Overview

The goal of this observational study is to assess the effects of nurse-led stroke transitional care in stroke survivors, caregivers and healthcare providers who participate in nurse-led stroke transitional care program to improve discharge preparedness, disease self-management and quality of life among stroke survivors. The main question it aims to answer is: does nurse-led stroke transitional care program improve discharge preparedness, disease self-management and quality of life among stroke survivors? Participants are currently participating in nurse-led stroke transitional care program as part of their medical care. Stroke survivors and their caregivers will be followed for six months period to assess their transitional care quality and clinical outcome measures.

Eligibility

Inclusion criteria

• Clinical nurses and physicians with six months of working experience in stroke care
• Clinical nurses and physicians with a minimum of diploma in their professions.
• Stroke survivors with 18 years old and above
• Stroke survivors admitted in the stroke units
• Stroke survivors with primary diagnosis of stroke confirmed by brain CT/MRI
• Stroke survivors who undergo usual discharge process
• Stroke survivors who live with their family caregivers
• Stroke survivors who have mobile phones
• Stroke survivors who can read and write
• Stroke survivors who are able to communicate
• Stroke survivors with National Institutes of Health Stroke Scale (NIHSS) \< 6
• Stroke survivors with Modified Barthel Index (MBI) \> 9
• Stroke survivors with Modified Rankin Scale (mRS) \< 5
• Stroke survivors with Montreal Cognitive Assessment Test (MoCA) \> 14
• Stroke survivors who are expected to stay in the ward for 3-5 days,
• Stroke survivors who are expected to survive for 3 months
• Family caregivers with mobile phones
• Family caregivers who can read and write
• Family caregivers who are able to communicate
• Family caregivers who live with the patient after stroke

Exclusion criteria

• Healthcare providers who will be on leave during the study period.
• Stroke survivors with previous stroke who are not admitted in stroke units
• Stroke survivors who are discharged against medical advice
• Stroke survivors who have end-stage organ failure
• Stroke survivors who have family caregivers
• Stroke survivors who can't read/write
• Stroke survivors who have no mobile phones.
• Family caregivers without mobile phone that is accessible