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Background: Understanding recovery is important for patients with stroke and their families, including how much recovery is expected and how long it might take. These conversations can however be uncomfortable for stroke unit staff, particularly when they involve breaking bad news. This study aimed to begin development of a novel complex intervention to improve conversations about recovery on stroke units. Methods: Informed by previously collected qualitative data, we used the Behaviour Change Wheel (BCW) approach to identify possible 1. barriers to communication about recovery on stroke units; 2. Intervention Functions; 3. Behaviour Change Techniques (BCTs) to incorporate in an intervention. We subsequently sought stroke professionals' perspectives through an online survey. Respondents rated the importance of barriers for intervention inclusion and evaluated the usefulness and feasibility of the suggested BCTs. Results: Our behavioural diagnosis identified a target behaviour of provision of information about recovery by stroke unit professionals to patients and carers. Twelve possible barriers to this behaviour were identified, with six potential Intervention Functions to address them, and 29 BCTs. Forty-eight multidisciplinary professionals responded to the survey. The six barriers rated as most important to address were: lack of confidence; perceptions of insufficient communication skills; lack of knowledge of the benefits; difficulties in deciding when and in what format to provide information; absence of private spaces for discussions; and lack of generic written information to support conversations. The developed intervention strategy comprised twelve clinically feasible and useful BCTs, encompassing the Intervention Functions of Training, Enablement, Persuasion, and Environmental restructuring. Conclusions: The BCW approach was successfully used to begin development of an intervention to improve conversations about recovery on the stroke unit; our survey enabled incorporation of stakeholder perspectives. Further development work is required to design intervention materials and test whether the strategies are effective in improving staff and patient outcomes. [ABSTRACT FROM AUTHOR]

Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units. Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken. Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers. The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision. Practice implications: Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs. • Stroke unit patients and carers report dissatisfaction with recovery information. • Ethnographic methods facilitated in-depth exploration of information provision. • A wide range of factors influence provision of recovery information. • A co-ordinated multidisciplinary approach can facilitate information provision. • Staff training is required to support effective delivery and improve confidence. [ABSTRACT FROM AUTHOR]

Objective: To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. Design: Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. Setting: Eight stroke units in four English regions. Subjects: Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. Results: Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. Conclusion: Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines. [ABSTRACT FROM AUTHOR]

Purpose: The use of standardised outcome measures is an integral part of stroke rehabilitation and is widely recommended as good practice. However, little is known about how measures are actually used or their impact. This study aimed to identify current clinical practice; how healthcare professionals working in stroke rehabilitation use outcome measures and their perceptions of the benefits and barriers to use. Method: Eighty-four Health Care Professionals and 12 service managers and commissioners working in stroke services across a large UK county were surveyed by postal questionnaire. Results: Ninety-six percent of clinical respondents used at least one measure, however, less than half used measures regularly during a patient's stay. The mean number of tools used was 3.2 (SD = 1.9). Eighty-one different tools were identified; 16 of which were unpublished and unvalidated. Perceived barriers in using outcome measures in day-to-day clinical practice included lack of resources (time and training) and lack of knowledge of appropriate measures. Benefits identified were to demonstrate the effectiveness of rehabilitation interventions and monitor patients' progress. Conclusions: Although the use of outcome measures is prevalent in clinical practice, there is little consistency in the tools utilised. The term 'outcome measures' is used, but staff rarely used the measures at appropriate time points to formally assess and evaluate outcome. The term 'measurement tool' more accurately reflects the purposes to which they were put and potential benefits. Further research to overcome the barriers in using standardised measurement tools and evaluate the impact of implementation on clinical practice is needed. [ABSTRACT FROM AUTHOR]

Background: Whilst pathways relating to the early stages of stroke care have become well established, strategies for longer-term care are less developed and longer-term outcomes remain poor for many stroke survivors. New Start, a complex intervention that includes needs identification, exploration of social networks and components of problem-solving and self-management, was designed to improve stroke survivors' quality of life by addressing unmet needs and increasing participation. It is delivered approximately 6 months post-stroke by trained staff (facilitators). We are currently undertaking a cluster randomised feasibility trial of the New Start intervention with an embedded process evaluation, which is an important component of the design and testing of complex interventions as it provides an understanding of how interventions are delivered and function in different settings.Methods/design: This mixed methods process evaluation will explore the degree to which New Start is implemented as intended, the impact of context on intervention delivery and the acceptability of the intervention for stroke survivors, their families and practitioners. It will include non-participant observation of facilitator training and intervention delivery. Interviews with stroke survivors, facilitators and other relevant staff (including administrators and managerial staff) will be undertaken. Qualitative data from interview transcripts, facilitator reflections and observational field notes will be analysed thematically alongside numerical data documenting intervention delivery collected as part of the trial.Discussion: This process evaluation will identify factors that aid and impede implementation of the New Start intervention and improve understanding of this novel approach to longer-term stroke care.Trial Registration: ISRCTN Registry, ISRCTN38920246 . Registered on 22 June 2016. [ABSTRACT FROM AUTHOR]