Organisation norms to change

A number of changes had occurred in stroke care. The organisation of stroke care was regarded as the most valuable change with the establishment of stroke units and provision of a quicker and more streamline service. Other important changes included the introduction of new medical interventions such as

thrombolysis, new protocols for stroke referral and end of life care, improved patient education and a move towards early rehabilitation. Competing priorities would often determine the organisation’s decision to implement a new

intervention. The implications for service and staff outside of stroke care were also raised when discussing changes in stroke care.

“ Erm, took a long time, but it did (adherence to stroke protocol)

eventually come along, medical receiving took it on, but it, it can be hard work sometimes for medical receiving and I, I can see their point of view because they’ve got loads of different things coming in and things.”

(ID 30, Nurse, non-VEM)

The approaches that staff described to introduce change differed. A risk-adverse approach to implementation was displayed by some hospitals, preferring to observe other hospitals’ experiences of implementation first. A gradual and unplanned approach was adopted:

“…creeping services where they just, kind of, started doing it, and then it’s got gradually bigger.”

(ID 22, Doctor)

Other hospitals opted for a more systematic and protocol driven approach. The later often involved rolling out the change from an established centre to a non-participating site. Advantages of this approach included being able to tailor existing protocols to local needs, to diffuse enthusiasm amongst staff and to impart operational knowledge to those that were soon to be undertaking the change. Communicating the details of the change to the staff involved was integral in the planning stage of change. It was frequently mentioned that if staff felt included in the decision to implement and plan for the change they were more likely to come onboard and support it.

“I think the communication aspect of it I think having experienced change elsewhere before as well is like if you don’t have everybody on board with the change, and people don’t understand why the changes are happening, or what, what the changes are going to, erm, what value the changes are going to have, erm, that doesn’t work.”

(ID 30, Occupational Therapist, non-VEM)

There was acceptance that change took time and needed to be managed in parallel with the dynamic nature of healthcare systems making the process even more convoluted.

“…it was kind of shelved for a period of time and whatever, but then obviously other things have happened since then as well like, you know, kind of more even like government wise there’s other things happen in the wider picture, which I think has obviously impacted as well on that and can take it further, but I don’t know where it’s at”

(ID 30, Occupational Therapist, non-VEM)

In some cases the emergence of research evidence had an immediate impact on stroke care. Two physiotherapists recall the day when the results from the ‘Clots in legs or stockings after stroke study’ where published.

ID 27: …“erm, clots was published we were all just, there was a buzz in the ward, erm, it was quite a...”

ID 28: It was literally...

ID 27: strange thing...

ID 28: it was literally the day, wasn’t it?

ID 27: stockings off… [laughing]

ID 28: Erm, it started with one consultant saying… and then we had to wait the next day for the other consultant to come in.... and he was like no, I’m happy as well.”

Paired interview ID 3 (ID 27- Physiotherapist, VEM; ID 28 - Physiotherapist, VEM)

The preference that physiotherapists stated for not using anti-thrombotic stockings was fitting with patient’s low compliance to wearing the stockings. It may be that the implementation of an intervention depends on the level of congruence between the opinion of the individual HCP and the preference of the patient. It should be noted that this extract is an example of discontinuing an

intervention as opposed to implementing a new intervention or changing the way in which an intervention is delivered. This issue of patient preference has

bearing for the implementation of VEM. Staff explained that there were times when patients preferred to remain sedentary as opposed to engaging in therapy or go for a walk. The most common reasons for this is that they were too tired, had a busy day of investigations or it was late in the day and would prefer to be seen in the morning.

“I’m sure most patients would, um, you know, the majority of patients would like more therapy and would benefit from it, but there’ll be some that don’t want any therapy. [Laughs].That’s a different story.”

(ID 13, Nurse, VEM)

The methods that were discussed to monitor the implementation of certain policies included audit, internal process meetings (quality circles), champions, hospital governance groups and regional forums. Some nurses and therapists did not view themselves actively involved in audit regarding this as the responsibility of the organisation. Process meetings were less commonly used than champions with both approaches used by one site during involvement with AVERT phase III.

I: “In terms of Very Early Mobilisation do you think either of these

approaches [use of a champion and quality circles] would be required and if so work?

R: because of the AVERT study both approaches have been used you know particularly discussions about how to make it better but certainly that requires someone to take a hold of it and they did.”

(ID 9, Doctor)

Forum meetings were used more as a platform for information and exchange to enable staff to compare and reflect on the practices of other units. Staff defined a champion as an individual who had a genuine interest in the change and was naturally enthusiastic in driving it forward and had responsibility for cascading new information. The profession of the champion was less important with more emphasis on the individual’s qualities and level of interest as this extract reveals when discussing a VEM champion. This contrasts to the theory that change is usually owned and operated by the discipline most associated with the new intervention as presented i.e. doctors with acute medical interventions

“I don’t know. I think it could be a physiotherapist, it could be a medic, it could be a nurse. If it’s someone who’s enthusiastic and, you know, and quite charismatic really, that’s what makes a difference just to put the point across.”

(ID 10, Doctor)

The champion was seen to have a role in solving problems and maintaining enthusiasm in order to sustain the change. Having one dedicated person overseeing and co-ordinating the process may become onerous or result in the rest of the team developing evasive attitudes towards the change.

“If somebody (a patient) came in, right (name of staff) will get them tomorrow. Tomorrow's not good enough, we want them in today. So I think sometimes with champions, it can work in some instances, but in others you're making it a very one person dependent system, and if that person's not there, nobody else steps up in their place.”

(ID 18, Nurse, VEM)

Therefore, success of the champion approach is reliant on having the organisation onboard and staff having a sense of responsibility.

“…says well it’s their responsibility, but it’s everybody’s responsibility, so that’s the, you know, the only negative thing.”

(ID 30, Occupational Therapist, non-VEM)

The champion role was not solely viewed as an adjunct to one staff member’s role but may emerge by staff collectively sharing experiences. Members of one stroke team visited another unit abroad, renowned for embedding VEM routinely in care, and on return to their own unit felt enthused and empowered to

imparted new knowledge and principles of what they had experience elsewhere.

This was believed to be the driver towards adopting early mobilisation in their practice. The following list of implementation strategies based on the current literature was presented to the HCPs to enquire about the specific use in the implementation of VEM; educational materials, small group education, audit and feedback, support tools i.e. decision making trees, reminders, financial

incentives, revision of professional roles, local opinion leaders. There was no clear consensus regarding the most appropriate for use in the implementation of VEM. Education and revision of professional roles were met with most

enthusiasm. Reservations were attached to feedback unless it was delivered in

an unthreatening manner and financial incentivises were believed to be unnecessary and unrealistic.

Provider characteristics

The themes within this category describe who is involved in mobilising the patient for the first time after stroke and providing subsequent mobilisation practice. The themes that are covered are as follows:

• Defining the providers

• Decision making

• Confidence and experience in stroke care

• Perceived risks and benefits

• Training and knowledge requirements

• Individuals’ attitudes to change

The factors that influence the provider’s decision making are identified. The provider’s perceived benefits of VEM and the value of these benefits to patients are outlined. The levels of enthusiasm for VEM were assessed including the steps that individual staff members take to appraise the impact a new set of practices has on their role.