Eighteen participants participated in the semi-structured interviews, including 12 males (66.67%) and 6 females (33.33%) (Table 1). The mean age of participants was 57.56 ± 10.67 years. Almost all participants (88.89%) were diagnosed with ischemic stroke. And they had a median course of stroke of 5 months (range 0.5 to 48 months). Only 5 participants (27.78%) were still working after stroke. And almost all participants (94.44%) lived with their family. The median time duration of the interviews is 14 min (rage 10 to 55 min). All participants were named with English letters as their code names to protect their privacy.
Based on basic psychological needs theory, participants talked about their needs for autonomy, competence, and relatedness during treatment and rehabilitation after stroke. According to the interview guide, the information in Question 1 and 2 are particularly associated with the need for competence. And the information in Question 3 presents 3 basic psychological needs of stroke patients. The information obtained from question 4 mainly describes the patients’ needs for autonomy. And the information in Question 5 focuses primarily on their needs for relatedness. As an open question, the information obtained from question 6 is considered to be associated with 3 basic psychological needs. As components of BPN, these three needs were identified as the main themes, according to directed content analysis. And data analysis yielded 115 codes dispersed in 31 sub-subthemes belonging to 9 sub-themes (Table 2). There were 10 sub-subthemes in main theme 1, 13 in main theme 2, and 8 in main theme 3. Since each sub-subtheme contains fewer quotes and implications, the Results and Discussion sections would mainly revolve around the sub-themes with more quotes and implications. All themes and their corresponding quotes are presented in the appendix. The result is presented with their quotes along with code name, gender, age, and course of stroke.
Main theme 1: the need for autonomy
The participants’ need for autonomy is reflected in various aspects, such as work, medical treatment, and activities in daily life. Although they have a mean age of 57.56 years, and most have retired or left the working environment, they still have tasks that can be called work in their daily life, like, doing housework and raising grandchildren. After abstracting and summarizing, this main theme includes three sub-themes, (1) the need for autonomy in daily life, (2) the need for autonomy during treatment and rehabilitation, and (3) making lifestyle changes consciously. There are 10 sub-subthemes included which are described in each sub-theme.
Sub-theme 1.1: the need for autonomy in daily life
Sub-subthemes 1.1.1 at a high degree of autonomy satisfaction in daily life
Most participants said that there were few things they had to do in daily life, and most of the things they did were out of their own will, that is to say, that participants were at a high degree of autonomy need satisfaction in daily life.
When it comes to food, my son said: “Mom, you can buy whatever you want. It’s not that we don’t have money, so don’t worry about it.” … And I can do what I want to do. Even though my son told me not to (do something), as long as I want to or like to, then I can do it in the end. (H, female, 64, a month after stroke diagnosis)
Sub-subthemes 1.1.2 an increased sense of autonomy in housework after stroke
After the stroke, most things changed in the participants’ life. A participant who had done housework for many years felt so tired of the overwhelming housework before stroke. And after stroke, she felt an increased sense of autonomy in housework, which made her feel relaxed and happy.
Before I got sick, I had to do housework even if I didn’t want to. When I saw things dirty and thrown everywhere, I could do nothing but clean them up…However, it comes different now. They do the housework, and I could do something if I want to and vice versa. (D, female, 62, 6 months after stroke diagnosis)
Sub-subthemes 1.1.3 do not feeling free during hospitalization
However, the disease also has adverse effects on the participants’ need for autonomy. Another participant felt sad about this and was reluctant to talk more about autonomy.
This… (a long silence) is that I don’t feel free and can’t do many things I want to do. (Researcher: “what do you want to do?“ The participant looked left and right repeatedly and did not answer the question.) (G, male, 59, a month after stroke diagnosis).
