Practical Experience of Humanistic Care Among Medical Staff in Stroke Wards: A Qualitative Research Study Conducted in China


 BackgroundAs a special patient group, stroke patients have a significant attachment to humanistic care. There are, however, still many problems in clinical practice. Medical staff in stroke wards are the main providers of humanistic care. Finding out the opinions of staff that provide the medical service is vitally important for stroke patients that need access to curative and humanistic care.ObjectiveThe aim of the study was to explore the psychological experiences of doctors, nurses and physiotherapists during the implementation of humanistic care in a stroke ward.MethodMedical staff including doctors, nurses and physiotherapists were selected from stroke wards in general hospitals (minimum level two) from 13 cities within six provinces in China. A purposive sampling method was used until no new data were generated (n=18). Semi-structured interviews were conducted by using a phenomenological research method. The Colaizzi seven-step method was used for analysis.ResultThe end user’s experience incorporated four themes: (1) Gradually improving the perception of humanistic caring in a stroke ward. (2) Required improvement of consciousness and ability of humanistic care implementors in a stroke ward. (3) Main problems and contradictions associated with implementing humanistic care in stroke wards. (4) Critical needs of staff in a stroke ward.ConclusionSteady advances have been made in the prevention and treatment of stroke in China. Care behaviour of staff in stroke wards has gradually improved. Nevertheless, while implementing humanistic care in stroke wards, the consciousness and ability of medical staff needs to be improved, in addition to the practical problems and contradictions affecting the development of humanistic care. In order to improve the level of humanistic care in stroke wards, attention should be paid to the overall improvement of the personal qualities of medical staff in stroke wards and the integration of a humanistic management mode.


Abstract Background
As a special patient group, stroke patients have a signi cant attachment to humanistic care. There are, however, still many problems in clinical practice. Medical staff in stroke wards are the main providers of humanistic care. Finding out the opinions of staff that provide the medical service is vitally important for stroke patients that need access to curative and humanistic care.

Objective
The aim of the study was to explore the psychological experiences of doctors, nurses and physiotherapists during the implementation of humanistic care in a stroke ward.

Method
Medical staff including doctors, nurses and physiotherapists were selected from stroke wards in general hospitals (minimum level two) from 13 cities within six provinces in China. A purposive sampling method was used until no new data were generated (n=18). Semi-structured interviews were conducted by using a phenomenological research method. The Colaizzi seven-step method was used for analysis.

Result
The end user's experience incorporated four themes: (1) Gradually improving the perception of humanistic caring in a stroke ward.

Conclusion
Steady advances have been made in the prevention and treatment of stroke in China. Care behaviour of staff in stroke wards has gradually improved. Nevertheless, while implementing humanistic care in stroke wards, the consciousness and ability of medical staff needs to be improved, in addition to the practical problems and contradictions affecting the development of humanistic care. In order to improve the level of humanistic care in stroke wards, attention should be paid to the overall improvement of the personal qualities of medical staff in stroke wards and the integration of a humanistic management mode.

Background
Stroke is an acute traumatic emergency that endangers human health, which can cause permanent nerve damage and lead to signi cant change in a patient's daily life [1,2] . With increasing incidences year on year [3] , stroke has become the primary leading cause of mortality in China [4] . Approximately 75% of stroke survivors have varying degrees of physical and mental disability [5] , which has become a huge burden to families and society [6,7] .
A study has highlighted that humanistic care not only improves the physical and mental health status of stroke patients but also affects the recovery outcome [8] . However, there is no uniform standard to evaluate medical humanistic care at the moment. Most of the care processes depend on the conscious awareness of managers and the personal qualities of implementors [2,4] . The practical status is not optimistic.
Qualitative research can be an excellenta magni cent way to thoroughly explore the connotations of this phenomenon in the eld of humanistic care [9] . This method has been used to investigate the work of nursing experience [10] and rehabilitation needs [11] from the different perspectives of doctors, nurses and therapists in Europe and US. In China, quantitative research focused on patients' quality of life and the effects of intervention occupying mainstream thinking [12] , especially on the mainland. Rarely do qualitative studies of humanistic care for stroke patients in China focus on humanistic care. Instead of studying the experience of the caregivers, most articles concentrate on the needs and feelings of patients and caregivers [13,14] .
This study is based on previous investigation on the subject of constructing humanistic care practice guidelines for stroke patients. This study will fully consider the experiences of both the care implementors and recipients. As the principal part of humanistic care practice in stroke wards, the feelings of medical staff can affect and even determine their own caring behaviours. In order to thoroughly investigate the details and problems associated with the implementation of humanistic care in stroke wards, this study explored the psychological experiences of doctors, nurses and therapists during the implementation of humanistic care in stroke wards through semi-structured interviews, to improve the overall level of care.

