Der Norden Chinas hat eine Schlaganfall-Rate, die etwa 10 mal so hoch ist, wie die in Europa. Das hängt damit zusammen, dass es in China extreme Temperaturunterschiede gibt: +40 Grad im Sommer, -40 Grad im Winter. Des Weiteren haben die meisten schlecht eingestellten Blutdruck, die Arbeit ist hart, das Essen ist fettig und scharf. Die Belegschaft im Heilongjiang University Hospital of Chinese Medicine ist aber topfit darin, diese Fälle mit wenigen Mitteln wieder auf die Beine zu bringen und das beschreibe ich hier am Beispiel einer 41jährigen Patientin. Sie wurde mit einer Hirnblutung eingeliefert und von den ÄrztInnen und ihrem Mann gesund gepflegt wurde. Ein Text, der viele Aspekte der Schlaganfall-Rehabilitation in Nord-China anschneidet.
The influence of nursing staff shortage on the treatment of patients affected by cerebrovascular accidents at the Heilongjiang University Hospital of Chinese Medicine applied using a concrete case.
Over recent years, evidence-based medicine in the West has increasingly emphasized the role of patients‘ relatives in the provision of nursing care and in the rehabilitation of stroke patients in particular. But in China, a lack of nurses has meant that family members have long played a key role in providing nursing services, even within hospitals. These carers receive little direct instruction and training from hospital staff, despite the proven benefits to carer and patient alike of expending resources on such training, but quickly develop expertise in caring for their patients and supporting them in the rehabilitation process.
In this essay, I examine the role of these support networks in the treatment of stroke rehabilitation using a case study encountered during my time at Heiljiongyang University hospital. I begin by detailing the nature of the treatment, and then analyze the wider cultural-social factors that influence the treatment.
The case study
While studying at the Harbin Hospital for Chinese Medicine in Heilongjiang province I witnessed the rehabilitation process of a 41-year-old woman who had suffered a brain haemorrhage about one month earlier. I met her and her husband the first time in the hospital’s neurology department on October 13, 2014. She was joined and supported by her husband with whom I talked a lot about their family situation, the rehabilitation process and his coping mechanisms.
I was stunned to learn that, even though she was severely affected by the hemorrhage, he looked after her all day, every single day, for the whole first month. This was necessary because the nurses there did not have the time to look after the basic needs of their patients such as turning, washing, toilet and bringing the patient to and from the rehabilitation exercises every day.
The husband was highly involved in day-to-day care. He was the main facilitator of his wife’s daily rehabilitation exercises in the exercise room and acted as the advocate for his wife’s needs. This came at great emotional and financial cost, however: To fulfill this role, he had to stop working and the couple’s income decreased to nothing.
The husband was challenged on a daily basis by his duties. He worried all the time about the future health of his young wife and about the fall in his income. However, he tried to stay affectionate, caring and loving of his sick wife. Both worked very hard to bring the rehabilitation process to the best possible outcome.
On first presentation
The hemorrhage had severely affected the right side of her body. On first presentation the right side of her face showed no movement and she was not able to speak but understood what she was told. The muscle strengths in her right arm and leg were at level 1 according to the manual muscle testing grading system developed by Florence and Henry Kendall in 1945 (Peterson Kendall et al., 2005).
After one month of treatment her speech was still slurred. The muscle strengths of her right arm and leg had improved from level 1 to 3+/4. She was now able to get up from her bed.
The patient was unusually young for the presenting condition of brain hemorrhage. Her doctor, Dr. Sun, explained that the patient has a family history of hypotension. The patient did not smoke or drink but worked outside all year. Being exposed to strong weather changes in combination with internal factors, is known to be a common precursor to cerebrovascular incidences. (McArthur et al., 2010)
Her tongue was swollen, with teeth marks and a white sticky coating. The pulse was a bit weak and could be considered to be an almost normal pulse.
Identifying the patterns and diagnosis
Cerebral hemorrhage consists of bleeding from an intracerebral artery into the subcutaneous space. The patient’s hemorrhage did not lead to her becoming unconscious or falling into coma and resulted in an attack of the connecting channels only. According to Flaws and Sionneau (Flaws and Sionneau 2001), this is characterized by unilateral paralysis of face and limbs, numbness and slurred speech. While an attack of the connecting channels only, there is no loss of consciousness or coma.