Sub-subthemes 1.1.4 the impact of stroke on interests
When it comes to autonomy, interest is seen as a primitive form of intrinsic motivation, which promotes the satisfaction of the need for autonomy. Different people have different interests. Participants who enjoy high-intensity activities such as running and dancing said they didn’t dare to continue doing these. But as for reading books or watching TY, stroke has little impact on these activities.
I usually just play TikTok and watch TV. Because I feel dizzy sometimes after stroke, I don’t dare to dance, which I used to. (E, female, 68, 18 months after stroke diagnosis)
Sub-theme 1.2: the need for autonomy during treatment and rehabilitation
Sub-subthemes 1.2.1 the sense of autonomy during treatment and rehabilitation
During treatment and rehabilitation, participants also have a sense of autonomy in making medical decisions. Especially in physiotherapy and rehabilitation training, they have more choices, which satisfies the need for autonomy.
Just like doing this (medium frequency physiotherapy), I’ll tell you where I feel uncomfortable and where I decide to do it. (D, female, 62, 6 months after stroke diagnosis)
Sub-subthemes 1.2.2 willing to follow the advice of a medical professional
However, it needs to be clear that the term autonomy does not refer to independence. People can do something independently and act volitionally. Yet, people can also depend on others as they would like to, which represents autonomous dependence. It means that participants willingly chose to follow medical professionals’ advice, which is also a manifestation of a sense of autonomy.
I have a good friend who is a doctor and a professor. I would always listen to his opinions. For example, I have been taking this medicine for a long time, which he introduced me to take. (C, male, 80, a month after stroke diagnosis)
Sub-subthemes 1.2.3 less self-determination due to the lack of knowledge
Unfortunately, there are few choices for patients to make in the medical decision. Perhaps one of the reasons is that they lack enough knowledge to make autonomous decisions.
I have been in the hospital for many months, and now I just want to go home, but I am not sure about that. Because I need to do rehabilitation training, staying in the hospital will have a better effect. However, I would feel better at home so that I may recover well. Therefore, I don’t know how to make a decision. (R, male, 66, 5 months after stroke diagnosis)
Sub-theme 1.3: making lifestyle changes consciously
In the interviews, we found an interesting phenomenon that almost all participants mentioned that they did think that they had engaging in some behaviors that are known as risk factors for stroke. Not only that, but some also said that they would change or had changed these unhealthy lifestyles consciously.
Sub-subthemes 1.3.1 correctness of unhealthy behavior in daily life
A participant who had drunk and smoked for many years said that, although many people told him it was not good for his health in these years, he never thought about making changes until this stroke.
I have been smoking and drinking since I was 20 years old. Now I would not smoke and drink anymore since I got stroke. I always told them to stop showing me alcohol and cigarettes. (G, male, 59, a month after stroke diagnosis)
One participant noted that her personality might have something to do with her stroke.
I feel like I’m being too impatient. I would get everything done at once and not stop until it was finished. (D, female, 62, 6 months)
Sub-subthemes 1.3.2 correctness of unhealthy eating habits
Besides the unhealthy behavior in daily life, many participants had unhealthy eating habits, such as high-fat and high-salt diets.
I eat less than before, especially rice, but more vegetables. And I am on a low-fat and low-salt diet. (P, male, 61, 10 months after stroke diagnosis)
Sub-subthemes 1.3.3 development of an exercising habit
Due to the rehabilitation training, some participants developed a habit of exercise. Some would insist on doing rehabilitation training learned from the hospital, and some would go for general sports like walking and running.
I emphasize exercising now…Every day I would go for a walk after dinner and do some exercises or something else. (L, male, 65, 48 months after stroke diagnosis)
Main theme 2: the need for competence
This theme focused on the impact of stroke on participants’ ability and the need for competence. The stroke can negatively affect the patient’s physical function and impair the patient’s ability to perform various activities, which reduces the satisfaction of the need for competence. This main theme includes three sub-themes, (1) the impact of stroke on the ability of daily living activities, (2) the impact of stroke on the ability to work, and (3) the need for competence during treatment and rehabilitation. There are 13 sub-subthemes included which are described in each sub-theme.
