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Stroke Units In Andalusia | Strategic Steps Towards Standardised Care

The journey towards standardising stroke nursing care in Andalusia takes a very significant coffee break.
Angels team 25 March 2022

The journey towards standardising stroke nursing care in Andalusia that began in late 2019 culminates two years later in the first face-to-face meeting of the Andalusian Nurses Steering Committee in a carefully chosen location.

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Joaquín Alberto García Gálvez leaves Almería early on Thursday morning 11 November. It’s late autumn on the Iberian peninsula and the sun won’t be up for another two hours as he heads northwest towards Antequera, a city known as “the heart of Andalusia” for its central location among Málaga, Granada, Córdoba and the region’s capital, Seville.

Joaquín is chief of nursing at Torrecárdenas University Hospital, an unsung superhero whose advocacy for stroke patients includes campaigning for interventions such as treating at CT and participation in the QASC trial and ESO Angels Awards. He’ll be a key player at today’s meeting in Antequera, to which he has invited his colleague Nicolasa Madrid Lopéz with the aim of infecting her with this spirit. They will keep each other company on the journey of around 2 hours and 35 minutes.

It will take María Yolanda Rodríguez Vicente an hour and 20 minutes to reach Hotel Finca Eslava, which is located in an 18th century Andalusian farm house on the outskirts of Antequera. The nursing supervisor at Virgen de las Nieves University Hospital in Granada is a born leader and a skilled communicator and the unofficial president of the group that will attend today’s meeting.

The new stroke unit at Virgen de la Victoria University Hospital in Málaga mirrors the youthful positive energy of nursing supervisor Paloma Caro Muñoz who is committed to implementing standardised protocols and following the Helsinki model from the outset. Antequera is just over 50 km from Málaga; Paloma will reach Finca Eslava in under an hour.

Paloma isn’t the only delegate who will arrive with learning foremost in her thoughts. Both Immaculada Martínez Porcel from Granada and María del Mar Cala Huertas from Jerez (Cádiz) represent stroke units that are about to open. They too hope to benefit from the experience of seasoned colleagues such as Seville’s Raimundo Caro Quesada and Lidia Ruiz Bayo, and outspoken Antonio Guerrero González from Córdoba. They can also count on encouragement from Sergio González-Román Montalbán from Málaga’s Regional University Hospital, an innovator and motivator who embodies the Angels spirit.

Leaving his home in Huelva at around the same time as Joaaquín but traveling in the opposite direction is David Bejarano Álvarez who recently became nurse supervisor of the stroke unit at Juan Ramón Jiménez University Hospital. The coffee in Antequera will be ready at 9.30am.

Coffee with Angels

The story behind today’s meeting starts late in 2019 when Alicia Arjona has just joined the Angels Initiative as a consultant for the south of Spain. She is soon aware that there is no standardisation between stroke units in the region, and no networking opportunities for nurses to share their knowledge and concerns. In addition, five new stroke units are on the cards.

A plan starts to take shape. With help from Raimundo and Joaquín she gets in touch with nurses from all 14 established and pending stroke units in the region and draws up the agenda for a full day conference that will take place in March 2020.

Then Covid gets in the way. With the conference postponed for the time being, Alicia has time for second thoughts. The conference, she realises, is both too long and too short – it’s too long for the participants to stay focused, and too short to cover all the topics on the agenda. It may not be the right format after all to achieve the goal of standardising stroke nursing care in Andalusia.

A virtual meeting of the Andalusia Nurses Steering Committee takes place eight months later in November 2020. It’s to be the first in a series that will be held at three to four week intervals over the course of a year. Each meeting will last two hours and focus on a different topic, with hyperacute treatment topping the agenda.

The participants have each received a welcome pack that includes, along with checklists and protocols, a certificate asserting their membership of the newly minted Comité Andaluz de enfermería experta en ictus, the sense of occasion heightened by a specially designed steering committee logo that incorporates the Andalusian flag.

The meetings are called “Coffee with Angels” with the intention to brand them as a companionable pause in the day, although while pandemic rules remain in place participants have to boil the kettle where they are and bring their cup to the keyboard.

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Ties that bind

Neurological scales, dysphagia tests, basic nursing care in stroke units, complications following thrombectomy, discharge reports and communication with patients and caregivers were all on the agenda at meetings of the Comité Andaluz de enfermería experta en ictus throughout 2021.

They were strangers when they first introduced themselves towards the end of November 2020 and talked about the way their stroke units were organised and their expectations of the project, but bonds developed that made each meeting an occasion to look forward to and kept the conversation going on WhatsApp.

Committee members who lived in the same city or region met socially after their shifts and at least one deep and lasting friendship was formed.

Everyone in the group understood the need for standardised care that would ultimately find expression in a set of unique nursing stroke care guidelines for Andalusia. This long-term goal would be achieved via a series of strategic short-term “critical moves” that would include a six-week quality monitoring project based on a supercharged version of the Helsinki poster, and training for nurses both in and outside the stroke unit.

As the year wore on, the nurses on the committee gained a sense of their own power with which they could infect their respective teams. Their self- perception changed and they cast off the cultural stereotype that depicted Andalusians as the indolent beneficiaries of sun and sand tourism. They motivated each other and began to own their achievements.

But first, coffee 

It’s no coincidence that the first face-to-face meeting of the Andalusian Nurses Steering Committee takes place in Antequera. As the region’s capital, Seville would have been the default setting, but Alicia has deliberately chosen a neutral location that doesn’t favour any one city or hospital. Holding the meeting in the heart of Andalusia means everyone has some distance to travel; it’s a strategic decision to signal that everyone matters equally.

The meeting will start with “why” to remind everyone of their common goal to improve outcomes for stroke patients by devising and implementing stroke nursing care guidelines in the region. Then the critical moves for 2022 will be discussed and refined, and after a late lunch everyone will gather in the courtyard with its soft arches and central fountain for a photograph to mark a milestone in stroke care in Andalusia.

When Alicia got to know Raimondo and Joaquín in 2019, she knew she had discovered two bright spots that would help her bring about change. Now she has an insight to share: when you find a bright spot, surround them with a team.

By 9.30am most of the team has arrived, soon to be joined by the stragglers who were delayed by the Thursday morning traffic in their cities. It’s a joyous meeting of colleagues who met as strangers almost exactly a year ago: finally, the Andalusian Nurses Steering Committee is having coffee with Angels.


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