Comparison Between Comprehensive Nursing Care Ward and Private Care Ward on Functional Recovery in Stroke Patients

Care for patients with stroke is important with neurological sequelae. In particular, subacute stroke patients with moderate or high disabilities must rely on others, mainly caregivers, for most of their daily activities [1]. In Korea, patients admitted to hospital wards are mainly cared for by their family members or caregivers. Caregivers’ employment incurs a social burden of approximately 2 trillion won per year, and the expenditure on caregiving is emerging as a social problem that goes beyond the economic burden of patients [2]. Korea has a longer hospitalization period than other countries do, and this issue is burdensome [3]. Currently, personal caregiving services are in the form of private contracts between patients and caregivers and are provided separately from the nursing system [4]. However, in Korea, caregivers are not systematically managed. Furthermore, 34.9% of medical institutions manage caregiving companies, and 40.6% evaluate companies indirectly rather than directly [5, 6]. In addition, only 53.4% of hospitals have caregiver management departments [6]. Meanwhile, only 37.4% of caregivers receive regular training, and the average training time annually is only 4.5 hours; hence, the education for caregivers is limited [7]. The Korean government previously attempted to establish hospitals without individual guardians to relieve the existing economic burden of nursing care and improve the quality of hospitalization services; based on this effort, it implemented a pilot project for comprehensive nursing care services in 2013 [8]. Comprehensive nursing care services are currently enforced by the government; however, hospital board members’ positions and leading intentions are essential until the service is settled. However, previous studies on comprehensive nursing care services were conducted with a focus on the adequacy of human resources, including the satisfaction of nurses and patients and the work stress of nurses; hence, the medical validity of such services has rarely been explored [2, 9, 10]. In the current study, we aimed to analyze the rehabilitation process of stroke patients admitted to a comprehensive nursing care service ward (CNCW) on the basis of specific indices to confirm the socioeconomic requirements of caregiving services and the validity of their medical aspects.

Data from 354 stroke patients were included in the analysis. Demographic characteristics of each group are presented in Table 1. In the CNCW, 51.4% of the patients were male, with an average age of 67.7 ± 11.75 years. In the general ward group, 48.5% of the patients were male, and the average age was 66.1 ± 12.13 years. There were no statistically significant differences in the demographic characteristics, including average sex and age, between the two groups. The average NIHSS scores were 7.39 ± 2.58 for the CNCW patients and 8.23 ± 3.2 for the general ward patients. The average NIHSS value was 0.8 lower in the CNCW group than in the general ward group, and this figure was statistically significant (p = 0.007). Table 2 shows the distribution of stroke severity based on the NIHSS scores. In the CNCW group, 45.6% and 54.5% of the patients were found to have mild and moderate strokes. In the general ward group, 35.5% and 64.5% of the patients had mild and moderate strokes. However, no statistically significant difference was found in the results (p = 0.052). The results of the functional evaluation and fall occurrence are presented in Table 3. K-MMSE and K-MBI scores in the early and late stages were relatively high in the CNCW group. The effectiveness of the K-MMSE recovery was significantly higher in the general ward group at 2.32 ± 2.04 than in the CNCW group at 2.78 ± 2.13 (p = 0.03). Likewise, the effectiveness of K-MMSE recovery was higher in the general ward group at 0.15 ± 0.15 than in the CNCW group at 0.12 ± 0.13 (p = 0.03). The incidence of falls was significantly higher in the CNCW group (p = 0.002). There were no significant differences between the 2 groups in terms of functional recovery in the other sectors.

Table 1
Demographics and clinical characteristics of the study participants

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Table 2
Distribution of stroke severity on each ward

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Table 3
Initial and final functional outcome and gain according to previous studies and fall occurrence

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As for the cost, the average daily cost was 176,395 won for the CNCW group and 200,662 won for the general ward group (admission fee of 70,662 won + personal care expenses of 130,000 won). Thus, the CNCW was estimated to be about 88% cheaper than the general ward. In addition, the actual self-burden was estimated to be 42,150 won for the CNCW group and 148,500 won for the general ward group (hospitalization fee of 18,500 won + personal care expenses of 130,000 won). In this case, the CNCW was 28% cheaper than the general ward (national policy grants and public health insurance are applied).

