Documentary analysis: five themes were identified: evidence-based practice and clinical effectiveness; management approaches and decision making structures; staff development and training; multiprofessional working; and support for the project.
Theme one: evidence-based practice and clinical effectiveness
The organisation supported evidence-based practice and research and development initiatives, although a process for implementing such innovations as part of clinical governance procedures was not identified.
'Clinical effectiveness and clinical governance are key pillars on which the government wants health care to be built. This Trust already has a reputation for quality.' (Trust Annual Report.)
'R&D is the foundation of evidence-based practice, and should be the basis for planning and delivering clinical care.' (R&D Annual Report)
An encouraging finding was the commitment to the provision of training in critical appraisal skills and development of nursing outcome indicators.
'The Trust will encourage training in R&D methodology and critical appraisal of research findings to contribute to evidence-based medicine'. (R&D Annual Report)
'... the development of valid nursing outcome indicators in collaboration with clinical audit, research and development. (Nursing and Midwifery Strategy).
Theme two: management approaches and decision making structures
The Trust Profile provided an overview of a clear and unambiguous decision making structure, with a commitment to participative decision making and multidisciplinary team work.
'The general approach taken to the management of the Trust is based on the following principles: maximum devolution of authority [and]multidisciplinary teams at all levels'. (Trust Profile)
Multidisciplinary teams were responsible for the management of ten service areas. Medical professionals were the leaders in nine teams. However, it was not clear how multidisciplinary teamwork operated at ward level.
Theme three: staff development and training
Although a strong emphasis on staff training and development was identified in all the documents analysed, exemplars of training and educational achievements were not presented. Explicit commitment was given:
'... to be a teaching, learning and research organisation' (Trust Profile)
A high profile was given to education as part of continuing professional development, and explicit links were made between education and improved patient care. Education was also presented as creating a positive environment that would improve staff recruitment.
'Education too is crucial to the delivery of patient quality care. All employees are encouraged to increase their knowledge and, as a result, achieve practical benefits' (Annual Report)
'... a progressive employer, enabling staff to realise their full potential and being an organisation in which people wish to work'. (Trust Profile)
While there was clear support for education and training generally, nursing leadership, research, and supervision were also emphasised in terms of commitment.
'... clinical and professional leadership, research and supervision'(Nursing and Midwifery Strategy)
Theme four: multiprofessional working
The decision making structure of the Trust highlighted the adoption of a multidisciplinary approach, yet little operational evidence was found of this commitment, with reference to only one initiative.
'... a multidisciplinary surgical procedure review committee will be established to assist the rationalisation of procedures based on outcome measures of success in accordance with a certification process developed by the Royal College of Surgeons' (Five Year Vision for Health Services)
Theme five: support for the project
It was important that the Trust demonstrated support for the project so that staff understood that the changes would be embedded into Trust business. Overt Trust support was also important for underpinning the relationship between the project leader and professional teams who would be implementing the change, as the project leader did not have any line management responsibility for the teams involved. The project leader had to use influencing skills to achieve changes in practice. Influence was needed at all levels in participating teams, including ward-based staff and senior managers. The project leader worked through formal structures, such as directorate meetings and Trust board members, and also through informal opportunities that occurred from visiting the wards every day. Teams were free to choose how they implemented the change. For example, ward sisters monitored the use of the multidisciplinary recording system in some wards, while medical consultants generally did not supervise its use by their junior medical staff.
Trust support was clear in terms of funding and the appointment of the researcher as cited in three documents. Furthermore, the Trust was moving towards implementing the unique electronic patient record and expectations were that the project would link with this.
'Nursing documentation/records will be completely reviewed and updated ready for incorporation into the "unique medical record"' (Nursing and Midwifery Strategy).
Interviews and focus groups (staff)
Four themes were identified: stroke assessment and recording, stroke services, the Trust as an organisation, and past history of change at the Trust.
Theme one: stroke assessment and recording
The assessment of stroke patients was fragmented, unidisciplinary, separately documented, and lacked cohesion. Furthermore, the use of evidence-based, validated assessment tools varied across disciplines. Exemplars included the Waterlow Scale [33
] and standardised swallow assessment [34
], both of which were used by nurses in conjunction with a series of questions based on the Roper, Logan & Tierney nursing model [35
]. Medical staff used an assessment model based on anatomical and physiological systems together with three validated assessments: the Glasgow Coma Scale [36
]; the Abbreviated Mental Test Score [37
] and the Barthel Index [38
]. Not all physiotherapists routinely used assessment tools, but in one area, a modified Rivermead Mobility Index [39
] had been adopted. In speech and language therapy, routine use of the Frenchay Dysarthria Assessment [40
]; the Frenchay Aphasia Screening Test [41
] and the Psycholinguistic Assessment of Language in Aphasia [42
] were reported.
All respondents described how each discipline undertook an individual assessment of stroke patients and documented the results in separate records. Only the medical and nursing assessments were accessible to all professional groups on the ward.