The Chinese pattern is a Wind Stroke in combination with a deficiency of Spleen Qi, leading to failure to hold the Blood in the vessels.
Aetiology and Pathology
Overwork and family genetics most likely lead to a deficiency of Kidney Yin in the patient. This deficiency of Kidney Yin leads to deficiency of Liver Yin and the rising of Liver Yang, giving rise to high blood pressure. This can give rise to Liver Wind. Liver Wind causes apoplexy, paralysis, mental cloudiness and the tongue moving or becoming deviated.
Eating irregularly weakens the Spleen and leads to formation of Dampness, which becomes Phlegm when congealed. Phlegm causes numbness in the limbs, mental cloudiness, slurred speech/aphasia and a swollen tongue with a sticky coating. Spleen Qi deficiency further leads to difficulties to hold the Blood in the vessels.
Strong weather changes can lead to sudden invasions of Wind, Heat and Cold adding to the risk of having a Wind Stroke.
How was the treatment of the patient structured at the Heilongjiang university clinic of TCM?
The patient was treated with three different treatment modalities. She had one hour of Acupuncture per day from Monday till Saturday from Dr. Sun. Every day from Monday to Friday the acupuncture was followed by 45 minutes of Tuina practiced by Dr. Zhang and at least an hour of free physical exercise in the training room at the rehabilitation unit. The hour of free exercise was facilitated and led by the family members of the patients who had to help with using and moving between the machines or exercises. The patient’s carer was responsible for bringing the patient on time to the rehabilitation ward as well as observing and assisting while the Tuina treatment and exercises were provided by Dr. Zhang.
The Acupuncture protocol with which the patient was treated was very much representative for all stroke patients in this department. The protocol was only slightly adapted to the individual presenting condition of the patient. There is no head acupuncture given to patients with brain hemorrhages till the blood in the brain is fully reabsorbed. The progress is observed by weekly MRI scans.
During my time at the hospital the patient discussed did not receive scalp acupuncture because the hemorrhage in her brain was not absorbed yet and this is a contraindication for scalp acupuncture.
The Acupuncture protocol:
Face: LI20 needled lower than usual but on the nasolabial fold, ST4 (Dicang)
Throat: RN23 (Lianquan) and two extra points I cun lateral of RN23 each side. These points are needled deep and towards the root of the tongue.
Shoulder: LI15 (Jianyu)
Arm: LI11 (Quchi), SJ5 (Waiguan), LI4 (Hegu), SI3 (Houxi)
Leg: ST31 (Biguan), GB21 (Fengchi), ST34 (Lianqiu), ST36 (Zusanli), 1 cun lateral to ST37 (Shangjuxu), nearly ST40 (Fenlong), SP9 (Yinlingquan), SP6 (Yinlingquan), LR3 (Taichong).
Ms. Sun needles LI4 (Hegu) at the end of the crease of thumb and index finger towards SI3 (Houxi). SI3 is located differently too: it is located halfway of the 5th metacarpal bone on the ulnar side of the hand. SI3 (Houxi) is needled towards LI4 (Hegu). On pressing, the combination of these two locations is very tender.
She needles the leg points of this patient more according to the dermatomal region of the perineal nerve (nerve running at the outside of the leg, exiting the spine at 2nd-4th lumbar vertebrae) than according to the classical leg points.
The inpatient stroke patients were treated on Mondays to Fridays with Tuina. The patient’s practitioner was Dr. Zhang, who is surprisingly strict with the patients. When the patients practiced standing with him he stepped extra far backwards to make the patient try a little bit harder. When I asked him why he did this he explained that with this technique he wants to build self-discipline and responsibility for the treatment progress in his patients. Dr. Zhang has high demands during the active movements. He considers this to be very important for the long-term treatment outcome.
Dr. Zhang massages every muscle and moves every joint. The classics say that in case of a wind stroke you should treat the Yang Ming but the modern approach is to treat the whole body.