The cost and resource issues involved in nursing care service is expected to be deepen as changing social structure into aging population and one person household. To solve these issues, the Korean government introduced comprehensive nursing care services, but the actual medical effectiveness of the system has not been studied. An important difference between the CNCW and general ward is that care is not taken on a one-on-one basis. Care is an important task that involves not only the continuous evaluation of patients’ daily activities and requirements, such as meal assistance, personal hygiene, bathing, and toilet use, but also education and feedback on deficiencies [13]. Based on this institutional and clinical background, we identified the need to evaluate the impact of the CNCW on clinical value. According to the results of this study, hospitalization in the CNCW did not significantly affect the recovery of motor function based on MRC and K-MBI scores (p > 0.05). This outcome was possibly due to professionally educated caregivers, even those assigned to multiple patients, being able to contribute to functional recovery by providing sufficient feedback on daily care [14]. Meanwhile, no difference was observed in the rehabilitation facilities where motor function rehabilitation was mainly performed. According to previous studies, CNCWs do not provide emotional support to patients [15]. However, given that patients’ recovery of motor function at the time of discharge can be reduced by affective problems [16, 17], and that family mediated exercise activities help patients achieve functional recovery [18], CNCWs can be regarded as important facilities. The degree of recovery based on the K-MMSE score was lower in the CNCW group than that in the general ward group. The recovery of poststroke enhancement can be affected in a combinational environment because of various influencing factors, such as sex, age, education level, patient participation in treatment, and underlying diseases [19]. In this study, the results were considered to be ceiling effects with lower recovery because of the high initial K-MMSE and low NIHSS scores in the CNCW group, which is consistent with previous studies [18]. In addition, cognitive function recovery can be negatively affected by affective problems [20] caused by a lack of emotional support, which is a disadvantage of the aforementioned integrated nursing and caregiving service ward [15]. The incidence of falls in the CNCW group was higher than that in the general ward group, which is consistent with the report by Son et al. [21], who analyzed falls in patients in a CNCW for 4 years. Previously, fall incidences were reported in cases of actual injuries; however, reports of falls not involving physical injuries have gradually increased, given the emphasis on patient safety issues and the conduct of medical institution evaluations. As falls are voluntarily reported by patients and nearby medical personnel, reports may actually be omitted, and the rate of omitted reports may be 25% [22, 23]. Most falls occur with no witnesses and nurses around [24, 25, 26]. Through longer contact between patients and nurses, patients can receive help quickly, and the possibility of injury is minimized, resulting in higher reporting rates of minor falls [21]. Relative to the general ward, the CNCW in our hospital increased the duration of face-to-face interactions between nurses and patients by reducing the number of patients per nurse by more than 50% and increasing the number of regular nurse rounds. In other words, the higher incidence of falls in the CNCW than in the general ward is attributed to the ward’s higher reporting rate of minor falls without injuries, which can be regarded as a positive effect in terms of patient safety [21]. Except for the MMSE, the MRC, MBI, and activities of daily living scores are not related to the type of ward. In terms of cost, admission to a CNCW can be a good economic choice for patients who need motor function recovery as CNCWs appear to be about 88% cheaper than general wards.

This study had several limitations. First, there is little published data that can be used for comparison; therefore, the interpretation of the results is limited. Second, owing to the limitations of the retrospective research method, it was not possible to evaluate the quality of treatment and patients’ motivation or participation in treatment. Third, caregivers in the general wards were a mix of family and private caregivers, but they were not distinguished in the study. Fourth, there might be significant differences in the initial evaluation of the K-MMSE and K-MBI scores between the two groups because of the restrictions on CNCW hospitalization for patients with low cognitive function or a high fall risk. These differences might have affected the results pertaining to the degree of functional recovery. Fifth, there was no statistically different distribution of stroke severity between the 2 wards, but there was a significant difference of about 0.8 in the average NIHSS score. This difference might have affected the results for the functional recovery of the CNCW group, which was a relatively mild patient group. Sixth, the possibility that a patient's mood influenced the recovery of cognitive and physical functions was discussed; however, due to the limitations of the retrospective research method, the patients’ moods during hospitalization in the study were inferred based on existing research data. Finally, in addition to the affective and ceiling effects, several factors can affect the recovery of patients’ cognitive function, but such factors were not considered in the study because of the limitations of the retrospective research approach.

In conclusion, hospitalization in integrated nursing and caregiving service wards not only helps relieve physical fatigue and financial burden on patients and their family members and prevents the spread of infectious diseases [27], but also provides a good treatment option with positive effects in terms of reducing fall accidents and improving the recovery of motor functions in stroke patients. Compared to the general ward group, the CNCW group in this study exhibited differences in cognitive function recovery. Given that functional recovery is influenced by various factors, such as sex, age, education level, patient participation in treatment, and underlying diseases, systematic research is needed in the future.