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DOI: 10.1016/j.sedeng.2020.02.002
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Available online 4 October 2020
Troublesome knowledge in undergraduate nursing students when learning about poststroke apathy care
Dificultades de aprendizaje de los estudiantes de enfermería en el cuidado a un paciente con apatía postictus
Jagoba Zarandonaa,
Corresponding author

Corresponding author.
, Marta Arrueb, Sergio Yustea, Itziar Hoyos Cillerob
a Escuela de Enfermería, Vitoria-Gasteiz, Spain
b Departamento de Enfermería, Facultad de Medicina y Enfermería, Universidad del País Vasco (UPV/EHU), Vitoria-Gasteiz, Spain
Received 02 September 2019. Accepted 13 February 2020
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Figures (1)
Tables (3)
Table 1. Problem and questions for the students.
Table 2. list of learning outcomes and the assessment questions.
Table 3. Conceptions from mixed method analysis, pre-test and post-test of a single group and phenomenography description on origin of apathy in a person who has suffered from a stroke.
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To obtain a vision of nursing students’ learning, exploring difficulties concerning understanding stroke care delivery when apathy occurs.


Mixed methods research combining a quantitative research method with a pre-experimental one group pretest-posttest design and a qualitative research method with a phenomenographic descriptive design. Data was collected from written self-assessments (pretest; n = 83) and exam papers (posttest; n = 82) completed by third-year nursing students enrolled in the 2016−17 academic year in one Nursing School in Spain.


The analysis revealed three conceptions in relation to understanding stroke care delivery when apathy occurs: (A) apathy as a multi-causal response; (B) apathy as a reactive psychological response; (C) apathy as a result of brain injury.


The analysis of conceptions in this research has shown that the percentage of students arguing apathy based on one single factor did not vary from pretest to posttest. The relationship between functional loss and reactive psychological answers was the abounding argument. Identification of conceptions will allow nurse educators to design evidence-based teaching-learning strategies focused on difficulties in stroke care delivery among undergraduate nursing students. Likewise, it will help to enhance the quality of care delivered by future nurses, improving these patients’ quality of life.

Nursing students
Nursing education research

Obtener una visión del aprendizaje de los estudiantes de enfermería, identificando dificultades en relación al manejo de la apatía en una persona que ha sufrido un ictus.


Investigación con métodos mixtos combinando un método de investigación cuantitativa con diseño preexperimental pretest-postest de un solo grupo y un método de investigación cualitativa con diseño descriptivo fenomenográfico. Los datos se recogieron a partir de las pruebas escritas de autoevaluación (pretest; n = 83) y de evaluación final (postest; n = 82) de los estudiantes de tercer curso de enfermería matriculados durante el curso académico 2016/17 en una universidad española.


Del análisis de los datos surgieron tres concepciones en relación a la comprensión de los estudiantes sobre el cuidado al paciente que tras sufrir un ictus presenta apatía: A) apatía como respuesta de naturaleza multicausal; B) apatía como respuesta psicológica reactiva; C) apatía como consecuencia de la lesión cerebral.


El análisis de las concepciones elaboradas en esta investigación demostró que el porcentaje de estudiantes que argumentó la apatía en base a un solo factor no varió del pretest al postest, siendo el argumento más utilizado la relación entre pérdida de funcionalidad y las respuestas psicológicas reactivas. La identificación de dificultades de aprendizaje permitirá diseñar secuencias de enseñanza-aprendizaje adaptadas a las dificultades que presenta el alumnado de enfermería en el tema de los cuidados al paciente que ha sufrido un ictus y así poder contribuir a que los futuros profesionales de enfermería puedan garantizar un cuidado de calidad.

