Health Organiza-
tion (2004), heart attack and stroke are leading causes of
death in the world and approximately 15 million people
worldwide survive stroke annually.
Dedicated stroke units are part of a widespread effort to
ameliorate the impact of stroke. Generally, these units house
comprehensive stroke programmes which include interdisci-
plinary teams of caregivers including nurses, pharmacists,
physicians, nurse practitioners (NP), social workers, occupa-
tional and physical therapists, and speech therapists. The
rationale behind the programmes is that the needs of
individual patients require caregivers with varied expertise
(Teasell et al. 2007). Stroke units yield clear benefits to
patients (Hill 2002, Stroke Unit Trialists’ Collaboration
(SUTC) 2007; Indredavik et al. 1991, Jorgensen et al. 1995a,
1995b, Kalra et al. 1993, Kalra 1994). Patients who receive
inpatient stroke care vs. care from a conventional or general
medical ward stand a better chance of surviving, and living
independently at home 1 year poststroke (SUTC 2007).
Patients on stroke units experience greater improvement in
functional outcome and quality of life, and a decreased length
of stay (Cifu & Stewart 1999).
Researchers have proven the effectiveness of interdisciplin-
ary stroke care (Cifu & Stewart 1999; SUTC 2007). This
study looks beyond outcome measures to the daily interac-
tions and beliefs that characterize comprehensive pro-
grammes, with a particular focus on the role of nurses.
Nurses have long believed that they play an essential role in
stroke care, but they remain uncertain about the nature of
their contributions (Gibbon 1993, Gibbon & Little 1995,
Waters & Luker 1996, Burton 2000). Using an ethnographic
approach, we examined nurses’ perspectives on the contri-
bution they make to the care of stroke survivors in acute
settings. Part of our concern was how nurses see the social
connections they have with other members of the interdisci-
plinary team, and what sort of values they hold toward their
practice.
Background
Henderson (1980) offered a vision of nurses with a leading
role in acute care and rehabilitation, including working with
patients to relearn activities, movement, and continence and
nutritional care. In contrast to this vision, nurses are moving
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Understanding nursing on an acute stroke unit
toward a managerial or understudy role that coordinates
rehabilitative tasks under the guidance of other professions
(O’Connor 1993, 2000a). This emerging role is ‘patchy’ in
that nursing ability in some areas (e.g. feeding and continence
care) is advancing while other areas (e.g. mobility and
exercise therapies) are lagging behind (Perry et al. 2004).
Without knowledge and skills in acute stroke care, and
accepting rehabilitation as a normal part of nursing,
Henderson’s vision is unattainable (Myco 1984).
The role of nurses in acute stroke rehabilitation is unclear
(O’Connor 1993, 2000a, 2000b, Forster & Young 1996,
Kirkevold 1997, Burton 1999, 2000, Elliott 1999, Thorn
2000). Researchers have identified nurses as managers or
coordinators (O’Connor 1993, Burton 1999, 2000), clinical
specialists (Elliott 1999), community integrators (Forster &
Young 1996) and caregivers who perform interpretive,
consoling, conserving and integrative tasks (Kirkevold
1997). Kirkevold (1997) describes four unique functions in
rehabilitation of stroke survivors that nurses perform but fails
to operationalize these functions (O’Connor 2000a).
Nurses vary in their attitudes and perceptions of their role
in stroke care. In an early qualitative study, Waters and Luker
(1996) found that nurses thought that they were good at basic
care, ranging from ensuring that patients were clean and
dressed prior to medical assessments to ensuring patients
were physically ready prior to therapy sessions, but the
considered that they had little time for rehabilitative care.
Burton (2000) discovered that nurses provided care, facili-
tated personal recovery, and managed multidisciplinary care
teams, and that these roles suggested that they could provide
focused 24-hour coordinated stroke rehabilitation. Perry
et al. (2004) agreed with Burton (2000) and suggested that
nurses must move beyond their traditional role of providing
basic care and become active participants in acute and
rehabilitative care.
