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Staff agreed a static base of HCPs trained specifically in stroke care was one of the strengths of their units. Most staff believed current staffing levels were adequate enough, yet, operated on a fine balance with staff deployment to other areas, illness or leave having an immediate and obvious impact on the ward. Participants, regardless of their experience in AVERT phase III, when asked what they would need in order to implement VEM in real-life, most

frequently stated that they needed an increase in the number of ward staff. The majority of nurses and therapists did not routinely see patients within the first 24 hours of stroke onset so limited by experience hypothesised that higher levels of dependency in this acute timeframe would require more staff to assist in the first mobilisation. There was agreement from all HCPs that to deliver an

increased daily level of mobilisations to patients would certainly require more staff.

“Also the early stages that you are probably talking about more staff again, if the person is more dependent at that stage then so, and you’re doing that maybe throughout the day which could be four, four times or so during the day if they’re able, so, you know, that staffing you literally would have to have staff there in, in those units to be able to, to do that, that are specially trained to do it.”

(ID 31, Occupational Therapist, non-VEM)

There were uncertainties associated with this requirement. Firstly, it was unclear what form these additional resources would take. Respondents found it difficult to speculate what type of worker would be required and how many additional staff members would be required to support VEM.

“Yes, yes, if you, if you’ve got quite a lot of dependent patients and you’ve needed two therapists per patient, or not even therapists, maybe even like assistant staff for technical instructor staff, and then you could potentially need another kind of one to two of each discipline”

(ID 29, Physiotherapist, non-VEM)

Secondly, how these additional resources would be allocated and utilised. The changeability of the types of patients in the unit at any one time in relation to dependency levels and the number of patients for VEM may pose problems.

“So you can’t actually, there’s no point in having an extra member of staff on, because……it might, it might be two weeks before you need them the next time.”

(ID 22, Doctor)

This need for additional staff to support the implementation of VEM was compared to the staff requirements required to deliver another acute stroke intervention (thrombolysis). As opposed to requiring an increase in nursing levels, staff revealed that thrombolysis was achieved within the current staffing compliment.

“You can’t have that kind of resource fail, so it’s just done within the complement, but most of the time, that doesn’t seem to be too much of a problem, and the staff have been very good actually, because, for

instance, if somebody gets thrombolysed late evening, and there aren’t enough staff over the night shift to cover, the day staff stay on.”

(ID 22, Doctor)

The current focus regarding staffing for nurses was more about reinstating

reduced staffing levels to their previous compliment rather than increasing them for the purpose of mobilisation, putting recent financial cuts to staffing budgets into perspective.

“We’re already at the kind of, we’ve… our numbers have dropped even further, so we’re at the point just now where we’re trying to push it back up to where we were before. Erm, I still don’t know that that would follow all that… again, maybe with therapists in at the weekend, that would help us slightly, maybe; I don’t know.”

(ID 30, Nurse, non-VEM)

Staff were aware that while increasing staffing levels would facilitate the delivery of more frequent mobility in the current economic climate of limited resources felt that this was unlikely to happen. Alternatively a more flexible shift pattern for therapists without necessarily increasing staff numbers was suggested. For example, having a back shift to extend the therapy working day would provide a means to support the mobilisations of patients later on in the day.

“Erm, you know, if they’ve got up in the morning, done well, gone back to their beds again, there’s no reason why they couldn’t be getting up

again...So, again, staff working twelve to eight as well...”

(ID 27, Physiotherapist, VEM)

This would provide therapists with a broader perspective about the patient’s mobility and function across the day. The nursing perspective of how a patient was mobilising can be quite different from what the therapy staff may see at selected points in the day i.e. transferring patients back to bed in the evening can be quite different from getting them out of bed in the morning. The majority of staff felt that VEM would require more equipment including specialist stroke chairs, hoists and hoist slings. In some instances when a particular type of chair was not available a flexible approach to alternating seating so as not to prevent the opportunity to get a patient up sitting out-of-bed.

“Er hoists. There's only one hoist on our ward at the moment [voices overlap] so we would need more maybe handling equipment.”

(ID 17, Physiotherapist, non-VEM)

At one hospital, one participant believed that it was the lack of equipment that could pose problems, however another participant viewed a lack of storage as the problem. The data from this focus group is presented below and highlights the strength of the focus group data to provide the opportunity for participants to disagree or provide an alternative viewpoint.

ID 7: “Sometimes we have an issue about appropriate seating in the

ward…well not often….but on occasion you don’t have enough stroke chairs or enough chairs that might be ideal for the patient so we work round that and modify that and swap seating about and things…but there an abundance of that…

ID 5: I would qualify that by saying that we have actually had the chance to a lot more equipment but our problem is that we have no where to store it and following the health inspectorate we even had to move stuff that we had stored…”

(Focus group 2, ID 5: Stroke specialist nurse; ID 7: Occupational therapist;

non-VEM)

Providing therapy cover at weekends was a recurring theme raised by all professional groups, although this did not meet with much enthusiasm from therapy staff. Therapy cover was seen as a facilitator to VEM but also had other advantages by reducing the pressure on the nurses at the weekends and

preventing the backlog of new patients to be assessed at the beginning of the week.

“You would think the ward was quiet at the weekend but it's busier because the patients aren't getting any of the OTs or physios so they are, there are more, they need us more. So we don't get as much time at the weekend as we would do during the week to maybe mobilise them as well.”

(ID 13, Nurse, VEM)

Therapy input at weekends is traditionally provided to patients considered to be at risk of respiratory problems or requiring input prior to discharge. For one unit the physiotherapists had recently secured a priority system for patients to be seen on public holidays. This was an isolated case and an evidence-base for VEM

was seen as one way in which stroke patients would be prioritised for such a service. Staff were uncertain how this would be funded.

“…if anyone in our ward had a respiratory problem that we wanted

weekend cover for that (respiratory care) would be fine, erm, but not for, not for mobilisation, not for any kind of rehab issues, erm, but as you say, orthopaedics do, and that comes out of orthopaedics budget, erm, so I don’t know if that would be, you know, whether it would come out of stroke budget erm, in, in the future that's how they would get.”

(ID 29, Physiotherapist, non-VEM)

Employing a more flexible approach to therapy working hours may accumulate to a six or seven day working week for therapists. Reducing working hours for

therapists Monday to Friday could create scope for therapy weekend cover without having to increase the number of staff.

ID 28: “Yeah, but they could take a wee hour off every day, you’re working Monday to Friday to… make a wee shift on Saturday… and Sunday.

ID 27: I think even a six day service would be good...

ID 27:…because I think everybody does need a rest, but it could be a staggered, somebody gets their rest on a Wednesday.”

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