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Results:Over 1000 hours of non-participant observations and 433 patient-specifictherapy observations were undertaken. The most significant factorinfluencing amount and frequency of therapy provided was the time therapistsroutinely spent, individually and collectively, in information exchange.Patient factors, including fatigue and tolerance influenced therapists’decisions about frequency and intensity, typically resulting in adaptationof therapy rather than no provision. Limited use of individual patienttherapy timetables was evident. Therapist staffing levels were associatedwith differences in therapy provision but were not the main determinant ofintensity and frequency. Few therapists demonstrated understanding of theevidence underpinning recommendations for increased therapy frequency andintensity. Units delivering more therapy had undertaken patient-focusedreorganisation of therapists’ working practices, enabling them to providetherapy consistent with guideline recommendations.
IntroductionNational clinical guidelines for stroke worldwide recommend providing as muchscheduled therapy as possible to stroke survivors. – Therapy provision (physiotherapyand occupational therapy) has been reported to be lower in England than thatprovided in comparable countries.
The CERISE study and systematic review evidence – informed the United Kingdom, guideline which recommends patients should ‘accumulate at least 45 minutes of eachappropriate therapy every day at a frequency that enables them to meet theirrehabilitation goals’ (p. 25).Recommendations are based on consistent evidence that increased frequency andintensity of therapy in the first six months post-stroke can improve recovery rateand outcome.
– There are limitations in thegeneralisability of this evidence to inpatient stroke units, as two recentrandomised controlled trials focussing on task-specific and task-oriented upper limb training found no evidence of a dose–response relationship.The Sentinel Stroke National Audit Programme (SSNAP) monitors therapists’(self-reported) performance against the guideline target, continuously collecting aminimum data set within acute hospitals in England, Wales and Northern Ireland, providing a high-level summary across 10 care domains. The SSNAP publishesquarterly performance ratings for each domain (A (first class service) to E(substantial improvement required)) and consistently identifies that therapyfrequency and intensity recommendations are not met in most stroke units. Similar problems in providing recommended therapy levels are reported inEurope, Canada and Australia. – These findings raise importantquestions about why recommendations are not being met.
The aim of the ReAcT (why dostroke survivors not receive recommended amounts of active therapy) study wastherefore to develop an in-depth understanding of therapy provision in stroke unitsin England, including how clinical guideline recommendations are interpreted andimplemented by therapists, and experienced by patients and their carers. MethodsThe study received a favourable ethical opinion from the Health ResearchAuthority, National Research Ethics Service Committee North-West (14/NW/0266).Our approach is summarised in the following; full details are published elsewhere.We employed a mixed-methods case-study approach to explore therapy provision(physiotherapy, occupational therapy and speech and language therapy).
Wepurposively sampled eight stroke units in four English regions to include a mixof hyper-acute, acute and rehabilitation units, with higher and lower nationalaudit ratings for therapy performance.Modified process mapping in each unit provided a staff-reported map of patients’ inpatient therapyjourney which we compared with our findings. We conducted non-participant observations for approximately 16 weeks in each unit using an established framework. The researcher was present in an area of the stroke unit or in a group orindividual therapy treatment session but took no part in activities orinteractions. We focused initially on stroke unit contexts, including the builtenvironment and facilities, how therapists’ time is managed and spent,approaches to multidisciplinary team (MDT) working and on therapy planning andprovision. Field notes were recorded contemporaneously. Observations progressedto study of a purposively selected patient group (up to 10) in each unit, tounderstand therapy provision for patients with different post-stroke impairmentsincluding those with mild, moderate and severe disability post-stroke and peoplewith aphasia.
For these 10 patients (in each unit), we categorised therapyinterventions , confirming categories with therapists,and recorded reported session aims after each session. These patients’ therapyrecords were also subject to documentary analysis to identify numerical andtextual discrepancies between our observations and therapists’ notes.Following observations, we conducted audio-recorded semi-structured interviewswith purposive samples of 15–20 staff per unit.