Observational studies of nurses in acute and rehabilitative
care settings includes work by Pound and Ebrahim (2000)
showing that nurses on a general medical unit and a stroke
unit provided impersonal, standardized care, considered
rehabilitation secondary to nursing practice and did not
regularly consult with therapists. In contrast, nurses on an
elder care unit valued and promoted patient independence,
and frequently consulted therapists to encourage optimal
rehabilitation. The authors concluded that optimal stroke
care requires engaging nurses in rehabilitation, increasing
training in rehabilitation and compassionate care. Booth
et al. (2001) compared interventions by nurses with those by
occupational therapists (OT) and found that OT used
patient prompting and facilitation while nurses favoured
supervision. Variation in care practice was because of
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C.C. Seneviratne et al.
different intervention and assessment styles and lack of
preparation and education in stroke rehabilitation on the par
of the nurses.
According to Bukowski et al. (1986), neuroscience nurses
could implement rehabilitation therapy over the 24 hour
period, support treatments recommended by physiotherapists
(PT), and ensure that patients and families learn therapy
techniques to continue rehabilitation at home. Nurses play an
essential role in acute and rehabilitative stroke care (Gibbon
1993, Gibbon & Little 1995, Waters & Luker 1996, Burton
2000) but the broader social construction of stroke rehabil-
itation and care providers’ perceptions toward this construc-
tion remains unclear.
The study
Aim
The aim of the study was to uncover nurses’ perceptions of
the contexts of caring for acute stroke survivors.
Methodology
Ethnography is a qualitative research approach (Spradley
1979, 1980). In anthropology, ethnography is a tool for
describing cultures, and the chief methods ethnographers
employ are observation and interviewing. Ethnographers
record their observations and interviews in field notes and
other media, including audio and visual formats. Postfield-
work, researchers analyse and interpret the records to
uncover dominant themes or understandings among members
of the culture (Spradley 1979, 1980, Aamodt 1991). In this
study, ethnography provided a means of exploring how
stroke unit nurses organized and coordinated care.
Participants and setting
The study took place on an18-bed acute stroke unit located in
a large tertiary medical centre in Canada. As part of a greater
health region, the stroke unit provided specialized interven-
tions, management and investigative care during acute and
sub-acute stroke phases. It had 18 beds, two located beside a
nursing station and 16 in four-bed rooms with connecting
corridors leading to a nursing station. Located on a different
floor from the neurosciences department, the stroke unit
shared space with another general neurological unit.
Staff on the unit included registered nurses (RN), licensed
practical nurses (LPN), patient care attendants (PCA), NP,
PT, OT, speech therapists and physicians. The staffing ratio
was one RN or LPN to every four patients. We used
1874  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
purposive sampling (Morse & Field 1995, Hammersley &
Atkinson 2007) to locate participants, and excluded individ-
uals who could not read, write, or speak English. In total, we
followed ten RN, two LPN, one PCA, one NP, two PT, a PT
and three physicians (n = 20), nine of whom we formally
interviewed. Participants ranged in age from 24 to 52 years,
15 were female and five were male. Nurses were the study
focus but we also interviewed four other professionals to help
contextualize interprofessional perspectives.
Data collection
Fieldwork took place from February to November of 2006.
Observations averaged 2–3 hours on 3 days/week. The field-
worker (CS) made observations during every type of shift. The
fieldwork began with 3 months of general observation on the
unit with the fieldworker watching at the charting desk,
nursing station and walking in the hall. Notes from observa-
tions were transcribed via computer. The fieldworker clarified
gaps in field notes by returning to the field site and making
more focused observations driven by informant comments. To
explore work practices, we interviewed participants (Emerson
et al. 1995) using ‘grand tour’ questions such as ‘Can you
walk me through your typical day?’ and asking for examples
of nursing practice vs. that of other professions.
Ethical considerations
The local health research ethics board granted ethical approval
for the study. We used several information sessions to
introduce the study to members of the stroke unit. During
these sessions and interviews we informed stroke unit members
about patient confidentiality. We sought written consent only
from observation and interview participants and verbal assent
from patients when participants were providing direct care.