His comment on pressure and intensity of treatment was: “In the spasm period the pressure applied while treatment is light. The neurons are highly active and need to relax. In the chronic period a higher pressure can be used. The body needs to still be tonified though.”
Typical active movement exercises while the Tuina treatment:
Lifting the arms straight up over the head (while lying)
Marching in bridge positions
Lifting the knees while lying
Sitting, standing up or walking according to individual presentation
Dr. Zhang considers „Tuina and physical exercise more important than acupuncture in the treatment of paralysis“. The Tuina protocol is representative for the different types of strokes at Heilongjiang University Hospital. The only exception is that „Patients with a brain hemorrhage need to be treated differently to patients with an infarction. With hemorrhage patients it is important to avoid movement and exercise till the patient is definitely stable. In patients with an infarction you can start the treatment very early.“
This is another aspect of treatment at the Heiljiongyang University Hospital that accords with up-to-date evidence-based research. Such research suggests that large doses of practice, on the order of hundreds of daily repetitions of upper extremity practice and thousands of daily repetitions of gait, may be required to produce lasting neural changes and optimize motor learning. (Lang, et al. 2009)
As Lang, et al. note in their 2009 study: “In summary, we found that the amount of task-specific practice currently provided during stroke rehabilitation is small compared with animal models and human motor learning studies. Given that patients, post-stroke, spend large portions of their day relatively inactive, the dose of practice provided during therapy is of utmost importance.”
In general Dr. Zhang suggests, „Treatment is most effective when started two weeks after the stroke and at latest when the patient is stable. When six months have passed only little improvement in the patients can be achieved.“
Progress and Outcome
After one month the muscle strength in the arm and leg had increased from level 1 to level 4. The increase from level 3 to 4 happened within the 4th week. The patient relearned speaking within the month but the speech is still slurred.
Strong carer involvement at the Heiljiongyang University Hospital
What struck me most about the treatment of stroke patients at the Heiljiongyang University Hospital was the extent to which practices that are increasingly recommended by modern evidence-based medicine have here long been in use. This includes self-responsibility of the patient (discipline), high-frequency and high-intensity exercise and, in particular, the strong involvement of the carers in nursing and rehabilitation of the patients.
Modern evidence-based medicine in stroke rehabilitation recommends the integration of the family and the spouse/carer in the rehabilitation process of stroke patients. (Visser-Meily et al., 2006) The research suggests that a stronger integration of the carer/spouse in the rehabilitation process leads to a decrease in sudden overburdening of the carers when the patients are discharged. Carers feel more confident about their nursing skills and can handle the day-to-day challenges better. Overextension of carers’ skill set influences the patient/carer-relationship negatively leading to carer depression, which subsequently has a negative influence on the morale and emotional state of the patient.
There has been a lot of research done on the positive impact of carers receiving sufficient information and theoretical skills on the subject of stroke, with the target to increase understanding and morale of carers and patients. Newer research by Kalra, et al (2004) and others has concentrated on the impact of practical nursing skills teaching to the carers. Their study could demonstrate a significant improvement in depression rates and overall self-reported happiness for the patients and carers.
At the Heiljiongyang University Hospital, the frequency of carer involvement seemed to have been primarily due to budgetary, social, and cultural factors. He, et al. (2013), Pang, et al. (2004), Zhan (2006) and others have carefully examined factors contributing to the high level of carer involvement. They concluded that the involvement of carers in the system is a result of limited resources in the Chinese healthcare system and a consequence of certain aspects of Chinese philosophy and culture.