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Interviews lasted about 1 hour;questions explored perceptions and experiences of working towards therecommendation, decision-making processes, service structure, working hours andskill-mix. The 10 patients and carers from each ofthe first six sites were invited to participate in audio-recordedsemi-structured interviews in their own homes 4–6 weeks postdischarge. Patientand carer interview data are not reported here.We transcribed interviews verbatim and managed them alongside process maps,field-notes and observational records in QSR-NVivo10 (QSR International Pty Ltd,2011). These data were analysed by four researchers working through each stageof the framework approach in pairs and as a group. An expert advisory group reviewed emerging interpretations andexplanations. SSNAP: Sentinel Stroke National Audit Programme; therapy provision inthe SSNAP is rated A to E: A – first class service; B – good orexcellent in many aspects; C – reasonable overall (some areasrequire improvement); D – several areas require improvement; E:substantial improvement required. Column 4 refers to SSNAP ratingsfor OT: occupational therapy; PT: physiotherapy; SLT: speech andlanguage therapy.
WTE: whole time equivalent; BASP: BritishAssociation of Stroke Physicians; MDT: multidisciplinary team. Time spent in information exchangeThe most significant factor influencing the amount and frequency of therapy providedin units performing less well in the SSNAP audit was the time therapists routinelyspent in information exchange activities. These included daily handovers or boardrounds where typically, one nurse delivered information to individual therapists orgroups of therapists on a unit. Each handover tended to report on all patients andlasted between 15 and 60 minutes (mean = 32.5, SD = 12.25).
Reported informationcovered new patients, changes in existing patients and planned discharges.Observations indicated that outside of hyper-acute units which had high turnover andlength of stay of less than 72 hours, information exchange activities wererepetitious and not always therapy focused; as these staff members noted,There’s often nothing new to report and sometimes that does seem a waste oftime to sit and hear the same thing as the day before. (Stroke co-ordinator,Unit 6)It’s all mainly medical stuff that gets handed over, they do ask discharge questions but I’m not sure if everybody should go on handover.(Occupational therapist, Unit 4)In five units, individual therapists attended routine nurse-led handovers at thestart of the daytime shift, before handing over the same information to all otheroccupational therapists and physiotherapists in an additional session. In the tworehabilitation units, board rounds attended by one or two nurses and all therapistsoccurred daily (for approximately 1 hour). Saint seiya episode g scan italian. Speech and language therapists attendednurse-led or therapist-led handovers only in Units 2 and 8.In the remaining site (Unit 7), two therapists started work 30 minutes before others,receiving a nursing handover from one nurse (10–15 minutes) and then preparing adaily therapy provision schedule (timetable) for all occupational therapists andphysiotherapists. No further handover occurred and individual therapy was providedaccording to the timetable; SSNAP data demonstrated that more therapy minutes wereroutinely delivered in this unit. The mean observed time spent in daily handoversranged from 34 minutes (Unit 7) to 5.2 hours per therapist per week (Unit 1).Some therapists reported handovers were valuable provided that the process was basedon exchange of information and not simply receipt:Some days it may feel as though the information that we get is notappropriate, but it’s important that we have handover, as the therapy team,we have our input as well as taking information from them. (Physiotherapist,Unit 4)Additional information exchange activities included MDT and goal-setting meetings.Typically, only one qualified therapist per discipline attended MDT meetings butdelays to start times and meetings over-running were common.
These meetings took uplarge amounts of therapists’ time in units 1, 4, 5 and 6 where multiple consultantphysicians each held weekly MDT meetings. When mean time spent in MDT andgoal-setting meetings is added to that spent in handovers, qualified therapists eachspent between 1.2 and 6.5 hours per week in information exchange activities, withmost spending 3–5 hours per week. Time spent in other non-patient contact activityThis included planning therapy, documenting therapy provided; discharge planning,ordering equipment and transport; developing patient and family/carer training andinformation packages; supervising and training staff.
