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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

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), 18721881. 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 eldwork was carried out in 2006 on a stroke unit in Canada. 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 eld notes and interview transcripts. Findings. Three local domains frame how nurses understand challenges in organizing 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 nd 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 fundamental 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, perceptions, space, time

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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 Organization (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 interdisciplinary teams of caregivers including nurses, pharmacists, physicians, nurse practitioners (NP), social workers, occupational 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 benets 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 interdisciplinary stroke care (Cifu & Stewart 1999; SUTC 2007). This study looks beyond outcome measures to the daily interactions and beliefs that characterize comprehensive programmes, 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 contribution 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 interdisciplinary 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

toward a managerial or understudy role that coordinates rehabilitative tasks under the guidance of other professions (OConnor 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, Hendersons vision is unattainable (Myco 1984). The role of nurses in acute stroke rehabilitation is unclear (OConnor 1993, 2000a, 2000b, Forster & Young 1996, Kirkevold 1997, Burton 1999, 2000, Elliott 1999, Thorn 2000). Researchers have identied nurses as managers or coordinators (OConnor 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 (OConnor 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, facilitated 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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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 rehabilitation and care providers perceptions toward this construction remains unclear.

purposive sampling (Morse & Field 1995, Hammersley & Atkinson 2007) to locate participants, and excluded individuals 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 ve 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 23 hours on 3 days/week. The eldworker (CS) made observations during every type of shift. The eldwork began with 3 months of general observation on the unit with the eldworker watching at the charting desk, nursing station and walking in the hall. Notes from observations were transcribed via computer. The eldworker claried gaps in eld notes by returning to the eld 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.

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 eld notes and other media, including audio and visual formats. Posteldwork, 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.

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 condentiality. We sought written consent only from observation and interview participants and verbal assent from patients when participants were providing direct 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 interventions, 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 oor 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 stafng ratio was one RN or LPN to every four patients. We used
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Data analysis
Analysis of eld notes focused on identifying central domains, specic domain components and related work typologies (Spradley 1979, 1980, Hammersley & Atkinson 2007). We discovered three main themes (domains) and further identied 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 eld notes, transcripts and then returning to the eld setting for further observations, we crosschecked our ndings and were assured that our study domains, components and related subcategories were culturally salient.

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Understanding nursing on an acute stroke unit Im too claustrophobic on this unit. Its like I am closed inif you look down the hall from the nursing station you feel like the walls and curtains are closing in around you. It is so narrow. I feel constricted because I cannot do my work in cramped space. I bump into other people all the time.

Reexivity
Ethnographers change in the process of conducting research and spending an extensive period learning cultural domains and categories, and from building relationships with study participants (Davies 1999, Hammersley & Atkinson 2007). Indeed, if an ethnographers ideas, beliefs and values did not change it might indicate that she failed in understanding the culture she was studying. To keep track of the sorts of changes they undergo and the impact of these changes on their eldwork, ethnographers employ reexive techniques. In this study, the eldworker used asides, integrative memos and research journals (Spradley 1979, 1980, Emerson et al. 1995) to make explicit her presuppositions and insider relationships, and to maintain awareness of her social position within the culture. Some staff knew the researcher as a nursing instructor or a previous employee. Asides and journaling helped her denote prior relationships, and highlight instances when she might have had built-in biases or made priori judgments. Reexive techniques helped control for potential biases from having an insider perspective, which we did not want to lose because it was essential for gaining access to the study setting, building rapport and building and maintaining trust with staff.

Nursing too close Limited space made it difcult to move, to use and relocate equipment, transfer patients, document nursing care and interact with colleagues. Limited space required alternative work strategies to ensure that one did not get in the way of ones colleagues. For example, nurses unlocked the wheels on beds in rooms near the nursing station, wheeled them to an open space, and then transferred patients to stretchers. One nurse said:
This unit is not set up for us to nurse or do rehab. It is designed so that we are constantly bumping bums, literally bum to bumwhen we transfer patients. We are bashing into one another when we feed patients and when we provide any kind of nursing care.

The layout of the unit caused nurses to bump into each other, and put patients in situations where staff could not ensure appropriate care, privacy or condentiality. Nursing under a state of code burgundy A code burgundy signals a lack of beds. The unit included an over-capacity bed in a shared hall. Caring for patients in hallways compounded having to work too close. Nurses disapproved of nursing under a state of code burgundy:
[We] feel badly for the lack of privacy for that patient in the hallway. I mean even I had to perform an intimate procedure, a urinary catheter insertion in the hall, and I hated doing it.