Palabras clave:
Accidente cerebrovascular
Estudiantes de enfermería
Investigación en educación de enfermería
Full Text

Stroke is currently one of the major causes of death and disability in both Spanish society1 and worldwide.2 Governments, institutions and organizations are well aware of the problem it represents and are making efforts for its prevention, control and the development of public health policies.3 However, despite the fact that in the last decade mortality rates and the number of years living with disability have dropped, both the absolute number of people affected and the number of people who remain disabled from this diseases continue to rise.4

Stroke is a complex disease which affects the quality of life of those people suffering from it and the carers of the survivors.5 The person who has a stroke may suffer from a broad spectrum of sequelae, from physical changes and difficulties in mobility to problems with communication, and cognitive and emotional changes, among others.6 It has been demonstrated that patients who receive care in stroke units are more likely to live, be autonomous and remain in their home one year after the episode.7 Although the factors promoting this reality have not been detailed, a review of the literature brings to light that the training of nursing professionals improves the health outcomes of people after a stroke.8

The development of a specific training plan regarding stroke is key to nursing professionals to guarantee quality of care to improve the health of the people affected by a stroke.9 Nursing undergraduate studies therefore provide an excellent opportunity to ensure that future professionals acquire basic skills in caring for these people. Regardless of their future specialization, nursing professionals should intervene in the prevention of stroke and in the care of the patients and families throughout the different phrases of the care process. In fact, stroke care delivery approach to a person who has suffered from a stroke is an essential theme in the educational curriculum of undergraduate nursing studies. However, in contrast to training research for nurses, the studies which have addressed this issue in students are scarce, with little empirical validity.10 Only one recent study was found in the literature on the learning difficulties regarding evaluation, physiopathology and stroke care delivery.11 Analysis of conceptions and difficulties must be a preliminary step, regardless of the teaching design used, for the assessment and re-design of teaching-learning sequences.12,13 This would result in knowledge being produced to guide teachers in developing quality, cost-effective and relevant strategies so that graduates could improve the health outcomes of the people and their families.14

Due to all of the above, the general aim of the study was to analyse the learning difficulties students have when addressing stroke care delivery to a person who has had a stroke, focusing on the rehabilitation phase. The specific aim was to describe learning difficulties of students with regards to the appearance of apathy which some people present after a stroke.

MethodsResearch design

A mixed method research approach was proposed to obtain the research objective, using quantitative research with a pre-experimental one group pre-test/post-test design15 and also qualitative research with a phenomenographic descriptive design.

The focus of phenomenography is in describing and explaining conceptions, i.e. different qualitative ways in which people perceive and understand the same reality.16 Phenomenographic research highlights personal conceptions as necessary constructs to understand the relationship between phenomena people experience and the personal significances derived from this experience.17 In this way, the value of using the phenomenographic focus versus other research methodologies, resides in its ability to discover the knowledge and beliefs of a certain exclusive phenomenon of a cohort of participants in a specific field.18 This research methodology has been precisely demonstrated to be valid for determining the variations in the understanding of complex concepts in nursing students,18 as well as generating scientific nursing knowledge.19 Marton20 states that a basic assumption of phenomenography is that a limited number of conceptions is given to a specific phenomenon. From this hypothesis ensues the idea that using random population samples may lead to arguments of generalisability and that a representative sample of a population can reflect the natural distribution of a conception.20 Therefore, and bearing in mind the above, phenomenography provides a framework to research with mixed methods,17 which leads to the use of quantitative and qualitative designs for research into the knowledge and beliefs of a certain exclusive phenomenon.

Research context

For 3 weeks, a teacher with experience in the Department of Nursing gave lectures at a university centre. The students received a total of 12 h of lectures on caring for a person after a stroke, withint the subject Clinical Nursing IV. Subjects addressed were: the diagnosis and prevention of stroke; hospital treatment; nursing care in dysphagia and motor, communicative, cognitive and behavioural alterations. The reference book used was Brunner and Suddarth. Medical-surgical nursing, 12th edition.21

Data collection

As part of the planned development of the subject, 2 tests were taken. The first was a self-assessment pre-test, where the students had to resolve a problem before the subject was taught, and the second was a post-test exam with a different problem, 10 weeks after termination of lectures (Fig. 1). Both problems were similar, and covered knowledge and reasoning of the students in the stroke rehabilitation phase (Table 1).