Sub-theme 2.1: the impact of stroke on the ability of daily living activities
Sub-subthemes 2.1.1 difficulty in performing some daily activities
Most participants said that stroke did produce physical symptoms that could not be ignored and impaired their daily activities, such as dizziness and numbness of limbs. Therefore, they had difficulty in performing some daily activities.
I used to drive, but now I don’t dare. I tried for one time, but I felt that my reaction was not so responsive, such as when turning and decelerating. (M, male, 48, 10 months after stroke diagnosis)
Sub-subthemes 2.1.2 difficulty in doing housework
Participants even had difficulty in doing housework due to the reduced physical mobility.
I didn’t do any heavy work either, just do some sanitation at home… My left hand is not so neat, but my right hand can work. (O, female, 55, 5 months)
Sub-subthemes 2.1.3 difficulty in caring for the family
As mentioned above, some participants usually did housework and took care of family at home, however, it was difficult for them to continue after stroke.
I have been caring and cooking for my son because he is not married yet and no one can do this, which is very tiring. Now it’s such a hassle since I got sick, I can’t take care of him anymore. (C, male, 80, a month after stroke diagnosis)
Sub-subthemes 2.1.4 part of the work is undertaken by others
Even so, some participants still continued doing the same things they did before got stroke while recovering at home. Certainly, their family members would help or undertake part of the work.
I used to grow some vegetables at home. But now I cannot do much hard work, so my husband would do most of the work and I just have to do the easy part. (I, female, 58, 9 months after stroke diagnosis)
Sub-subthemes 2.1.5 recuperating at home and no need to work
One participant said she didn’t need to do anything at home, even though it had been a long time since she was diagnosed with stroke and she was capable to do something. Thanks to her family, she is indeed felt relieved from the hectic housework finally.
I used to do housework at home and take care of my grandchildren… And I stopped working since the cerebral hemorrhage last year. (E, female, 68, 18 months after stroke diagnosis)
Sub-theme 2.2: the impact of stroke on the ability to work
This sub-theme focused on work, or job, which is paid and in a specific environment. Because the medical treatment and rehabilitation would last a long time, most participants quit their jobs or asked for some days off.
Sub-subthemes 2.2.1 return to work
Coincidentally, two participants owned a store and worked there. They all said they would go back to work in the store after being discharged from the hospital. One participant was confident and thought she was capable of continuing to work.
I will definitely return to work after I am discharged from the hospital. Because this disease does not affect me, I don’t need to do heavy work in the store. Ah, I work there because it’s better to have someone in the store to supervise the employees. It’s just that. It’s nothing. (H, female, 64, a month after stroke diagnosis)
Sub-subthemes 2.2.2 reducing intensity and content of the work
However, the other participant said she would reduce the intensity and content of the work due to her physical condition after stroke.
…I can only walk around, do what I can, and instruct employees to do what I can’t do. Because of dizziness, I dare not walk for too long. Maybe I should just sit there and look at the monitoring system. (D, female, 62, 6 months after stroke diagnosis)
Sub-subthemes 2.2.3 planning to do something new after being discharged
Due to retirement age, one participant planned to retire and do something new after being discharged from the hospital.
…Now I plan to renovate the house, um, the house I am living in. (G, male, 59, a month after stroke diagnosis)
Sub-subthemes 2.2.4 not able to return to work yet
However, some participants failed to return to work, even though they had been in rehabilitation for quite some time.
I don’t know how to talk about it. Anyway, I haven’t gone to work. And I just do housework and take care of my children at home. (K, male, 34, 10 months after stroke diagnosis)
Sub-theme 2.3: the need for competence during treatment and rehabilitation
Stroke can be a considerable challenge and change many things in participants’ life. Changes in participants’ abilities, environment, and what they need to do will affect the satisfaction of the need for competence.