'It's often difficult for us nurses because we don't know what's happened to them (the patient) in physio or OT, there's nothing written for us to read, they (the physios and OTs) do their assessments in the gym and we don't get to see it' (Nurse – interview)
Some therapists, in addition to maintaining separate, full assessment records, also recorded abridged versions in the medical and nursing notes, omitting technical details. Some professionals reported that the current approach to stroke assessment did not have any gaps, but nurses were concerned that their assessments did not contain enough information to inform the care plan.
'... that's a big gap, it's about how we as a professional organisation enable nurses to link the two together, with assessment informing care planning' (Manager – interview)
Similarly, lack of written detail in the medical assessment relating to functional assessment was also identified as a gap.
'Doctors use a structured approach to assessment but sometimes don't write down enough detail, for example, right hemiplegia doesn't tell you much' (Doctor – focus group)
Theme two: stroke services
Many respondents acknowledged that comprehensive multidisciplinary working did not occur, and identified multidisciplinary team meetings that varied functionally as the main focus.
'The level of multidisciplinary working varies, but the multidisciplinary team meetings are the focus of multidisciplinary working on the wards, and they work better on the elderly care wards' (Allied Health Professional – interview)
Liaison was highlighted as part of multidisciplinary working, with mixed views expressed about its efficacy. The diverse geographical spread of wards to which stroke patients were admitted, the numbers of different nurses involved, and lack of a stroke unit made liaison difficult.
'Its hard keeping track of patients, there's no dedicated stroke unit, that's the problem, if all stroke patients were in one place it would be so much easier for all staff to liaise, therapists would be there on the unit' (Manager – interview)
Despite the lack of a stroke unit, perceptions varied of the quality of service delivered.
'The service varies, in some areas it's not very good, within some areas there are probably some areas of good practice as well, but I would say that overall it is about average' (Manager – interview)
Theme three: the Trust as an organisation
Overall, participants identified many strengths, most commonly the positive working environment and management structures which were flat hierarchies, with devolved decision making.
'There aren't too many layers of management, the Trust has a fairly flat hierarchical structure' (Doctor – interview).
'I think people feel involved in decisions, the Trust has made good attempts to devolve decision making' (Manager – interview)
Limitations were also evident. Notably, the devolved management structure often led to communication problems. Furthermore, shortages of nursing staff were evident, however this was part of a wider national problem. A lack of qualified nurses had led to use of agency and bank nurses. Different agency nurses worked on the wards each day, which led to lack of continuity.
'Sometimes I despair, I don't know why we can't have the same agency nurse if she's available, it means that each shift I have to start again, tell her all the things about how we do things on the ward' (Nurse – focus group)
Theme four: the organisational history of change
The general consensus from participants was that the Trust responded positively to change and that this was a constant feature of working in the NHS.
'... it's (change) so constant now isn't it, if you can't cope with it you're gone, its very hard, you're still reeling from the last one when the next one comes along' (Manager – interview)
Many exemplars of well-managed change were cited, including a recent rationalisation of services, introduction of pharmacy stations on wards, introduction of swallow screening and extended roles for nurses. Key characteristics of these changes were good communication, planning, involvement of staff, and training provided prior to implementation. Exemplars of less well-managed change, including changes to catering services, a change in the way ward-based nursing was organised, changes from mixed to single-sex wards. These changes were described as poorly communicated, brought in too quickly and lacking adequate staff consultation and preparation.
All patients reported their care to be good to excellent and five patients said they would recommended the care and treatment to others. A need for improvements in access to a wheelchair and the poor quality of food were noted by two patients. Three patients and one caregiver were satisfied with the information provided on admission. Three patients were not provided with discharge information. Four patients could recall specific positive aspects of treatment by therapists. All who were referred to therapists were satisfied with their treatment, and five patients generally were satisfied with their recovery. In four cases, occupational therapy was restricted to a home assessment due to staff shortages.
Team climate inventory
Important findings from the Team Climate Inventory questionnaire (Table ) were variability in teamwork across the professional groups. Scores of eight or above indicated excellent team working; scores between four and seven indicated room for improvement; scores of less than four indicated low levels of teamwork.
Results of team climate inventory: STEN scores for each team
The therapy team scores ranged from six to ten, with nine subscale items scoring more than eight (indicating excellent team working) and scores on only four items (range six to seven) suggested room for improvement. In contrast, the medical team subscores ranged between one and nine, with only two items scoring more than eight and six items less than four. Low scores on 'interaction frequency', 'clarity', 'sharedness', 'appraisal', and 'excellence in task orientation' were matters of concern. Nursing team two (range on subscores three to seven; one item scored above eight) and seven (range on subscores tow to six; no item scored above eight) demonstrated the weakest teamwork. All aspects of 'participative safety' in team seven produced low scores, and the low score for 'sharedness' in team two were matters of concern. In contrast, nursing teams one and three were the highest scoring, the former with nine items scoring above eight, and the latter with eight items scoring above eight.
Developing a tailored strategy for local change
A summary of the barriers and facilitators for change in stroke assessment practices together with their implications as identified from this diagnostic assessment are summarised in Table . Key issues related to communication and perception of the change, workforce issues including severe shortage of professional staff, unidisciplinary assessment and working practices, and a lack of organised stroke care in the organisation.
Diagnostic findings: implications