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1Background
Although health care professionals have been caring for stroke patients for hundreds of years, the past 15 years have been marked by dramatic changes in the way care is delivered. Seemingly overnight, stroke care changed from essentially a focus on rehabilitation, to being viewed as a true emergency. This time frame coincides with the acceptance of evidence-based practice as the cornerstone of the nursing profession. This convergence of nursing’s professional growth and research-guided evidence has ignited a revolution in stroke care nursing. The specialty of neuroscience nursing has been well established for over 40 years, but has shown remarkable growth with the surge of interest in cerebrovascular nursing. Along with advances in neuroelectrophysiology and neuro-oncology, cerebrovascular nursing has contributed to the phenomenon of neuroscience nursing as the new frontier in nursing.
Stroke care nursing is not new; in fact, people have been having strokes for thousands of years. The first time the term “stroke” was noted in English literature to refer to a health condition was in 1689 by William Cole. Hippocrates is credited with coining the word “apoplexy” as far back as 400 BCE to represent episodes of convulsions and paralysis, typically on the opposite side of the body 2from the side of injury in the brain. He also described episodes of impaired speech, similar to what is known as aphasia today. The ancient Greeks believed that someone suffering a stroke had been struck down by the gods.
Stroke care first appeared in nursing texts in 1890, but only as very brief discussion. The treatment was supportive care and rehabilitation, but only if the patient survived the stroke and avoided the multitude of secondary injuries that could occur.
The World Health Organization defined stroke in 1970 as “rapidly developing clinical signs of focal or global disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.” This definition is still used today, but an update is needed given the advances in knowledge about the nature, timing, recognition, and imaging of stroke (Sacco et al., 2013).
With the advent of tissue plasminogen activator (tPA), the year 1996 could be considered the watershed moment for acute stroke care. That year the Food and Drug Administration (FDA) approved IV tPA as the first—and still only—medication for the treatment of acute ischemic stroke. The research outcome was that patients who received IV tPA would have 30% better functional outcomes at 3 months than those who did not receive it. The FDA approval of IV tPA has become known as the turning point for acute stroke care. Stroke was now an emergency, a brain attack.
Introduction of the Brain Attack Coalition
The Brain Attack Coalition (BAC) began in 1991 with a group of neurosurgeons who conceptualized improving stroke care through standardization and evidence-based guidelines. The improved outcomes seen with trauma guidelines served as their incentive. The BAC has grown to include membership from 17 professional organizations. This group of highly educated professionals passionate about stroke care reviewed over 600 research articles related to stroke care, and in 2000, published “Recommendations for the Establishment of Primary Stroke Centers” in the Journal of the American Medical Association. This publication, coming just 4 years after the FDA’s approval of IV tPA, contributed to the buzz that was developing in the more progressive health care organizations around the country: Stroke patients should receive care that had been proven through research to improve outcomes. This meant that hospital organizations had the opportunity and responsibility to support evidence-based practice for stroke care (Box 1.1).
Box 1.1 BAC Member Organizations
American Academy of Neurological Surgeons American Academy of Neurology American Association of Neuroscience Nurses American College of Emergency Physicians American Society of Neuroradiology American Stroke Association Centers for Disease Control and Prevention Congress of Neurological Surgeons National Association of Chronic Disease Directors |
National Association of EMS Physicians National Association of State EMS Officials National Institute of Neurological Disorders and Stroke National Stroke Association Neurocritical Care Society Society of NeuroInterventional Surgery Stroke Belt Consortium U.S. Department of Veterans Affairs |
BAC, Brain Attack Coalition; EMS, emergency medical services.
3Nursing’s Leadership Role in Stroke Care
Despite the unfortunate fact that the BAC did not mention the importance of having nurse coordinators to oversee the immense job of implementing evidence-based standards in acute care hospitals, the majority of organizations came to that conclusion sooner or later, and a whole new category of neuroscience nurses was born—stroke program coordinators. The BAC made amends for that omission with their 2005 Recommendations for Comprehensive Stroke Centers. In this they detailed the importance of not only educated and competent bedside nurses, but also the importance of having advanced practice nurses (APNs) as well.
Specialty nursing certification signifies the attainment of a higher level of knowledge and competence in a specific area. Unlike licensure requirements, 4certifications are optional, although the popularity—and number—of nursing certifications continues to grow. As far back as 1997, Barbara Stevens Barnum wrote, “We are in the throes of a love affair with certification in this country, and virtually every RN has a string of (possibly) inexplicable certification initials following their signature.” Certification requirements ensure that continuing education and clinical experience are maintained, a practice proven to raise the level of nursing professional practice. The CNRN (Certified Neuroscience Registered Nurse) established in 1978, and the SCRN® (Stroke Certified Registered Nurse), established in 2013—both by the American Board of Neuroscience Nursing (ABNN)—are excellent examples of stroke-related nursing certifications.
The American Association of Neuroscience Nurses (AANN) and the ABNN recognized that a subspecialty of neuroscience nursing had been born as a result of the research evidence and care guidelines for the complex stroke population. AANN members were asking for more educational opportunities specific to stroke care, and as these nurses developed more expertise and experience, it became clear that there was an opportunity for recognition of that level of knowledge and expertise. The SCRN exam was developed to provide the tool to prove stroke nursing expertise.
Reference
Sacco, R., Kasner, S., Broderick, J., Caplan, J., Connors, B., Culebras, A., . . . Vinters, H. (2013). An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44, 2064–2089.