Method
Design A phenomenological method and thematic analysis were used within qualitative semi-structured interviews, which is part of the part of the practice guideline structure for stroke care. Before starting, the research group de ned the practical meaning of humanistic care for stroke survivors. The expertise group consisted of a nursing methodology professor, a director of the hospital nursing department, a director of the neurology department and a chief nurse. This expertise group conducted a feasibility study and quality control analysis regarding the processes of topic selection, study design and potential problem nding in this draft study and put forward suggestions for revision.
Two interviewees were involved in each interview. The main interviewer is the systematic literature evaluation specialist authorised by the Joanna Briggs Institute, who has nearly 10 years of clinical work experience and is competent in the use of communication and interview skills. The interviewer maintained a neutral attitude throughout the interview, without inducing or hinting to obtain statements from interviewees. The analytical process is suspended, looking at things with an open mind, so as not to be in uenced by existing knowledge and experience [15] . SRQR reporting speci cation is used to present the research results, and the quality evaluation method of qualitative research is used to review the level of rigor applied.

Participants
The study was conducted from September-October 2019. Participants from stroke wards in general hospitals (graded level two or above) from 13 cities within six provinces engaged in an advanced study in

Data collection
Based on the previous research, an outline was made of the interview following group discussion, consultation with experts and a pre-interview. The semi-structured interview included four main questions (Table 1). All of the participants were briefed about the study and informed of their rights and obligations in the study. The rst author made appointments with participants after they acquired written consent for the interview from participants. To encourage the participants to describe speci c experiences of humanistic care in stroke wards, follow-up questions were asked later by the researcher. The average interview length was 60 minutes (range 30-90 minutes) and an audio recording was made of each interview.

Ethical considerations
This study was approved by the Ethics Committee of the General Hospital of the Southern Theater Command of the Chinese People's Liberation Army. A full explanation of the research purpose and method, rights and obligations, use of recording equipment and other related matters was given to the interviewees. All participants provided a written and signed letter of consent to be interviewed.

Data analysis
Colaizzi's data analysis method was used for clustering themes from the known phenomenon [16] . Every audio-recording was transcribed verbatim and reviewed as soon as it had nished by the rst author (ML). The rst author (WJZ), who is uent in both Mandarin and English, translated the interviews into English after double-checking the transcripts. All the transcripts were read multiple times by rst authors in order to reach a common understanding of the perceptions of the participants and gain a deeper understanding of the content. Then, authors continued the data analysis process by labelling the data extracts from all the interviews with a coding system.

General participant information
Eighteen participants were recruited, including ve doctors, eight nurses and ve rehabilitation technicians. Their average age was 36.66 ± 5.57 years. The average work experience time was 11.83 ± 6.82 years. One of the participants is a follower of Islam, with the others having no religious beliefs.