Figure 1.

Design of the research: descriptive design of the pre-test and post-test with a single group.

Students enrolled in the Clinical Nursing IV course subject (n = 95).

Table 1.

Problem and questions for the students.

Pre-test problem 
Sara García, a woman aged 75, is about to be discharged from a rehabilitation unit, 6 weeks after having suffered from a stroke. Her husband says that before her illness they went out for walks in parks every afternoon but now this will not be possible because she needs a walking frame and has difficulties with coordination. Her husband says she also has difficulties to find words, memory problems and a passive attitude. According to her husband, in her current situation it is difficult to go out waking with his wife and sometimes he is embarrassed by Sara’s attitude in front of other people. The supervisor of the rehabilitation unit has coordinated follow-up with the social worker, the physiotherapist and the occupational therapist on discharge. 
Q1: Explain the manifestations of aphasia. Identify measures to deal with this problem. 
Q2: Why do you think Sara has this passive attitude? Describe guidelines to deal with this problem. 
Post-test problem 
You are a member of a multidisciplinary team formed by the supervisor of the unit, the co-ordinating nurse, the social worker, the occupational therapist, the speech therapist and the neurologist. This morning you are planning the discharge of Aurora Altube, a 75-year-old woman who after suffering a stroke has been in a rehabilitation unit for 10 weeks of a medium-term care hospital. Aurora is a widow and has a 50-year-old daughter who she is going to live with when she is discharged. The daughter has commented that before her illness her mother went for a walk every day and in the afternoons collected he grand-daughters from school. She believes it will be difficult to recover this routine, since she now needs a walking frame and has coordination difficulties. Her daughter also says that she is particularly concerned by her mother’s aphasia, and her passive attitude. 
Q1: Explain what the manifestations of aphasia are. Identify measures to deal with this problem. 
Q2: Why do you think Aurora has a passive attitude?? Describe guidelines to deal with this problem. 

In both scenarios the students had to respond to 2 questions which covered part of the subject material and measured the same learning outcomes. Question Q1 studied the answers of the students in relation to manifestations of aphasia in a patient after suffering a stroke and question Q2 probed into the arguments for justifying a change in behaviour, the appearance of apathy, after suffering from a stroke. The correspondences between the outcomes of learning and the questions are contained in Table 2.

Table 2.

list of learning outcomes and the assessment questions.

learning outcomesQuestions 
LO1  Define aetiology, physiopathology and clinical manifestations characteristic of the people who have suffered from a stroke  Q1, Q2 
LO2  Provide details of a nursing assessment in people who have suffered from a stroke  Q1, Q2 
LO3  Develop consistent care plans from the nursing diagnoses identified, in people who have suffered from a stroke.  Q1, Q2 

Q: question; LO: learning outcome.

This documents examines the results relating to question 2 since this study is part of a broader research study, the aim of which is to design and assess a teaching-learning sequence of care a patient should receive after suffering from a stroke.


The written tests of the students who enrolled in Clinical Nursing IV in the academic year 2016–2017 are included in this study. This was taught in the third year of nursing undergraduate studies. In order to avoid bias, the papers of students who resat the exams were excluded and of those who had had previous professional experience in the health sector. All students whose written tests were considered in this study had received the same previous training and had passed the same subjects. Students were randomly assigned to the group through the programme of university academic management.


The presented problems were validated by 4 professionals who had no links to the research team: 2 lecturers from the university department of nursing and 2 clinical nurses with over 10 years of experience in the areas of care for patients with neurological alterations. Their suitability was confirmed in keepin with the year objectives, their adherence to content and the questions for any nursing student. Additionally, a pilot study was conducted with 25 students in their final year. This study confirmed that the students had no difficulty in understanding the problems and the questions attached.

