An observational study in Stroke Acute and Stroke (CVA) or Transient Ischemic Attack, sponsored by Shandong University. Recruiting at 1 site in Tanzania. Open to participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2026-01-06.
Sponsored by Shandong University · Observational
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.
8,255 studies on the registry are indexed under Stroke; 2,056 are open to participants now.
This study's planned enrollment of 130 is below the median of 152 across 1,968 observational studies indexed under Stroke.
Browse Stroke studies →Shandong University is the lead sponsor of 292 studies on the registry; 60 are open to participants now.
Counted across the registry records on this site, refreshed daily.
The study will include nurses, doctors, stroke survivors and caregivers who are directly involved in hospital-to-home transition.
Go through the criteria one by one — yes, no or not sure — and take the list to your doctor or the study team. Kept in this browser only.
Exclusion criteria
Underlined terms in the criteria open these too. Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Short tests of memory and thinking, each scored out of 30. Lower scores suggest more difficulty; criteria give a range, either to include people with memory problems or to leave them out.
MMSE and MoCA
Short tests of memory and thinking, each scored out of 30. Lower scores suggest more difficulty; criteria give a range, either to include people with memory problems or to leave them out.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Stroke survivors and their caregivers received usual care
Behavioral: Nurse-led stroke transitional care program
Participants in intervention group will receive usual care plus nurse-led stroke transitional care. Two nurse champions will conduct the face-to-face sessions while other two nurse researchers will conduct the telephone call sessions between August and December, 2025. During hospitalization, the two nurse champions will conduct five face-to-face sessions (2 individual sessions at admission; and at discharge), and three group sessions with 2-4 dyads of patients and caregivers. After hospitalization, two nurse researchers will conduct seven follow-up sessions for three months via phone calls at day 3, week 1, week 3, week 5, week 7, week 9, and week 11. The face-to-face sessions and phone call sessions will take 40-60 minutes and 20-30 minutes respectively
Self-efficacy among stroke survivors
Ability to take control and perform recommended health behaviors and discharge instructions. Self-efficacy will be measured by the Stroke Self-Efficacy Questionnaire (a=0.9) developed by Jones and colleagues. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better ability to follow and adhere to healthy lifestyles after stroke
Time frame: 6 months after discharge
Quality of life among stroke survivors
Quality of life that will be measured by the Stroke Specific Quality of Life (SSQoL) with (a=0.85). This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better quality of life as evidenced by ability to perform self-care activities, improved cognitive function, mobility, and engaging in social activities
Time frame: 6 months after discharge
Discharge preparedness among survivors
Discharge preparedness that will be measured by the Short Forms of the Readiness for Hospital Discharge Scale (RHDS) developed by Weiss. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate readiness for hospital-to-home discharge among stroke survivors.
Time frame: within 1 month after discharge
Discharge preparedness among health care providers
Discharge preparedness that will be measured by the Short Forms of the Readiness for Hospital Discharge Scale (RHDS) developed by Weiss. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate agreement on readiness for hospital-to-home discharge among nurses and doctors.
Time frame: within 1 month after discharge
Resilience among caregivers
Resilience will be measured by the 10-items Connor-Davidson Resilience Scale (CD-RISC) validated by Laura with a=0.85). This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better ability and readiness to take care giving responsibilities.
Time frame: 6 months after discharge
Quality of transition care among survivors and caregivers
Quality of TC will be measured by the Care Transitions Measure (CTM) Tool developed by Eric Coleman. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better perceived quality of transition care.
Time frame: within 1 month after discharge
Caregiver self-efficacy
Caregiver self-efficacy will be measured by the 10-items Family Caregiver Activation Tool (FCAT) developed by Coleman with a=0.6. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better ability to assist the stroke survivors to follow and adhere to healthy lifestyles and clinic appointment after stroke
Time frame: 6 months after discharge
Depression and anxiety among survivors and caregivers
Depression and anxiety that will be measured by the locally validated 10-items Kessler Psychological Distress Scale with a=0.85. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate poor mental health status after discharge.
Time frame: 6 months after discharge
Care satisfaction among survivors and caregivers
Satisfaction of hospital care will be measured by a questionnaire developed specific for this study. It will be measured as total scores and mean scores. High total and mean scores indicate good satisfaction with transitional care.
Time frame: within 1 month after discharge
Mortality among survivors
This will be counted as a death event after discharge.
Time frame: 6 months after discharge
readmission among survivors
This will be measured as number of times the patient is readmitted at the hospital after discharge. High frequency will indicate many readmissions.
Time frame: 6 months after discharge
length of hospital stay among survivors
This will be measured as number of days spent in the hospital before discharge. This will be calculated as number of days spent at the hospital from admission to discharge. High number above 5 indicates long hospital stay.
Time frame: Day 1 after discharge
PDFs hosted by the registry, ClinicalTrials.gov.
Plan to share: Undecided — I will consider sharing it upon finishing enrollment of participants
Started Aug 2025 (actual). Primary completion is estimated for Mar 2026, 7 months after the start.
Of 835 non-industry observational studies under Stroke, half reached primary completion within 41 months of starting (the median), counting those still running; a quarter within 18 and three quarters within 92. This study's planned 7 months is below that.
Counting every sponsor, half of 897 studies reached it within 40 months; a quarter within 18 and three quarters within 85.
How these figures are worked out, and which studies are left out of them.
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