How is the audit of therapy intensity influencing rehabilitation in inpatient stroke units in the UK? An ethnographic study

Abstract

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.

Current therapy for the upper limb after stroke: a cross-sectional survey of UK therapists

“…It could also indicate, as observed by others, that therapists may have overreported or struggled to accurately recall the actual time spent on treatment 31. However, the differences in findings between studies might reflect different interpretations as to what upper limb therapy actually comprises in this study as some therapists may have considered the time to include activities where the upper limb was likely to benefit from therapy, but was not the direct target of intervention (eg, aerobic exercise) 32 33. This ambiguity might be an inevitable limitation of the current study’s findings, but focus on content of therapy and who delivered it attempted to minimise this effect by providing some guidance to therapists on what did, and what did not, constitute therapy.…”

“…In addition to research trials, large improvements in upper limb functioning have been reported in a NHS-funded clinical service (the Queen’s Square Upper Limb Programme) that delivers 90 hours of multidisciplinary upper limb rehabilitation over 3 weeks 33. When the intensities of therapy in these studies are compared with those measured in observational studies,32 39 SSNAP data8 and the current study, they emphasise that service provision for rehabilitation of the upper limb after stroke needs radical alteration if it is to empower therapists to provide effective therapy and maximise recovery for people after stroke. Further research is therefore urgently needed to find ways to upscale services so that they can deliver greater intensities of high-quality, personalised, evidence-based therapy for the upper limb in clinical practice.…”

Using co-production to increase activity in acute stroke units: the CREATE mixed-methods study

“…Importantly, therapy is rarely a 7-day service; in 2016, SSNAP data showed that only 31% of stroke units had access to at least two types of therapy 7 days per week. 35 Several authors have stated concerns about the focus on a 45-minute therapy guideline: 11,12 first, the accuracy of reporting and what is being counted and, second, that direct contact time with therapists could be considerably lower. Clarke et al 11 carried out an ethnographic case study across eight stroke units comprising > 1000 hours of non-participant observations and 433 patient-specific therapy observations and found that a considerable amount of time was spent carrying out activities relating to information exchange rather than patient-focused therapy.…”

“…Clarke et al 11 carried out an ethnographic case study across eight stroke units comprising > 1000 hours of non-participant observations and 433 patient-specific therapy observations and found that a considerable amount of time was spent carrying out activities relating to information exchange rather than patient-focused therapy. In another ethnographic study across three stroke units, Taylor et al 12 found that therapists wanted to provide more therapy and felt guilty for not doing so; there was also a lack of multidisciplinary rehabilitation. Both research teams found that rehabilitation was largely the responsibility of therapists, and patients were often observed as inactive outside their designated therapy sessions.…”

“…9,10 However, audits and standards have not improved the experience of patients or increased activity opportunities outside these structured rehabilitation sessions with therapists. 11,12 This is critical as when patients are bored and inactive it can have an impact on aspects of their recovery and potentially foster a feeling that 'nothing is being done'. 7 In a recent commentary on mainstream approaches to quality improvement and the potential role of co-production, Batalden 13 highlighted how professionals and patients can become increasingly frustrated by product-dominant models, which focus solely on processes, actions and outputs, and that such approaches risk neglecting relationships and outcomes that are important to patients but are less easy to measure (such as patient preferences).…”