Discharge planning forpatients with complex needs increased administration, which therapists (usuallyoccupational therapists) prioritised over face-to-face therapy. As one occupationaltherapist describedWe have a large indirect role; because indirect isn’t included in your45 minutes therapy it’s not part of achieving your target, but it is avital part of somebody’s treatment with us. Sometimes it can take 30 minutesto fill out a bed-rail risk assessment. (Occupational therapist, Unit 4)In six units, therapy was documented in shared MDT notes. Unit 8 used electronicpatient records (EPRs) with no obvious reduction in documentation time. Speech andlanguage therapists in six units duplicated therapy provision documentation indepartmental records. In units where therapy timetabling occurred (5, 7, 8),documentation time (10–15 minutes) was factored into hour-long scheduled ‘slots’; inthe remainder, documentation mainly occurred before 09.30 or after 15.30.The most time-consuming other non-patient contact activity was duplication ofdocumentation; completion of SSNAP and internal audit records is an example of thisduplication.
In all units, including that using EPRs, therapists recorded therapyminutes provided per patient on paper records. These were also entered into theon-line SSNAP audit and into internal audit systems, for example, SystmOne. Thesesystems do not allow data sharing.
In four units, dedicated clerks entered data, inothers therapists or nurses completed data entry. Staffing levels and deploymentOccupational therapists and physiotherapists were commonly co-located on strokeunits; for speech and language therapists, this occurred in only two units (7 and8).
In all sites, speech and language therapists covered more than one ward; infive, they provided services for the whole hospital and community.We found marked between unit variations in therapist numbers. In all but one unit,these were lower than recommended., particularly for speech andlanguage therapists. The two units (Units 7 and 8) with the highest therapist numbers hadthe highest ratings (AAA) for SSNAP therapy domains, indicating more therapy minuteswere delivered. Even in those units, maintaining or increasing staffing levels andproviding therapy consistent with guideline recommendations was challenging, as thisspeech and language therapist suggests:When you have the staff, you’re able to deal with other things that come upbecause there’s more of you and you’ve got more time. A couple of weeks agowe were fully staffed, our stats looked amazing, everyone was seen for45 minutes, we had the groups, that being fully staffed really helps.(Speech and language therapist, Unit 8)In seven of eight units, therapists worked 08.00/08.30 to 16.00/16.30 but rarelyprovided therapy before 09.30. There were exceptions; occupational therapists inUnit 4 conducted mealtime assessments from 07.30 to 08.00, and in Unit 7 washing anddressing practice occurred before 08.00. Protected patient mealtimes (1 hour) andstaff meal breaks (30 minutes taken during protected mealtimes) reduced timeavailable for therapy in seven units.
In six units, documentation was typicallycompleted after 15.30; little therapy was delivered after this time. In Unit 7,therapists’ start, finish and mealtimes were staggered to extend the working day;protected patient mealtimes were reduced (30 minutes).
Therapists or therapyassistants were observed supporting patients at mealtimes. While no therapist inUnit 7 worked longer than 7.5 hours per day, they delivered more therapy minutes andachieved ‘A’ ratings for physiotherapy, occupational therapy and speech and languagetherapy.Six units provided seven-day occupational therapy and physiotherapy and two providedspeech and language therapy on six days. Weekend therapy provision occurred mainlyin hyper-acute services and focused on meeting SSNAP targets that newly admittedpatients should be assessed and managed by at least one member of the specialistrehabilitation team within 24 hours, and all relevant members within 72 hours. Patient factorsPatient factors divided into two categories: (1) those relating to patients’condition and (2) those relating to patients’ physical readiness and availability toparticipate in therapy.Category 1 factors identified by therapists included clinical instability,post-stroke fatigue and concurrent medical illness. Experienced therapists reportedthese factors did not mean therapy would be withheld. Instead, they discussedintervention safety with medical and nursing colleagues, completed individualassessments and adapted therapy accordingly, as this physiotherapist comments:If we feel patients can do more then we’ll try and push them, if we feel apatient is too fatigued, then we like to end on a good note because that’sthe carry over they’re going to get. So, we’re restricted by patients’fatigue rather than NICE guidelines or staffing levels.
(Physiotherapist,Unit 2)Therapists frequently provided shorter, less intensive treatments for fatiguingpatients, reporting that ideally they would return to them later the same day toprovide an appropriate overall therapy ‘dose’. As one occupational therapist described,There are patients who can’t concentrate for that length of time so they’d bebetter being trained in two or three 10-minute sessions throughout the daywhich we might try to do.
