ObjectivesOccupational therapy, physiotherapy and speech and language therapy are central to rehabilitation after a stroke. The UK has introduced an audited performance target: that 45 min of each therapy should be provided to patients deemed appropriate. We sought to understand how this has influenced delivery of stroke unit therapy.DesignEthnographic study, including observation and interviews. The theoretical framework drew on the work of Lipsky and Power, framing therapists as ‘street level bureaucrats’ in an ‘audit society’.SettingStroke units in three English hospitals.ParticipantsForty-three participants were interviewed, including patients, therapists and other staff.ResultsThere was wide variation in how therapy time was recorded and in decision-making regarding which patients were ‘appropriate for therapy’ or auditable. Therapists interpreted their roles differently in each stroke unit. Therapists doubted the validity of the audit results and did not believe their results reflected the quality of services they provided. Some assumed their audit results would inform commissioning decisions. Senior therapy leaders shaped priorities and practices in each therapy team. Patients were inactive outside therapy sessions. Patients differed regarding the quantity of therapy they felt they needed but consistently wanted to be more involved in decisions and treated as individuals.Conclusions and implicationsStroke unit therapy has different meanings in different hospitals. Measuring therapy time is problematic due to varied interpretations of ‘what counts’ and variation in reporting practices. Although stroke policy, guidelines and audit are potential tools of improvement, their benefits are not automatic. Their actual effects depend largely on the attitudes and values of local influential ‘street level leaders’. More work is needed to promote an integrated whole team approach to rehabilitation. Further research into contextual and human factors, including the roles and views of therapy leaders, would enable a better understanding of implementation of guidelines and service improvement.
Conceptual, individual and professional factors impact on the delivery of rehabilitation. Further research is needed to examine how therapists negotiate the sometimes conflicting factors shaping delivery of therapy.
As it appears rehabilitation is affected by a language barrier, this is likely to impact on the outcome of an individual's rehabilitation. The concept of "subtle communication" should be recognised as a vital component of therapeutic skills. Improving access to formal interpreters, extending their role and introducing training could reduce practical barriers. The conceptual model could be utilised by clinicians as a tool for reflection or education.
IntroductionArm weakness is a common problem after stroke (affecting 450 000 people in the UK) leading to loss of independence. Repetitive activity is critical for recovery but research shows people struggle with knowing what or how much to do, and keeping track of progress. Working with more than 100 therapists (occupational therapists and physiotherapists) and patients with stroke, we codeveloped the OnTrack intervention—consisting of software for smart devices and coaching support—that has the potential to address this problem. This is a protocol to assess the feasibility of OnTrack for evaluation in a randomised control trial.Methods and analysisA mixed-method, single-arm study design will be used to evaluate the feasibility of OnTrack for hospital and community use. A minimum sample of 12 participants from a stroke unit will be involved in the study for 14 weeks. During week 1, 8 and 14 participants will complete assessments relating to their arm function, arm impairment and activation. During weeks 2–13, participants will use OnTrack to track their arm movement in real time, receive motivational messages and face-to-face sessions to address problems, gain feedback on activity and receive self-management skills coaching. All equipment will be loaned to study participants. A parallel process evaluation will be conducted to assess the intervention’s fidelity, dose and reach, using a mixed-method approach. A public and patient involvement group will oversee the study and help with interpretation and dissemination of qualitative and quantitative data findings.Ethics and disseminationEthical approval granted by the National Health Service Health Research Authority, Health and Care Research Wales, and the London—Surrey Research Ethics Committee (ref. 19/LO/0881). Trial results will be submitted for publication in peer review journals, presented at international conferences and disseminated among stroke communities. The results of this trial will inform development of a definitive trial.Trial registration numberNCT03944486.
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