Findings
Space
Participants described space as a challenge to patient care. Three themes predominated in the data: nursing in a submarine, nursing too close and nursing in a state of code burgundy. Nursing in a submarine Staff used the term submarine to refer to the unit. Command centres are located near the front of submarines, with missile rooms at the rear. The nursing station was located near the entrance of the unit, while the majority of four-bed rooms were located at the middle and far end. According to one nurse:
Our submarineits just a more condensed unit. But the thing that most bothers me is its not centred. If you have patients in the last roomat the other end you are not in close proximity to anything or anybody youre alone. That drives me crazy because the nursing station is so far away.

Ironically, despite disapproving of these conditions, nurses often faced criticism from patients families for the conditions:
I think it really stressed [us] out, because [we] were taking the brunt of family complaints. You try telling the patient that you are just following procedure. This is a region issue and we are obligated to do what the region tells us, but we dont agree.

A state of code burgundy means increased workloads and the ethical challenge of hallway care.

Time
Participants talked about time in three major ways: lack of time, preserving time and time with and without space. Each concept denotes limitations and challenges to providing care.

Participants connected their feelings of claustrophobia on the unit with being on a submarine. The unit lacked work space and storage space:

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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 workrelated 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 patientsSo if things get missed so be it.

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 conict on the unit that its really hard sometimes to set things up optimally, so we would rather work with patients down in the gym without the nurses.

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 specic window of time.

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 thingslike assist patients in their room with feeding or mobilization and all of those thingsthat would be great, but it doesnt happen.

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 andfor themselves. But, that requires a whole lot of time and effort, which the nurses dont have. So I am sure some of [the patients] are frustrated because they realize that and they arent able to do as much as they would like to doSome days you just cant wait, you have to get it done and move on.

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 iswell, just repetitive.

Preserving time To preserve time nurses coordinated their work and cared for patients as a team. They met and identied tasks they could do more efciently 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 consequence of familiarity. As one nurse related:
For me team nursing is knowing who you work with. I dont know whether its 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.

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 professionals 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

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.

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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.

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 developed 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 dont 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 physicians role is relatively minor. Its 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.

Communication and collaboration Participants claimed that communication and collaboration were critical to the success of the unit. Regular communication ensured everyone understood how other members envisioned 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 theyre 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 inuencing 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 benecial in the long run for all the staff because we can learn so much from each other especially about stuff we dont have time to nd out.

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 attendance of nurses at stroke rounds would have reinforced the notion that the unit was 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 professionals 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:

Discussion
Study limitations
Ethnography is not a science of generalization. Ethnographic ndings come from certain individuals, situations or single cases from a particular context and a particular time (Hammersley & Atkinson 2007). Our ndings 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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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. Notwithstanding 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 investigation 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 perceived 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 insufcient time. They did not take the time to assist patients to wash, dress and practise mobilization. They complained about inadequate 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 thrombolysis 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 decit (Barber et al. 2005). Team members have a second term, door to needle time, which refers to the time between a patients arrival at the hospital and the start of thrombolytic therapy (Hill et al. 2000). Temporal metaphors denote boundaries and different dimensions within the work space (Gell 1996, Bluedorn 2002,
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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 organized stroke units improves outcomes and the temporal demands of thrombolysis motivated the adoption of coordinated 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 (Va kangas et al. 2008) showed that nurses who incorpoha rated rehabilitation into their daily care increased the amount of time working with patients to maximize patient independence. 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 wellpositioned to assist in the development and evaluation of appropriate stafng 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 assessments and interventions mainly in team meetings. Nevertheless, 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 interdisciplinary 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,

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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, independence and likelihood of living at home 1 year poststroke. Nurses are important and essential members of interprofessional stroke teams as they work with and care for patients 24 hours a day.

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 professionals 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.

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 rehabilitation 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 facilitative 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.

Acknowledgement
Many thanks go to Dr Kathryn King for assistance with manuscript preparation and to the late Dr Marlene Reimer, mentor and colleague.

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 difcult 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 ndings 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 representative 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

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.

Conict of interest
No conict of interest has been declared by the authors.

Author contributions
CS, SM and KLT were responsible for the study conception and design; CS performed the data collection; CS, CM and KLT performed the data analysis; CS and CM were
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responsible for the drafting of the manuscript; CS and CM made critical revisions to the paper for important intellectual content; CS and KLT obtained funding; CS provided administrative, technical or material support; KLT supervised the study.

References
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The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientic journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit the journal web-site: http://www.journalofadvancednursing.com

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