(Occupational therapist, Unit 2)However, our observations indicated this rarely occurred. Some therapists describedconflict between their clinical judgement that these patients could not toleratelonger, more intensive sessions, and their awareness of the guideline recommendationfor 45 minutes of therapy daily, fearing the negative impact that regularlyrecording single short episodes could have on SSNAP performance ratings.Category 2 factors included patients’ physical preparedness and availability toparticipate in therapy. Ensuring patients were ready for therapy was largely viewedas a nursing role. Numerous factors impacted on the process of ensuring patientswere out of bed, had received meals and medication and were appropriately dressedfor scheduled therapy, as one physiotherapist explained:A lot of the time patients are not ready for the therapy session, so you endup spending half that session getting them out of bed, assisting them,change their pads, nets, pyjamas, by the time you get to do active therapyyou’re limited to 15 minutes, so that’s a big factor. (Physiotherapist, Unit6)Nursing staff reported better communication could support them in their role:If the day before, they therapists could let us know who they’re going tofirst in the morning, then obviously nursing staff would be able to preparefor that. (Registered nurse, Unit 2)As staffing levels were often less than recommended , this influenced patientpreparation; nurses prioritised other tasks; as one ward manager explained,They therapists do a lot of group sessions to try and get the 45 minutesin, if I’m short staffed we may not be able to get a patient up in time you’re not going to leave someone who’s been incontinent in a wet bed, toget a patient up for breakfast club.
(Registered nurse, Unit 5). Therapists’ limited knowledge of the evidence that increased frequency andintensity of therapy improves outcomes within the first six months afterstrokeAlthough all therapists were aware of recommended daily therapy minutes, few wereaware of evidence underpinning the recommendations, or discussed how this informedclinical decision-making and therapy provision. The evidence that more therapy moreoften is associated with improved outcomes was rarely referenced during observationsor in interviews.
On occasion, a contradictory perspective was voiced:I don’t see how you can ever set a standard, your standard has got to be thatthe patient has whatever therapy is appropriate and that is not going to bethe same every day. We’ve got to get out of this habit that just becausea patient needs physiotherapy that the more they have, the better it is,that’s completely wrong thinking. (Physiotherapist, Unit 5)However, some therapists’ views indicated knowledge of the evidence underpinningrecommendations.
This comment identified the need to interpret and apply theevidence to specific areas of rehabilitation:The 45 minutes, doesn’t always fit with my, our model of working, it’s notspecific to OT necessarily where it came from, some of the evidence thatthey’re basing on is very physio-orientated, rather than this type of ward,rehab people going in and out on visits. (Occupational therapist, Unit2)All therapists referred to clinical reasoning as the basis for decision-makingregarding therapy frequency and intensity. In each unit, this followed patientassessment involving direct observation, ‘hands-on’ assessment, pencil and papertesting (of language, cognition), verbal/written information from colleaguesregarding patient engagement, and from patients and their families about pre-strokefunctioning. Clinical reasoning was discussed in terms of deciding whether patientswere suitable for therapy on specific days and appropriate interventions. Patients’engagement in and tolerance of particular interventions appeared to be the primarydeterminant of subsequent therapy provision. Therapists relied on tacitunderstanding of improvement with limited reference to or observed use of validatedoutcome measures. Influence of external audit of stroke servicesTherapists described an ambivalent relationship with national audit requirements.They recognised the contribution that the SSNAP has made in improving strokeservices, and the value of a therapy provision target, as described by this stroke co-ordinator:It’s better to have some standard about the amount of therapy that patientsshould be receiving, because that gives a target to work towards and you’remore likely to give patients adequate therapy.
That is measured andknown throughout your region and to the public, and the Trust is going to bejudged upon it. (Stroke co-ordinator, Unit 6)However, therapists viewed audit of therapy provision as different to other auditedtargets (with dichotomous responses), for example, whether computerized tomography(CT) scanning was completed within 1 hour of hospital arrival. There was disquietacross disciplines and sites that provision of individualised therapy, andindirectly, the quality of therapy services, was measured and performance-ratedagainst a numerical target: as this therapist indicatesIt makes me wonder how some units are getting the results they are thenumbers, the letters performance rating.