Sub-subthemes 2.3.1 knowledge of treatment and rehabilitation
In sub-theme 1.2, it was found that lack of knowledge would impair the satisfaction of the need for autonomy, and so did it in this theme. Inadequate knowledge reduces their ability to deal with events and circumstances, making them appear somewhat helpless and have no idea what to do and how to do it during treatment and rehabilitation . Some participants didn’t know how to adjust their daily diet and whether they should take medicines for a long time. And they didn’t know where and how to do rehabilitation training.
I don’t know. (laughs) I don’t understand those things. …(hesitation) Then where can I go to do the rehabilitation training? …Oh… Is the community hospital where can do it? OK, let me ask. I often feel pain, and it’s not good, so I’ll ask the workers there. (I, female, 58, 9 months)
Some had a misunderstanding about rehabilitation, which may slow down the recovery process.
I guess that the effect of rehabilitation training is not significant, and I feel much better now, so I didn’t ask for the training. (Q, male, 52, 2 months after stroke diagnosis)
Fortunately, part of the participants could obtain relevant knowledge from the Internet.
Just when I was sleeping, I felt numb in my feet, which I had never met before. But I know that, um, sometimes I see videos in TikTok saying that because of high blood pressure, the numbness in my feet may imply a stroke. (H, female, 64, a month after stroke diagnosis)
Sub-subthemes 2.3.2 rehabilitation training is within the ability
Most participants indicated that the rehabilitation training was within their ability, so they could keep doing it.
The rehabilitation training is not difficult, and I can do it. (K, male, 34, 10 months after stroke diagnosis)
Sub-subthemes 2.3.3 creating his own rehabilitation plan
And a participant was so proud to tell the researcher that he had created his own rehabilitation training plan.
Now I do rehabilitation exercises several times a day, every day, which was designed by ourselves. (laughs) (N, male, 57, 4 months after stroke diagnosis).
Sub-subthemes 2.3.4 rehabilitation training ended for various reasons
However, some participants ended their rehabilitation for various reasons. The main reason was that they did not get an obvious effect in rehabilitation training. He may have no idea that rehabilitation training needs to last for a long time to get obvious results.
I had been doing rehabilitation training for about half a year. Because I felt that the effect was not obvious, I stopped doing it. (E, female, 68, 18 months after stroke diagnosis)
The other reason was that their poor physical condition resulted in poor mobility does not allow further training.
Running sometimes makes me feel comfortable, um, sometimes it’s not. Because I have arthritis, sometimes running makes me feel painful, so I stop it. (I, female, 58, 9 months after stroke diagnosis)
Main theme 3: the need for relatedness
The theme focused on the impact of stroke on participants’ relationships and their need for relatedness during treatment and rehabilitation. Stroke might not only change the relationship with family and friends, but it could also develop new relationships between participants, medical workers, and wardmates. This main theme includes three sub-themes, (1) the need for relatedness during hospitalization, (2) the need for relatedness in the rehabilitation stage, and (3) the impact of stroke on relationships. There are 8 sub-subthemes included which are described in each sub-theme.
Sub-theme 3.1: the need for relatedness during hospitalization
Sub-subthemes 3.1.1 longing for the company of family during hospitalization
Almost all of the participants indicated they were very eager for the company of their family during hospitalization.
My sons and daughters-in-law all have busy jobs, so they don’t have time to come here and take care of me. And I don’t think I need someone to care for. However, sometimes when they call me, tears run down my face. (Laughs) Actually, I want someone to be here with me. (E, female, 68, 18 months after stroke diagnosis)
In addition, a participant said that he felt happy when his family visited him and believed that being with his family would help him recover.
I’ve recovered well now, and so do my language function. Since I got sick, I have had difficulty in speaking. For example, sometimes I didn’t know how to say something. When my grandchildren came to visit me, I felt so happy and could call their names and talk to them about anything. But after that, I couldn’t speak well again. (R, male, 66, 5 months after stroke diagnosis)
Sub-subthemes 3.1.2 relatives and friends were unable to visit the patient in hospital
Although it may be difficult for relatives and friends to visit patients in hospitals, they often contact patients by phone or WeChat.