Data analysis
Analysis of field notes focused on identifying central domains,
specific domain components and related work typologies
(Spradley 1979, 1980, Hammersley & Atkinson 2007). We
discovered three main themes (domains) and further identi-
fied theme components (componential analysis). Finally, we
broke work activities into types on the basis of relationships
between nurses, and between nurses and other professionals
(typological analysis). Through an ongoing process of reading
field notes, transcripts and then returning to the field setting
for further observations, we crosschecked our findings and
were assured that our study domains, components and
related subcategories were culturally salient.
JAN: ORIGINAL RESEARCH Understanding nursing on an acute stroke unit

Reflexivity I’m too claustrophobic on this unit. It’s like I am closed in…if you
look down the hall from the nursing station you feel like the walls
Ethnographers change in the process of conducting research
and curtains are closing in around you. It is so narrow. I feel
and spending an extensive period learning cultural domains
constricted because I cannot do my work in cramped space. I bump
and categories, and from building relationships with study
into other people all the time.
participants (Davies 1999, Hammersley & Atkinson 2007).
Indeed, if an ethnographer’s ideas, beliefs and values did not
Nursing too close
change it might indicate that she failed in understanding the
Limited space made it difficult to move, to use and relocate
culture she was studying. To keep track of the sorts of
equipment, transfer patients, document nursing care and
changes they undergo and the impact of these changes on
interact with colleagues. Limited space required alternative
their fieldwork, ethnographers employ ‘reflexive’ techniques.
work strategies to ensure that one did not get in the way of
In this study, the fieldworker used ‘asides’, integrative memos
one’s colleagues. For example, nurses unlocked the wheels on
and research journals (Spradley 1979, 1980, Emerson et al.
beds in rooms near the nursing station, wheeled them to an
1995) to make explicit her presuppositions and insider
open space, and then transferred patients to stretchers. One
relationships, and to maintain awareness of her social
nurse said:
position within the culture. Some staff knew the researcher
as a nursing instructor or a previous employee. Asides and This unit is not set up for us to nurse or do rehab. It is designed so
journaling helped her denote prior relationships, and high- that we are constantly bumping bums, literally bum to bum…when
light instances when she might have had ‘built-in’ biases or we transfer patients. We are bashing into one another when we feed
made priori judgments. Reflexive techniques helped control patients and when we provide any kind of nursing care.
for potential biases from having an insider perspective, which
The layout of the unit caused nurses to bump into each other,
we did not want to lose because it was essential for gaining
and put patients in situations where staff could not ensure
access to the study setting, building rapport and building and
appropriate care, privacy or confidentiality.
maintaining trust with staff.

Nursing under a state of ‘code burgundy’

Findings A ‘code burgundy’ signals a lack of beds. The unit included
an over-capacity bed in a shared hall. Caring for patients in
Space hallways compounded having to work ‘too close’. Nurses
disapproved of nursing under a state of code burgundy:
Participants described ‘space’ as a challenge to patient care.
Three themes predominated in the data: ‘nursing in a [We] feel badly for the lack of privacy for that patient in the hallway.
submarine’,’ nursing too close’ and ‘nursing in a state of I mean even I had to perform an intimate procedure, a urinary
code burgundy’. catheter insertion in the hall, and I hated doing it.

Ironically, despite disapproving of these conditions, nurses

Nursing in a submarine
often faced criticism from patients’ families for the conditions:
Staff used the term ‘submarine’ to refer to the unit. Command
centres are located near the front of submarines, with missile I think it really stressed [us] out, because [we] were taking the brunt
rooms at the rear. The nursing station was located near the of family complaints. You try telling the patient that you are just
entrance of the unit, while the majority of four-bed rooms following procedure. This is a region issue and we are obligated to do
were located at the middle and far end. According to one what the region tells us, but we don’t agree.
nurse:
A state of code burgundy means increased workloads and the
Our submarine…it’s just a more condensed unit. But the thing that ethical challenge of ‘hallway care’.
most bothers me is it’s not centred. If you have patients in the last
room…at the other end you are not in close proximity to anything or
Time
anybody – you’re alone. That drives me crazy because the nursing
station is so far away. Participants’ talked about time in three major ways: ‘lack of
time’, ‘preserving time’ and ‘time with and without space’.