Themes revealed
Four main themes were extracted from the manuscript: 'Gradually improving the perception of humanistic caring', 'Required improvement of consciousness and ability of humanistic care implementors in stroke wards', 'Main problems and principle contradictions in implementing humanistic care in stroke wards', 'Critical needs of staff in stroke wards'. Table 2 displays both the prime motivators and obstructions to implementing humanistic care in stroke wards. Due to the widespread nature of stroke prevalence areas, inconsistent service levels and non-standard stroke prevention rescue system, the National Health Commission has established a stroke specialist management system and formed an integrated process of pre-hospital treatment, family recuperation and social rehabilitation by integrating multi-disciplinary advantages, which has changed the traditional pattern of stroke care. In the study, eight participants described how the treatment mode has transformed into multi-disciplinary cooperation, which has also improved the conscious awareness of humanistic care among doctors, nurses and technicians: 'The construction of stroke units has become more mature in our country, which makes a big difference in the care of patients.' (a1, a5) 'Nursing patterns has changed a lot these days, which also put new demand on us … …, we need to be aware of all aspects of patients.' (b3) 'Some relatives of seriously ill patients put the 'nation ag' like bedspread on the bed and play some scriptures that we could not understand. In the past, we would certainly try to stop them, but now we will not intervene too much.' (b4) Solving patients' problems Ten participants agreed that fully addressing the speci c problems of dysfunction and hospitalisation is an important way for them to fully experience the core components of humanistic care: 'I have treated a patient with dysphagia very well, and he said I had been his benefactor all his life.' (b1) 'The patient couldn't sleep because the light was too bright, so the nurse bought the patient an eye mask at her own expense.' (b8) 'A post-burn stroke patient was transferred from the primary hospital. After our efforts, his 2-month-long urine and gastric tubes had been removed. He sent us a pennant.' (c4) Initially create a caring atmosphere Creating a harmonious and caring atmosphere is the essential condition for humanistic care of stroke patients, which enables patients to feel the medical temperature and enhance their sense of social participation. It is mentioned by all participating professions, and they all took it seriously: 'On some major holidays or their birthdays, we will give gifts or throw parties for patients who cannot be discharged from the hospital, so that they can feel the warmth of home in an unfamiliar environment.' 'There are patients in our department with similar hobbies, then we will introduce them to each other.' (b7) 'Our director used his rest time to visit the patients and do crafts together… …' (c2)

Weak professional value
Consciousness is the subjective impression of objective things, and practice is the internal power of consciousness development. They in uence each other and are a reciprocal causation. Doctors are not only the behavioural subjects of medical services, but also the holders of different social roles. Multiple pressures will directly affect their loyalty, sense of responsibility, dedication and sense of achievement, which will be transferred to patients through medical services. Among the participants, seven of them said that their professional honour makes them feel more comfortable, six of them said they only work to support their families, and ve complained about their career choice.

Insu cient voluntary caring behaviour in stroke ward
Too much attention is paid to the treatment of the condition instead of treating the person. Six of the participants said that humanistic care was highlighted for many reasons, such as insu cient conscious care behaviour of staff, caring carried out by escorts, and coping with education: 'We couldn't even perform (humanistic care) on lucid (patients), let alone those in a com. What's the point of the care?' (a3) 'At present, patients can only be brie y introduced to the ward environment during admission evaluation, there is nothing else.' (b5) Inadequate attention and capacity for whole-process rehabilitation Self-realisation places the highest demand on individuals in Maslow's hierarchy of needs, and rehabilitation is an important way for patients to return to society. The lack of a rehabilitation concept and comprehensive skills will increase their resistance to forming social ties. Nine respondents said that they felt guilty due to insu cient awareness, implementation and follow-up guidance. In the interview, many interviewees also re ected on the impact of inadequate competence, including professional competence and humanistic practice on the rehabilitation process of stroke patients.
'Because we did not do well in early recovery, a sober patient contracture and shrunk like a ball(because of the complication). Every time I passed his ward, I could not bear to see him (tears in eyes).' (b1) 'Rehabilitation is so important. But we just overlook it. We don't know whether it does good to patient, and whether there is a difference in the treatment.' (b3) Theme 3: Main problems and principle contradictions in implementing humanistic care in stroke wards