Data analysis

To prevent any type of interference between research and teaching, the research group received the tests once the teaching of the subject had terminated. Furthermore, all personal data and references to the student were eliminated to prevent identification.

Statistical analysis of data was performed using the Statistical Package for Social Science (SPSS) for Windows version 24.0. A descriptive statistical analysis was performed of the nominal variables using percentages and of the numerical variables using means and standard deviation. Phenomenographic analysis of data was performed in accordance with the sequence defined by Akerlind ET al.22 Responses to the questions were analysed jointly, not as isolated extractions. The researchers focused on identifying similarities and differences in student responses. Firstly, they identified the conceptions of learning appearing in each questionnaire, to later clarify the characteristics of each conception from the comparison and contrast with the other conceptions that arose. An initial draft of conceptions was made from the first reading, accompanied by a description of the significant characteristics of each conception. One of the authors (JZ) carried out a preliminary analysis with a subsample of 20% of the questionnaires. After this each researcher team member read them independently and repeated the responses of the students and matched the responses to one of the preliminary conceptions. To promote study reliability, the authors compared response distribution, reaching a mean level of agreement of the Cohen’s kappa inter-rater reliability coefficient of > .85.

The analysis process continued with a reading of the responses based on the initial description categories. In this iterative process, the categories with the data were compared to achieve the stability of the conceptions generated. The final outcome space was built up with consideration of the criteria of distinction, hierarchy and parsimony.23

Ethical considerations

Participation in this study had no drawbacks for the students. The identity of the participants was strictly confidential and all responses were anonymously analysed. The University Ethics Committee approved the study (CEISH UPV-EHU, Report M10/2017/025).


The sample was composed jointly of 83 written self-assessment tests in the pre-test and 82 written exams in the post-test (Fig. 1). Of the total sample, 90.2% were women and 9.8% men. Mean age was 21.6 years (SD 3.2).

In this section we present the results of phenomenographic analysis and interpretation regarding the resolution of the problem presented in Table 1. The aim of this study was not to show how many students gave the right answer to the questions but to analyse the different ways in which the students explained and discussed the care of a patient after a stroke.

From analysis of the research results, with its mixed methodological design, 3 conceptions arose regarding the comprehension of the students on care of the patient who after suffering from a stroke, presented with apathy. Analysis of the conceptions was completed with a quantitative description as a percentage of the response which the students gave to each conception. This is all contained in Table 3.

Table 3.

Conceptions from mixed method analysis, pre-test and post-test of a single group and phenomenography description on origin of apathy in a person who has suffered from a stroke.

  Pre-test (N = 83) n (%)  Post-test (N = 82) n (%)  Awareness of problem 
Apathy as a response of a multi-causal nature  7 (8.4)  11 (13.4)  ”Limit passive behaviour to one reactive psychological response”
Apathy as a reactive psychological response  49 (59)  36 (43.9) 
Apathy as a consequence of the brain injury  13 (15.7)  26 (31.7) 
Incoherent/incomplete  14 (16.9)  5 (6.1) 
Does not respond  0 (0)  4 (4.9) 

We will now give a brief deception of the conceptions accompanied by extracts from the students’ response in the written test after having received instruction (post-test) and the corresponding percentages which are representative of the different forms of experiencing and understanding apathy in a person who has suffered from a stroke.

Conception A: apathy as a response of a multi-causal nature

This conception collected students’ responses based on multifactorial reasoning, where the response which related to the appearance of apathy was due to different reasons which interlinked to form a coherent whole. The reasons governing behaviour and changes to behaviour in a person after a stroke are many and varied. They include motor changes which prevent carrying out movements, to difficulties in the planning of these movements due to brain injury, communication difficulties or difficulties as a consequence of emotional changes derived from the process of coping with the disease.

Out of the total study sample, after lectures, only 13.4% of the students identified and explained multiple-cause factors relating to the origin of behaviour changes in the patient after a stroke.