Participants connected their feelings of claustrophobia on the
Each concept denotes limitations and challenges to providing
unit with being on a submarine. The unit lacked work space
care.
and storage space:

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C.C. Seneviratne et al.
Lack of time
Participants complained that care errors, missed therapy or
treatment appointments, and awkward patient transfers
occurred because of lack of time to plan. Lack of time also
compromised nurses’ wellbeing. They associated work-
related injuries to the pressures of needing to work quickly to
complete all the work before the end of a shift:
We are always injuring ourselves because we rush around. There is
just not enough time for us to do things properly with our
patients…So if things get missed so be it.
Lack of time hindered working on patient rehabilitation.
Participants knew that correct positioning and transferring of
patients assists in stroke rehabilitation, but they believed that
they lacked the time for patients to move and position
independently:
It is easier to take over for patients, dressing them or brushing their
teeth rather than helping them do the tasks. It is a matter of
accomplishing what is required for patients in a specific window of
time.
Nurses organized their time according to what they believed
they were physically capable of accomplishing during the
work day. When patient acuity was high there were time
constraints and rehabilitation was not a priority:
The patients need time for us to let them do what they can and…for
themselves. But, that requires a whole lot of time and effort, which
the nurses don’t have. So I am sure some of [the patients] are
frustrated because they realize that and they aren’t able to do as much
as they would like to do…Some days you just can’t wait, you have to
get it done and move on.
Preserving time
To preserve time nurses coordinated their work and cared for
patients as a team. They met and identified tasks they could
do more efficiently working together. Alternately, individuals
who had fewer patients volunteered to ‘pick-up’ patients
from colleagues who had a heavier patient load. A more
implicit approach to preserving time developed as a conse-
quence of familiarity. As one nurse related:
For me team nursing is knowing who you work with. I don’t know
whether it’s the people I normally work with, but we just know each
others rhythms. It is a matter of not talking about what we should do
but just knowing each other.
Participants organized their work to meet timelines and
prescribed schedules. They prepoured medications, and
arrived early to complete stroke assessments, vital signs and
morning care prior to the start of their shift.
1876  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Time with and without space
Time and space were evolving and interconnected concepts.
As result of a lack of space, patients received physiotherapy
and occupational therapy in the main therapy department. A
PT commented:
I know that it is much easier for [physiotherapists] to do transfers in
the main therapy department because the setup is ideal. There is so
much of a space conflict on the unit that it’s really hard sometimes to
set things up optimally, so we would rather work with patients down
in the gym without the nurses.
One nurse said it was hard to do rehabilitation on the unit
because of limited time and space:
There are limitations on what we can do in the time and space allotted.
To be able to come in and have the time to do all of those extra
things…like assist patients in their room with feeding or mobilization
and all of those things…that would be great, but it doesn’t happen.
Time with and with out adequate space affected nurses’
participation in bedside rounds. Unit policy stated that nurses
should attend and review patients’ neurological status, vital
signs and changes in condition. Rounds occurred at
09.00 hours, when nurses were preparing patients for therapy
appointments and tests, and/or were providing acute medical
care. For nurses attendance at rounds was not a priority:
Then there is the issue of doing rounds on the unit with the docs. I
really do not like the idea because your time is so compressed. You
have so much going on during the day and to just repeat what the
[charge nurse] already knows is…well, just repetitive.
One reason to miss bedside rounds was a lack of space in the
four-bed rooms. Field observations revealed that the stroke
neurologist, stroke residents, one or both NP and the charge
nurse attended bedside rounds. Gathered around each bed, the
group discussed patient status. According to the nurses there
was ‘never enough room any way’, and attendance did not give
them new patient information and was thus ‘a waste of time’.
Interprofessional practice
Participant descriptions of interprofessional practice included
two main components: ‘relationships between stroke profes-
sionals’ and ‘communication/collaboration’. Each component
highlights how participants understood interactions on the
stroke unit and interprofessional practice more generally.
