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How is the audit of therapy intensity influencing rehabilitation in inpatient stroke units in the UK? An ethnographic study
  1. Elizabeth Taylor1,
  2. Fiona Jones1,
  3. Christopher McKevitt2
  1. 1 Faculty of Health, Social Care and Education, Department of Rehabilitation Sciences, Kingston University and St George’s University of London, London, UK
  2. 2 School of Population Health and Environmental Sciences, King’s College London, London, UK
  1. Correspondence to Dr Elizabeth Taylor; elizabeth.taylor{at}


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.

  • stroke
  • rehabilitation medicine
  • therapy
  • quality In health care
  • clinical audit

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  • 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.