Contradiction between reality and demand in the management of medical institutions
In this study, a number of participants said that humanistic care attributes were not taken into account in staff selection, existing work processes and management systems, resulting in patients not bene tting from it. Instead, many complaints were lodged, and the staff themselves felt weary and helpless: 'The average number of hospitalized patients is more than 170, with only approximately 20 nurses, and the corridor is full of camp beds… …' (b1) 'We have to go around and make an inspection every hour. Points will be deducted if the rounds are too short. Patients are disgusted that they cannot get to sleep easily and then are woken up by our rounds (helpless, sigh).' (b5) 'Some people who are not paraplegic can sit up and move moderately with the help of others, but we really cannot spare the time and energy to help them (helpless).' (b6)

Disparity between rehabilitation conditions and patients' needs
The social security mechanism and the medical rehabilitation system are gradually improving in China. However, due to past restrictions, an uneven distribution of high-quality medical resources, insu cient total amount and other problems, stroke rehabilitation conditions do not meet the requirements of patients. '

Build a more harmonious relationship between patients and doctors
A good doctor-patient relationship is not only the premise for mutual trust and close cooperation between doctors and patients, but also the basis of a humanistic service. The stereotypical image and false impression of stroke by patients or their families leads to the communication between doctors and patients being blocked, which then affects the harmony between doctors and patients, bringing greater challenges to the implementation of humanistic care. Participants were frustrated with the behaviour of the patient or family member: 'Some patients or family members are very anxious, asked for transfer when the effect is not so signi cant, admitted to the hospital 1-2 days, looking at the effect is not so obvious immediately, completely not explained.' (a1) 'At the beginning, he took the medicine on time, but as soon as he saw the improvement, he stopped. He relapsed again and again, and his condition became worse. It was because of our poor skills that he failed to meet his expectation of recovery.' (a2) 'Many people do not trust the primary hospitals and even think it is a waste of money to go there. Some of them will guard against medical staffs, so we hardly dare give our hearts to them in the process of care.' (c3)