Relationships between stroke professionals
Nurses’ understanding of stroke care differed from other
professionals and this affected how they developed and
JAN: ORIGINAL RESEARCH
maintained relationships on the stroke team in three major
ways. First, working together and sharing experiences were
the cornerstones of relationships between nurses.
Second, relationships between nurses and therapists devel-
oped around perceptions of how best to address patient
needs. Nurses felt that therapists’ failure to recognize and
acknowledge the role of nurses in rehabilitation can lead to
resentment and half hearted attempts at rehabilitation. One
nurse lamented:
We are not recognized for the mobility things we do or in any
concerns we have about our patients. So, sometimes we don’t work
hard at it. The physios are only concerned that we get the patients
ready for their rehab times in the gym. So we do that for them and
then concentrate on our patients’ medical needs.
Nurses felt that therapists had a narrow view of nursing
practice. In the course of their professional interactions,
nurses were responsible for patients’ medical needs while
therapists were responsible for rehabilitation.
Third, nurses saw their relationships with stroke physicians
and NP in terms of interprofessionalism. Participants claimed
that in its original state the stroke team was a matter of
interprofessional practice. Nurses and physicians candidly
discussed patients and collaborated. One of the stroke
physicians summarized his view of the situation:
It should be interprofessional, ideally. In general, stroke units are
interdisciplinary. Only a small part of stroke unit care is the physician
roles. So during most of stroke care, beyond the acute phase, when
you have somebody settled, the physician’s role is relatively minor.
It’s all about excellent nursing care and rehabilitation. So the team,
by accident of history and hierarchy, is led by a physician but we have
a NP, all the nurses, the physiotherapist, and social work...Everybody
is involved in care including home care planning, etc.
Another participant commented:
We needed something different on our stroke unit. Our unit was not
designed to be exclusionary in any way. It was intended to be
interprofessional.
The stroke unit was supposed to be an interdisciplinary place
where staff felt comfortable sharing information. It would
work in a non-hierarchical way, with each professional’s
opinion being valued and forming part of the plan for
medical and rehabilitative care.
Stroke nurses thought that collaboration was important,
and that it involved open communication with physicians and
NP. They felt that they had positive relationships with the
two NP because these professionals were approachable and
accessible during acute and non-acute situations. One nurse
asserted:
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Understanding nursing on an acute stroke unit
Having both NP has helped as sort of go between to advocate to the
doctors for the things that we need. The NP are more available to
come see the patient in an emergent or urgent situation. That helps
because you can get the ball rolling for whatever procedures that
need to be done.
Communication and collaboration
Participants claimed that communication and collaboration
were critical to the success of the unit. Regular communica-
tion ensured everyone understood how other members envi-
sioned patient care. Weekly stroke rounds provided
opportunities to discuss patients, collaborate on care and
share alternate plans or possibilities. Attendance did not
guarantee participation, and inclusion in discussions was
predicated on who led rounds. One stroke team member
commented:
When I lead rounds I like to spend more time on the functional and
the social end of things than the medical. I want to make sure the
team feels like they’re involved and valued.
This individual thought that it was important to include all
team members, and was concerned that some did not feel
valued or believe that they were influencing progression and
discharge plans for their patients.
Nurses were the only team members who did not regularly
attend stroke unit rounds because ‘[they] did not have enough
time to leave [their required duties] and attend an hour-long
stroke round’. One of the physicians claimed that the
attendance of nurses at the stroke rounds would have
provided more information for both doctors and nurses:
I think that maybe if we could arrange the time for once a week in the
[stroke unit] rounds for the nurses to attend. I think that might be
beneficial in the long run for all the staff because we can learn so
much from each other especially about stuff we don’t have time to
find out.
The attendance of nurses at stroke rounds would have
reinforced the notion that the unit was interprofessional.
Discussion
Study limitations
Ethnography is not a science of generalization. Ethnographic
findings come from certain individuals, situations or single
cases from a particular context and a particular time
(Hammersley & Atkinson 2007). Our findings are not
necessarily indicative of what happens on all stroke units
and thus the study is not about how stroke units are, but
rather about how a stroke unit can be. Although we accept
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C.C. Seneviratne et al.
limitations where representativeness is concerned, we also
believe that we have found common issues in stroke care in
particular, and medical care more broadly.
