Whanaungatanga, the presence of meaningful connections and relational linkages, is core to engaging and meaningful stroke care [12]. Whanaungatanga should underpin, and run through all aspects of psychosocial care, and requires attention in its own right throughout the episode of care.
Clinicians should invest time in whakawhanaungatanga: engaging and building connections with people with strokes and their whānau. This shows manaaki (care) and aroha, builds genuine relationships and sense of wairua, and helps create a space where people feel welcome and supported and trusting in their clinicians, and comfortable sharing.
Services need to be flexible to ensure that staff have the time and flexibility to build genuine connection is built, and that the key people who need to be involved in screening are there (e.g. whānau).
Incorporating cultural practices in screening processes is one way of creating space for whanaungatanga. Models such as the Hui Process [14] may provide a framework for engagement. This refers to the processes of mihimihi (initial greetings and engagement), whakawhanaungatanga (building connections), kaupapa (attending to the main purpose of the interaction), and poroporoaki (closing the session). It is important to attend to each process before going tothe next, whilst also recognising that whakawhanaungatanga is not a ‘one off’ – there needs to be continued attention to building and maintaining the connection throughout and across sessions.
Correct pronunciation of te reo Māori and other languages is important and will strengthen the ability to communicate and develop a connection or reconnect through this process of whanaungatanga. The use of te reo Māori in conversation, signage and resources also shows acknowledgement and respect for tangata whenua [15].
All staff should have the skills to communicate with people with aphasia or other communication and cognitive impairments. Communication supports should be readily available on the ward and all staff should know how to use them.
All team members should be cognisant of people’s psychosocial needs after stroke and should know what they can do to support them. People should feel confident and competent to provide this support. Team members include non-clinical staff such as ward staff and cleaners.
A person’s medicine includes their whānau. Whānau are a source of well-being that are present before, during and after stroke, and “a functional unit of healing” [16].
Whānau hold knowledge of the person with stroke and are an important part of the stroke rehabilitation team. They are often a key source and support of well-being during and after discharge from services. It is important for teams and services to recognise how whānau support the person and also consider the well-being needs of whānau. Furthermore, when one person’s well-being is affected, the whānau unit is impacted (see page 33 for more information about supporting whānau).
When people have autonomy and control, it supports well-being. The person with stroke should decide who is involved in their care. It should be made clear that whānau are welcome as active partners in care, actively involved in information-sharing and decision-making.
Enhancing the physical environment supports well-being and people's engagement with services (18). How are whānau welcomed into the space? How are people able to have privacy, time for rest, and space for socialising and daily activities? How are people’s identities evident in the environment through therapy materials, signage, and images?
Encourage people to personalise their environment so they feel comfortable, enhanced mana, greater connectedness, and a sense of at-homeness – e.g., photos of whānau, images of their hobbies, interests, their own clothes, a quilt from home, and easy access to technology for connecting with those important to them.
Existing models that draw from and ground Māori perspectives of hauora include: Te Whare Tapa Whā, Te Wheke, Te Pae Mahutonga and the Meihana Model. These models provide invaluable understandings of hauora when working with Māori post-stroke. In a clinical setting, they can be helpful to:
Different whānau will draw on different models of hauora. Because of this, it is important to talk with whānau about what supports hauora and oranga (well-being), and work with their whānau, hapu, or iwi models of well-being.
Preventative approach to psychosocial care
Te Whatu Ora Whanganui’s acute and rehabilitation stroke service takes a preventative approach to psychosocial well-being. They endeavour to prevent psychosocial distress by identifying risks and issues and addressing these early.
Whānau are considered a critical component in well-being and are invited to take part in care from the start of the person’s journey.
All disciplines attend a rapid review each morning. In the rapid round, well-being is discussed, including staff observations of mood, eating and drinking, sleep and general engagement. Each patient has a holistic assessment during admission which also covers all of these areas.
If concerns are raised during daily rounds or at any point during the person’s care, the team develop a plan to monitor and address issues.
A psychologist runs a weekly whānau session. The psychologist completes screening as required, and provides early intervention as needed.
Southern’s community rehabilitation service, REACH, embeds psychosocial screening in their initial interdisciplinary assessment form. Rather than having specific questions to ask patients, they have areas for discussion with associated prompts.
These include topics such as ‘social situation’ with prompts that staff should explore, such as family, neighbours, relationships, intimacy, roles and pets.
The form requires that they identify the person’s living situation, whether they feel socially supported or feel socially isolated or lonely, and a prompt to provide details about the person’s mood.
Other areas explored include the person’s cultural and spiritual beliefs and values, their hobbies and interests, work and productivity, fatigue, support systems and transport.
Whilst their initial screening is long, it can be broken over several sessions and is helpful in identifying psychosocial issues early.