Discussion
Improvement of the treatment process is the key to promoting the humanistic experience of patients Time is the brain. Early endovascular therapy can save lives and reduce disability, which can then maximise the opportunity to return to society. Therefore, establishment of the humanistic stroke rescue process is the basis of humanistic care. Canadian Stroke Best Practice Recommendations for Acute Stroke Management [17] recommended that emergency centres should speed up the thrombolytic process by means of multidisciplinary collaboration, joint networking centres, optimisation of pre-hospital care procedures and opening of green channels. The establishment of a green channel for emergency stroke care is the rst step in process improvement, from strengthening the stroke identi cation ability to reducing the process for a single disease. By moving the treatment site forward, the time from arrival to treatment initiation (door-to-needle) can be greatly shortened and the treatment e ciency can be improved.
This study concluded that the idea of a single stroke department treatment centre had a subtle effect on stroke ward workers, and the concept of the service was also changed accordingly. In addition to actively creating a caring atmosphere and taking care of patients' personalised needs, the most in uential factor was the establishment of a rapid response medical channel. Stroke centres in our country are a multidisciplinary medical mode leading by category of disease [18] . It effectively integrated the resources and normalised the treatment through the whole process and standardised the management of stroke diagnosis. The treatment process should be reorganised according to the needs of speci c diseases, and a humane treatment process should be established to provide patients with faster, safer and fairer services so that personnel participate effectively based on providing good treatment. Furthermore, the role of the nurse should be fully highlighted. As the most capable person to perform humanistic care, the nurse can not only give priority to the care of emergency patients, but also act as the coordinator in the process, guiding and integrating medical resources [19] . Care should be integrated into the details of the process, and improve the humanistic care of patients by effectively attending to their needs.
Improving the ability of personnel is the foundation of humanistic care Comprehensively improving the humanistic quality of medical staff is the basis of implementing humanistic care. In many continuing education training programmes, 60% of the content is aimed at improving medical behaviour rather than focusing on the patients [20] . Most interviewees during the interview said that 'The failure to pay comprehensive attention to patients in clinical work is mostly related to the lack of caring awareness and ability. Worse still, there are not enough effective knowledge and skill training programmes in hospitals. As a result, their knowledge structure does not meet the needs of patients' care needs.' Related studies [21,22] have shown that it is di cult for some medical staff to truly understand patients, with poor overall care consciousness, insu cient communication skills and low humanistic practice ability. The proportion of medical disputes caused by humanistic factors, such as service attitude, service language and medical ethics, is as high as 80%, which has become an important driving force in affecting patients' level of satisfaction with care received [23] .
Researchers believed that education and management of care can be important factors in improving quality of care from workers [24] . As a consequence, medicine, humanistic care and personal qualities should be a vital integration to provide continued education. To enhance the professional values of medical staff, training programmes should include professional basic knowledge and humanistic ability.
A further in uence is motivating them to consciously have a people-oriented attitude in their work [25] .
It was reported that, using the same recognised rate of stroke patients among doctors and nurses, there is a difference as nurses take more prompt action. Strengthening professional basic training of nurses is of great importance. The curriculum content should be designed according to varying levels and targeted towards collaborative education. This could further improve the prognosis for stroke patients. In terms of training methods, repetitive active knowledge uptake [26] and diversi ed teaching situations [27,28] are more conducive to improving the comprehensive care ability of doctors, nurses and therapists in stroke wards.
Optimising stroke ward management systems is a guarantee of a humanistic care service A people-oriented approach to management is the key to improving care in stroke wards. A collaborative method, put forward by the American Association of Critical Care Nurses, has been widely used in nursing management [29][30][31] . From a management perspective, it advocates reasonably equipping human resources by matching the needs of the patient with the ability of nurses and clinical systems, forming a corresponding nursing service process and management system based on the requirements of patients.
Therefore, it essential to optimise the combination of medical workers and set up necessary specialist positions such as rehabilitation therapists, psychological counsellors, case managers and specialist nurses according to the characteristics of stroke specialty [32] . This not only makes a positive difference, but also improves their professional value, which then has a positive impact on their job satisfaction and their caring effectiveness. Meanwhile, managers and employees should jointly shape the organisational culture and set a shared vision for motivation. Managers should make full use of 'leading by example' to provide a visible model of behaviour so that employees can be led towards a better professional ethos, which will consequently build a better type of hospital and create a more harmonious medical environment [33] .

Conclusion
Through in-depth interviews with 18 respondents in 13 cities in China, this study found that the implementation of humanistic care in stroke wards was not an optimistic experience from the perspective of medical staff. With many existing problems and contradictions, it posed a challenge to the development of humanistic care in stroke wards. Although great progress has been made in stroke prevention and treatment in China, there is still a gap in humanistic care service. In medical behaviour, medical staff should be keen to capture the psychological responses and needs of patients and solve practical problems for them based on the characteristics of the condition. Medical staff also need to realise that personalised care involves the whole person from psychological needs to speci c needs after the stroke. Whole-person nursing for stroke patients with physical, mental, social and spiritual problems can help to alleviate their negative emotions, improve their coping ability and promote physical and mental rehabilitation [34] . In order to make the respondents more representative and more able to present the uniform distribution of samples with different characteristics, basic data such as the age and educational background of the respondents have been fully considered in the selection criteria. However, samples from third-level hospitals account for the majority, and the data from hospitals and community units below third-level need to be mined to obtain more comprehensive information and provide reference and practical evidence for improving the overall level of care in stroke wards.

Abbreviations
Not applicable.

Declarations
Ethics approval and consent to participate: This study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of General Hospital of Southern Theatre Command.