Space and time
Space limitations and time constraints are the backdrop of
clinical care throughout North America. Weinberg (2003)
notes that nurses have long faced a lack of resources to
complete daily tasks safely and effectively, interact with
patients, or attend in-service education sessions. Notwith-
standing the apparent universality of these problems, in our
view it is not advisable to dismiss or devalue the concerns of
those who work in caregiving environments. Our investiga-
tion presented an opportunity to re-open dialogue about the
importance of institutional organization and structure
regarding appropriate space and use of time related to stroke
care (Peszczynski et al. 1972, Ulrich et al. 2004).
A substantial body of literature supports the view
that organized stroke unit care improves stroke outcomes
(Indredavik et al. 1991, Kalra et al. 1993, Kalra 1994,
Jorgensen et al. 1995a, 1995b, Hill 2002, SUTC 2007). What
the literature fails to address is the importance of adequate
work space for providing this care. Our participants per-
ceived lack of space as a constant challenge to providing care.
Rather than describe what they did regarding stroke and
rehabilitative care, nurses talked about what they were forced
to do because of inadequate spaces and insufficient time.
They did not take the time to assist patients to wash, dress
and practise mobilization. They complained about inade-
quate physical space for medication delivery, charting and
interactions with patients. These comments are concerning
because they show that nurses did not (and probably cannot)
make rehabilitation and patient autonomy (Burton 1999,
2000) priorities in their acute stroke care.
How conceptions of time affect work practices in stroke
care have not been explored in the literature. In the past,
stroke physicians adopted ‘watchful waiting’ for patient
recovery. Thrombolytic therapy changed stroke care in the
1980s, providing a means of treating a class of acute cases of
ischaemic stroke. The window of opportunity for thrombol-
ysis is three hours after symptom onset. Members of the
stroke team now use phrases such as ‘time is brain’ as a
reminder that the longer it takes for intervention, the greater
the resulting neurological deficit (Barber et al. 2005). Team
members have a second term, ‘door to needle time’, which
refers to the time between a patient’s arrival at the hospital
and the start of thrombolytic therapy (Hill et al. 2000).
Temporal metaphors denote boundaries and different dimen-
sions within the work space (Gell 1996, Bluedorn 2002,
1878  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Hearn & Michelson 2006, Patmore 2006). Thrombolysis
made stroke an acute event, and thereby helped radically alter
the practice of stroke care. Armed with a novel intervention,
stroke teams had to work within the boundaries of a narrow
therapeutic window. Both the acknowledgment that orga-
nized stroke units improves outcomes and the temporal
demands of thrombolysis motivated the adoption of coordi-
nated interprofessional care teams and units such as the
stroke unit in this study.
Although the ideal acute stroke care team includes a focus
on rehabilitation, the nurses in this study chose not to
consistently spend time walking with their patients or taking
time to assist with dressing and grooming (all important
rehabilitation activities). They believed that if they had the
time, they would perform rehabilitative care. A recent study
(Vähäkangas et al. 2008) showed that nurses who incorpo-
rated rehabilitation into their daily care increased the amount
of time ‘working with’ patients to maximize patient indepen-
dence. The question is whether our stroke unit nurses were
aware that a re-evaluation of their time from focusing on
nursing tasks to facilitating rehabilitation might increase or
‘preserve’ time spent with their patients. Organizing and
implementing an education session for the stroke nurses about
facilitation of care, as established by Booth et al. (2005), could
increase their use of facilitative interventions in rehabilitation.
They could have advocated for change by documenting their
lack of time concerns and by requesting more staff through
evaluation of patient acuity levels. A recent American study
(Neatherlin & Prater 2003) illustrates that nurses are well-
positioned to assist in the development and evaluation of
appropriate staffing levels on rehabilitation units through
documentation of how they spend their time at work.