Last night my worker sent a WeChat message asking how I was in the hospital. I said it was all good. (Laughs)… My son often calls me, asks if the food is good, and tells his wife to buy some delicious food for me. (H, female, 64, a month after stroke diagnosis)
However, some participants chose not to inform relatives and friends of the illness, so as not to increase their burden.
I haven’t officially told my friends about my illness, but I will definitely tell them after I am discharged…And I also wanted to tell my wife after I was cured and discharged, because I was afraid that if I told her, it would make her feel stressed and sad. (C, male, 80, a month after stroke diagnosis)
Sub-subthemes 3.1.3 geting along well with healthcare workers and other patients
Although participants didn’t get enough company from family and friends, they still had healthcare workers and other patients with whom they got along well. Most participants felt that they got enough care from healthcare workers.
I have a lot of confidence in you all. You are all professional and care much about (me), so I trust you. In a word, you doctors and nurses are all very responsible in all aspects. (A, male, 45, 5 months after stroke diagnosis)
But he didn’t talk too much with other patients.
When it comes to other patients in the ward, I don’t talk to them too much. Because I don’t know exactly how they are, I dare not laugh and act too happy if they feel so bad. (A, male, 45, 5 months after stroke diagnosis)
Sub-theme 3.2: the need for relatedness in the rehabilitation stage
Sub-subthemes 3.2.1 rehabilitation training accompanied by family members
After being discharged from the hospital, participants moved into a rehabilitation stage. Most participants stay at home or go to specific institutions for rehabilitation training at this stage. And the training takes a long time. Therefore, most family members would accompany the participants to do the exercise or training.
I do rehabilitation exercises every day, (laughs), and my wife also exercises with me at least three times a day. After the exercises, she also massages my hands and feet. (N, male, 57, 4 months after stroke diagnosis)
Sub-subthemes 3.2.2 receiving help from other patients
Those who go to specific institutions for rehabilitation training can often meet other patients and get their help.
On the past day, the older adults in the rehabilitation institution said that the training was helpful, so I went there and tried. And I also bought a physiotherapy device they recommended, and I use it every day. (E, female, 68, 18 months after stroke diagnosis)
Sub-subthemes 3.2.3 socializing with friends
As participants’ physical function recovered, their lives went back on track. They usually socialized with friends in their spare time, such as playing cards, traveling, etc.
I live in the countryside and don’t have much to do. I usually play cards and chat with the people next door, which makes me quite happy. (O, female, 55, 5 months after stroke diagnosis)
Sub-theme 3.3: impact of stroke on relationships
Sub-subthemes 3.3.1 feeling like family cares more about him
Through interviews, almost all the participants said their relationships with their families improved after stroke. Because of the illness, they felt that family cared much more about them than before, and so did friends.
The way that my family treats me must be different. For example, the time when they come home has been changed. In the past, when they came back, I had already been asleep…And nowadays, when I felt a little bit not good, they became so nervous and wanted to send me to the hospital. (N, male, 57, 4 months after stroke diagnosis)
Sub-subthemes 3.3.2 the response of company staff to the illness
However, the relationship between participants, and their workmates or boss is much more complicated. The response of company staff to his illness can be very different. A participant said he had a considerate boss, so he successfully got sick leave.
My boss was so concerned about me and he just gave me a sick leave. And he told me not to return to work until I recovered. (A, male, 45, 5 months after stroke diagnosis)
But unfortunately, another participant lost his job. He appeared a little sad and angry.
I worked before but would not return to work after being discharged. They said I didn’t need to go back, and how do I know why! Definitely, they thought I needed to have a long break! (B, male, 54, a month after stroke diagnosis)