It’s kind of out of your control,but it’s made us, the 72 hour assessment target thing, I would never havewanted to stand at the bottom of somebody’s bed and say, ‘oh they’re toopoorly to be seen,’ and call that specialist assessment, but if we do thatthen it makes a massive difference to the results so, we’ve introducedourselves to the patient and checked that they’re positioned well within12 hours of them being admitted. (Physiotherapist, Unit 2)Despite these reservations, a concern to achieve the ‘45-minute’ target dominated thethinking of senior therapists and therapy services managers, who accounted for SSNAPperformance ratings to hospital managers and service commissioners. In contrast,inexperienced therapists, who provided a substantial proportion of therapy, oftenhad very limited understanding of the guideline recommendations, the underpinningevidence, the purpose of the SSNAP or the wider purpose of clinical audit. Theyrecorded therapy minutes data routinely but without a clear sense of the purpose orimportance of these data.The SSNAP defines therapy as assessment and/or treatment (individual or within agroup), provided by qualified therapists or supervised assistants. However, therapists across sites were uncertain about what should and shouldnot be recorded. This impacted on the number of minutes recorded and whether timespent treating a patient was recorded in the SSNAP at all.
One example involvedtherapy to maintain function while awaiting discharge. This was recorded in someunits while in others, lead therapists actively directed colleagues not to recordthese minutes. Similarly, some speech and language therapists were unclear whethertime spent documenting their recommendations and advising other staff or patients’families should be recorded.
Although the SSNAP provides comprehensive informationabout completing the audit to registered staff via on-line help pages, fewtherapists were aware of this or how to access it.Observations indicated over-estimation and error in SSNAP data entry. We observed 433therapy sessions and accessed SSNAP data for 364. Therapists did not routinelyrecord session start and finish times, typically estimating times afterwards. Onaverage, sessions recorded by physiotherapists, occupational therapists andassistants were 5.48 (SD = 12) minutes longer than observed( t = –8.75, df = 363,p. Limited use of a planned therapy timetableTherapists commonly understood ‘timetabling’ to mean weekly allocation of patients’treatment sessions with assigned staff members, at specified times.
This occurred infour units: two timetabled daily and two (rehabilitation units) held weeklytimetabling meetings. However, whether labelled timetabling or not, therapists inall units spent time planning which patients would receive therapy and who wouldprovide it.
A concern highlighted by therapists not timetabling weekly was theperceived time commitment. In practice, when totalled, we observed little differencebetween weekly (90–120 minutes) and daily timetabling (90–150 minutes). Therapistsfelt daily timetabling should happen after nurse handover so they had informationabout who was appropriate for therapy. This often delayed planning until 10 a.m. Inseven sites, all physiotherapists and occupational therapists were involved in dailyor weekly planning activity.Two units shared weekly-prepared timetables (on laminated cards) with staff, patientsand relatives. Observed benefits included nurses using timetables to prioritisetheir workload to ensure patients were physically prepared, and staff not involvedin timetabling (speech and language therapists, dieticians and doctors) usingschedules to work around planned therapy. Comments about benefits of timetabling included,If they are asking the care staff to go back to bed, they’ll actually checkto make sure they’re not due therapy before they put them back in.(Registered nurse, Unit 6)Otherwise you clash with another therapist when you want to see them and youwaste time.
(Physiotherapist, Unit 8)The net effect of shared timetables was that patients were available for therapy,therapists did not compete for the same time-slot, few sessions were missed and moreminutes could be provided. DiscussionOur findings reveal that a complex array of factors impacts on therapy provision instroke units. These comprise work organisational and patient factors, and theinfluence of national audit requirements. While no single factor explained whypatients with stroke do not receive the recommended amount of therapy, mean timespent in information exchange and other non-patient contact activity took up between1.2 and 6.5 hours per therapist per week. Staffing levels for all disciplines werelower in the stroke units in this study than recommended in the National ClinicalGuideline for Stroke.