(He, et al. 2013) underlines the shortage of nursing personnel reported by the Ministry of Health of the People’s Republic of China. In 2012, the number of nurses was 2.24 million, represented a nurse to population ratio of 1.66 nurses per 1000 people, compared with a global average of 4.06 nurses per 1000. (Ministry of Health of the People’s Republic of China 2012)
Moreover, traditionally in Asian societies, care and caring are family responsibilities (Pang, et al. 2004; Zhan 2006), and the Confucian belief system leads to an avoidance of sharing emotions with non-socially related people. “Indeed bedside nursing care is traditionally considered to be the responsibility of the family and Chinese hospital nurses mainly carry out doctors’ orders, completing routine tasks and medical treatments. (Yun, Shen and Jiang 2010)
The third reason behind Chinese’s hospitals‘ reliance on carer involvement might lay in the translation of nursing techniques from theory into practice. My conversations with patients suggest that Chinese nurses are often considered not to be looking after their patients properly. Even though Chinese nursing theory and teaching instructs the nurses „to care for the patients as if they were related by blood”, (Meng, Xiuwei and Anli 2011), the reality shows a sharp contrast between theory and reality. He, et al. (2013) conducted a study that compared the opinion of patients on the care they had received with the self-evaluation of the Chinese nurses. “The results showed that the nurses’ evaluation of their own caring behavior was significantly higher than the rating the patients gave them. The subscale categories ‘knowledge and skill’ and ‘assurance’ were rated ‘good’ by both patients and nurses, but both groups gave lower scores to ‘respectful’ and ‘connectedness’.”
The shortage of nursing staff at Heilongjiang University Hospital lead to a situation in which the husband of the case study patient had to take on a lot of responsibility for the care and rehabilitation of his wife very early after her hemorrhage. At the beginning he even stayed in the hospital overnight and slept on the bench in the waiting area to ensure that she was looked after at night and to check that “she has warm hands when she sleeps”. He went out of his way to ensure optimal care. He learned on the job what needed to be done to support the rehabilitation process of his wife: he was surrounded by other family members feeding their patients, taking them to the loo, and lifting them into wheel chairs. He was given a student to show him where to bring his wife for her daily rehabilitation practice, where he found Dr. Zhang for the first time. He admitted in conversation that his mood fell very low in the process of caring, but thanks to his wife’s relatively fast rehabilitation process he was able to keep his optimism up about the future. He was sure that she would become able to go alone to the toilet, to wash herself, to walk, to take on household chores and to potentially work again.
Stroke patients in the eastern and western world require particularly high levels of care. This type of patient rarely leaves the hospital in a self-sufficient state. They tend to need help by family carers – often the spouses – for a longer period of time after discharge, and often suffer long-term physical and psychological effects from these cerebrovascular accidents. In China the burden on family carers and spouses of stroke patients is particularly high because of the high day-to-day care required in the hospital environment, the support needed by patients to facilitate the rehabilitation process, the shortage of nursing personnel and China’s still-lacking social security system. At the same time Chinese carers quickly gain skills in how to look after and in how to facilitate the rehabilitation process of the patient from a very early stage. This seems to be to the considerable benefit of the patients I met at the Heiljiongyang University Hospital: They seemed to be very motivated and disciplined as a consequence of working closely together with their family member carer. I believe that this high level of motivation and discipline is also partly due to the lacking social security system in China leading to discharged patients worrying about becoming a financial burden on the family. The carers, from very early stage, seem to feel responsible for facilitating the rehabilitation process of their patient.
Modern evidence-based research demonstrates that patients and their spouses/ family carers in the west would very much benefit from more training in nursing skills and rehabilitation provision. Even though the training of stroke carers in China seems primarily borne out of necessity and driven by cultural factors, rather than an understanding of modern evidence-based practice, care in China can still be taken as an example of the positive effects of such training. The teaching of nursing and rehabilitation supporting skills would enable patients and carers to better cope with the challenges of day-to-day post-stroke life, would improve the relationship between carer and patient, and would reduce depression, helplessness and overextension for all parties.
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He, T. et al., 2013. Perceptions of caring in China: patient and nurse questionaire survey. International Council of Nurses, pp.487-92.
Kalra, L., Evans, A., Perez, I. & Meloburne, A., 2004. Training carers of stroke patients: randomised controlled trial. British Medical Journal, 328.
Lang, C. et al., 2009. Observation of Amounts of Movement Practice Provided. Archives of Physical Medicine and Rehabilitation, 90, pp.1692-98.
McArthur, K., Dawson, J. & Walters, M., 2010. What is it with the weather and stroke? Expert Review of Neurotherapeutics, 10(2), pp.243-49.
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