“(…) also, this is the loss of role. Before she was the carer of her grandchildren and now it’s the reverse, she has to be cared for. She may feel frustration… ) because of this and the difficulties in communication. Even if she wanted to, she cannot communicate in an effective way” (Student 11).

“A consequence of the stroke could be changes in motivation (many neurons have been damaged and cognition and motivation may be affected). Also, she may feel frustrated by her situation (….)” (Student 33).

Conception B: apathy as a reactive psychological response

This conception of apathy is based on the unifactorial reasoning which contains isolated elements of the theory. Thus, this conception stemmed from the response which connected the appearance of apathy with the loss of motivation, or with alterations to mood or even frustration in a separate and isolated form. This conception brought together the group of responses of most students in both pre-test (59%) and post-test (43.9%).

Among the arguments found for marking this choice based on the loss of motivation we found:

“Passivity is linked to lack of motivation, since the patient is no longer self-reliant and needs a walking frame, affecting their ability to do the things she likes doing (…)” (Student 2).

“Aurora might have a passive attitude: 10 weeks have gone by since she began physiotherapy and she has not fully recovered the mobility she previously had. This situation might lead the patient to become demotivated since she has seen she cannot fully recover.” (Student 31).

According to our analysis of student response, a substantial element for justifying the lack of initiative of the patient resided in the loss of roles derived from the changes suffered as a result of the disease, these being mainly motor or functional losses.

“As a consequence of the losses suffered, passivity may appear. The patient may feel that recovery of losses will not be possible and they lose hope. Faced with this situation, we should motivate them, prompting confidence and offering positive reinforcement (…)” (Student 18).

“Aurora’s passive attitude may be due to the change in lifestyle she will have to make after suffering from a stroke. Before she had an active lifestyle, she independently carried out daily life activities and now she needs devices to help her move, i.e. she has loss her autonomy (…)” (Student 77).

In other cases the students based the justification of the passive attitude on the changes in mood which occur after suffering from a stroke:

“After the stroke, Aurora may have anxiety and depression, and this affects her attitude” (Student 10).

“Aurora’s passive attitude may be due to her negation of what has happened (…)” (Student 81).

The belief that the lack of initiative arises as an inappropriate response to coping is completed with the identification of other factures such as frustration:

“(…) she cannot do the activities she did before suffering from the stroke. Also, the process of recovery is very long and goals are achieved little by little. Maybe she has given up” (Student 12).

“Aurora’s passive attitude is possibly due to the fact that after spending 10 weeks in hospital, maybe she has not evolved as much as she would have wished. These processes are slow and maybe she created expectations that she has not been able to fulfil. We should talk to her and explain, if necessary, what her situation is (…)” (Student 69).

“(…) She cannot express her emotions, has little desire to do things and also has difficulties in communicating, this is causing frustration and also weariness “(Student 24).

Conception C: apathy as a consequence of head injury

In a similar manner to the previous conceptions, this third and last conception is also based on unifactorial reasoning. Thus, this conception was based on the response relating to the appearance of apathy as a consequence of the isolated and separate head injury. A total of 26.8% of the sample stated that the origin of the apathy was exclusively due to this cause. This was the case for the following students:

“The stoke has affected certain brain structures (…)” (Student 57).

“Aurora’s passive attitude may be due to cognitive or behavioural alterations (…)” (Student 71).


In this study we researched the difficulties of comprehension third year undergraduate nursing students had in relation to the problem of apathy which some patients suffer from after a stroke. As may be observed in Table 3, analysis of the conceptions created in this research study showed that the majority of students (around 75%) attributed apathy after a stroke to a single cause. The distribution of the percentages of the Table may be understood as a reflection of the superficial learning made, 24 since, after the traditional style lecturing, a very small percentage (13.4%) of the nursing students were able to argue that apathy arose as the result of different causes. Over 40% of student responses in our study were related to the loss of functionality and reactive psychological responses, which places this as the predominant category in both the pre-test and post-test. The hegemony of this conception remains despite having received training on it, which reveals that the interventions based on beliefs are imposed on interventions based on the scientific arguments acquired in the classroom.25 This statement would determine the limitations of traditional lectures, because it does not offer every guarantee for the development of critical thinking.26,27