Therapists’ limited knowledge of the evidence that increased therapyfrequency and intensity improves outcomes in the first six months post-stroke was anunexpected finding.To our knowledge, ReAcT is the largest and most comprehensive study of factorsinfluencing therapy provision in stroke services. The main strengths are sustained,direct observation of the day-to-day work of almost 200 therapists and 77 patientsacross eight sites providing both hyper-acute services and early hospital-basedrehabilitation, combined with follow-up interviews with therapists, patients andtheir carers ( n = 230). A limitation is that most were located inthe North of England; inclusion of units in other regions may have generateddifferent findings.Although ReAcT was a UK-based study, it is likely that our findings will berecognised by, and prove relevant for therapists, managers and researchers in othercountries where there are national clinical guideline recommendations related toincreasing the frequency and intensity of inpatient post-stroke therapy. Werecognise that provision of face-to-face or small group therapy by therapists isunderpinned by other important activities which collectively contribute tohigh-quality rehabilitation; these include complex discharge planning. Nonetheless,our findings draw attention to routine working practices in stroke units, whichcould be revised to improve efficiency, which might allow increased frequency andintensity of therapy, including supervised practice where that is appropriate.Previous observational studies have reported similar results, with reduced therapycontact time attributed to administrative tasks., In a European comparisonstudy, less therapy was provided in the English unit. ReAcT contextualises the evidence in Clinical Guideline recommendations andupdates and extends the findings from these important earlier studies.
Our findingsindicate that in the last decade, despite major service improvements in acute strokecare in particular, therapists in English stroke units may be spending even moretime in information exchange and administration and providing less therapy thantheir counterparts in comparable countries.Single-centre studies of physiotherapists’ decision-making have consistentlyidentified that as well as individual patient factors, established (local)organisational protocols and working practices are influential in shapingdecision-making. – We identified,in a much larger sample of therapists and stroke units, that therapists’ clinicalreasoning and awareness of the recommendation for 45 minutes of daily therapy weremore influential in shaping therapists’ practice than research evidence forincreased frequency and intensity.Our findings suggest recommendations for therapy frequency and intensity will remainunmet in many stroke units unless radical revision of therapists’ routine workingpractices is undertaken. This should focus on the appropriateness of therapists’current working hours and information exchange activities, meetings and duplicationof documentation to use therapists’ time more efficiently.
Simplifying therapyrecording requirements for national audits and reducing local duplication ofdocumentation would reduce time spent on administration and enable therapists toundertake patient-focused activity. Routine sharing of individualised therapytimetables with patients and stroke unit staff may also be beneficial.
Our studyincluded two high-performing units; both had revised the whole stroke pathwayconsistent with types of changes highlighted above. While staffing levels areclearly part of the equation, these units and others provide examples of stroketeams as a whole (rather than therapists alone) using audit data and qualityimprovement methods to improve stroke care. Targeted education focused onunderstanding the evidence for and importance of increased frequency and intensityis another necessary part of improving post-stroke rehabilitation services.However, wider service reorganisation may be required which will require action andsupport from stroke service management groups. In England, the successful Pan-Londonand Greater Manchester initiatives demonstrate how such changes can be effected atregional level. Similar initiatives focused directly on improving therapy frequency andintensity are also reported in Canada. These initiatives highlight the value of co-ordinated, collaborativeapproaches to maximising the effectiveness of stroke services.
Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respectto the research, authorship and/or publication of this article: A.H. IsProgramme Manager for the SSNAP and provided technical information on SSNAP datacollection and analysis.
SSNAP is funded by the Healthcare Quality ImprovementPartnership on behalf of NHS England. Are members of theIntercollegiate Stroke Working Party who developed the National ClinicalGuideline for Stroke, Fifth Edition 2016.
The authors declare no other financialrelationships with any organisations that might have an interest in thesubmitted work in the previous three years.Funding: The author(s) disclosed receipt of the following financial support for theresearch, authorship and/or publication of this article: This article presentsindependent research funded by the National Institute for Health Research (NIHR)under its Research for Patient Benefit (RfPB) Programme (grant reference numberPB-PG-0213-30019). The views expressed are those of the author(s) and notnecessarily those of the NHS, the NIHR or the Department of Health.Supplement material: Supplement material is available for this article online.ORCID iDs: David J ClarkeLouisa-Jane BurtonSarah F Tyson.