Interprofessional practice
The nurses in our study discussed how their role in the
interprofessional team developed out of day-to-day working
relationships. The stroke team is multidisciplinary because
each team member works independently and reports assess-
ments and interventions mainly in team meetings. Neverthe-
less, participants used the term interprofessional to refer to
the stroke team. This suggests a lack of clarity about the type
of work relationships and team interactions that exist on the
unit. In multidisciplinary teams individuals work separately
and come together to share information, while interdisciplin-
ary teams members collaborate to create care plans as
they jointly assess and treat patients (Ovretveit 1997,
Sorrells-Jones 1997, Payne 2000, Pollard et al. 2005).
Healthcare professionals commonly use the terms
synonymously, although in the case of acute stroke care,
JAN: ORIGINAL RESEARCH
What is already known about this topic
• Stroke is a devastating neurovascular disease that
affects over 15 million people worldwide annually.
• Organized stroke units decrease overall mortality and
average length of stay, improve quality of life, inde-
pendence and likelihood of living at home 1 year
poststroke.
• Nurses are important and essential members of inter-
professional stroke teams as they work with and care
for patients 24 hours a day.
What this paper adds
• Limited work space and lack of time to care for
patients are important issues for neuroscience nurses.
• Interprofessional practice is a key factor that requires
re-evaluation in acute stroke care.
• Nurses should assume a leadership role as rehabilita-
tion practitioners who promote ‘working with’ rather
than ‘doing for’ their patients.
Implications for practice and/or policy
• Providing education sessions for stroke nurses about
facilitation of care could increase nursing use of facil-
itative interventions in rehabilitation.
• Nurses ought to become advocates for change by
documenting their space and time concerns and by
requesting workspaces and temporal environments
appropriate for stroke survivors.
interprofessional and interdisciplinary teams are the gold
standard (Canadian Stroke Network and the Heart and
Stroke Foundation of Canada: Canadian Stroke Strategy
2006; SUTC, 2007; Teasell et al. 2007).
Despite desiring to work interprofessionally, team members
found it difficult to communicate and collaborate consistently.
Participants explained that only some nurses wanted to attend
rounds and perceived that only some members of the stroke
team valued nursing attendance. These findings are consistent
with literature exploring team members’ perceptions of nurse
attendance at unit rounds or team meetings (Cott 1998,
Milligan et al. 1999). According to Cott (1998), nurses do not
regularly attend team meetings except through a representa-
tive such as a charge nurse. The exclusion of nurses may be as
a result of lack of interest in attending team meetings or to
how a culture typically organizes team meetings. In our study,
nurses said that whether or not they felt welcome depended on
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd
Understanding nursing on an acute stroke unit
which physicians were present. Ultimately, nurses stopped
attending because of time constraints and their perception
that the charge nurse could provide requisite information on
their behalf.
Conclusion
Nurses are an undervalued and underutilized resource in
rehabilitation. Our study shows that in some cases nurses
hold themselves back from incorporating rehabilitation
principles, and that they believe this occurs because of ‘real
world’ structural and temporal work issues. An embedded
cultural belief exists that nurses only have time for basic care
and that rehabilitative care requires expert knowledge usually
held by PT and OT. However, nurses do not work in
isolation and have the capacity to work with other profes-
sionals outside traditional boundaries.
Stroke nurses world wide must embrace professional
development and attend education sessions regarding the
use of facilitative interventions in rehabilitation. We see no
reason that nurses cannot take on a leadership role as
rehabilitation practitioners who promote ‘working with’
rather than ‘doing for’ their stroke survivors. Furthermore,
nurses ought to become advocates for work spaces and
temporal environments appropriate for patients admitted to
acute stroke units.
Acknowledgement
Many thanks go to Dr Kathryn King for assistance with
manuscript preparation and to the late Dr Marlene Reimer,
mentor and colleague.
Funding
Dr Cydnee Seneviratne received funding for this doctoral
research from the Canadian Association of Neuroscience
Nurses research fund and from the FUTURE Program for
Cardiovascular Nurse Scientists, a CIHR Strategic Training
Fellowship.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
CS, SM and KLT were responsible for the study concep-
tion and design; CS performed the data collection; CS, CM
and KLT performed the data analysis; CS and CM were
1879
C.C. Seneviratne et al.

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