The risk of having post-stroke depression may be linked to the degree of functional loss for daily life activiites.28 However, this is not the only causal factor of a passive attitude. In a high percentage the problems of cognition, apathy and depression present jointly, although they represent different problems.29–31 In other words, the students realised that the brain is the organ responsible for regulating and integrating cognitive activities, emotional experiences and behaviour patterns.29

According to the results of this research it was observed that, after the teaching through lectures over 50% of students failed to recognise the possible endogenous causes derived from brain injury as the cause of the passive attitude. Studies conducted with nurses32 and nursing students33 relating to the causes of depression confirmed the tendency of this study’s participants to identify the exogenous factors and to mention brain injury among the multiple causes leading to cognitive changes or behavioural changes. There is evidence that shows that behavioural changes are often a much under-diagnosed or inaccurately diagnosed and treated area.34 However, it is obvious that for the prevention of erroneous diagnoses and early identification of complications such as post-stroke depression it is necessary to train competent professionals with the ability to provide care throughout the whole care process.35 The health outcomes of patients will depend on the capacity of the nursing professionals to convert clinical knowledge into practical actions.36 What students learn as future professionals is therefore highly important. Non recognition of the factors causing post-stroke apathy would affect the development of the rehabilitation phase and prevent the patient from receiving the right treatments.30

It is therefore essential as several authors have recommended26,37 in recent research studies, to insist on the problem of the quality of the nursing student’s ability to reason and argue. Study results coincide with other studies which highlight that the teaching model based exclusively on transfer of information is insufficient to obtain the competences established in university student curricula.38,39 Lecturers must therefore reflect on what the best strategies would be to match results to the learning they wish to achieve, because giving a lecture, just like introducing an educational innovation in the sequence of teaching, does not in itself imply that learning will automatically follow.40

The limitations of this research, associated with the pre-experimental design of research, need to be considered when taking into account the results. In this study, specifically, we used written assessment tests relating to the teaching of the subject taught in the traditional expository manner in a single university. To apply the results of research to a broader audience it would be necessary to continue researching through studies with longitudinal, multi-centric designs and to increase sample sizes.


The results of this research contribute to providing evidence on an area of troublesome knowledge for third year undergraduate nursing students, relating to the care of a patient after a stroke. Specifically, a high number of students had learning difficulties regarding comprehension of the presentation of apathy after a stroke. Three out of every 4 students suggested a single argument for justifying its presence. In the majority of cases they referred to a reactive psychological response, prior to receiving lectures.

In view of the results obtained, including teaching the subject of stroke care delivery in the curriculum is no guarantee that students will learn and internalise the necessary theoretical and practical concepts for addressing the care of a patient who has suffered from a stroke.

Future studies should continue to develop the identification of conceptions and learning difficulties, together with the effectiveness of teaching methodologies. Advancing in g knowledge of the teaching disciplines requires knowing whether the students, as future professionals, are learning in such a way that they may contribute to improving the health outcomes of the population. To achieve this purpose it is vital and necessary to assess teaching and learning with more solid research designs. Future research studies must include the definition of competences and learning outcomes of nursing students, and also identify the learning difficulties. To apply the results of research, it is necessary to continue researching with longitudinally, multicentrically designed studies and to increase samples sizes.


This research did not receive any specific funding from public sector, commercial or not-for-profit agencies.

Conflict of interests


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Please cite this article as: Zarandona J, Arrue M, Yuste S, Hoyos Cillero I. Dificultades de aprendizaje de los estudiantes de enfermería en el cuidado a un paciente con apatía postictus. Rev Cient Soc Esp Enferm Neurol. 2020. https://doi.org/10.1016/j.sedene.2020.02.002

Copyright © 2020. Sociedad Española de Enfermería Neurológica
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