Objectives Occupational 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.
Design Ethnographic 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’.
Setting Stroke units in three English hospitals.
Participants Forty-three participants were interviewed, including patients, therapists and other staff.
Results There 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 implications Stroke 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.
- rehabilitation medicine
- quality In health care
- clinical audit
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
Contributors The first author (ET) conducted the study, supervised by CM and FJ. All authors made substantial contributions to the conception and design of the work. ET was primarily responsible for the acquisition, analysis or interpretation of data for the work and drafting the work and revising it critically. CM and FJ viewed and commented on all drafts and gave final approval of the version to be published. All authors agree to be accountable for all aspects of the work.
Funding The Stanley Thomas Johnson Foundation provided funding for the doctoral study. The research was supported by the National Institute of Health Research Comprehensive Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust, King’s College London and National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London.
Competing interests None declared.
Patient consent Not required.
Ethics approval Ethical approval was obtained from National Research Ethics Committee on 18 July 2014.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Correction notice Since this paper was first published online the conclusion section has been added to this paper.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.