The analysis process

The LoTS care trial considered outcome measures completed by the patient and carer participants. This study considered the changes in service delivery expected through the provision of new resources and training i.e. the outputs that if realised might impact on the patient and carer outcomes. The outputs were explored in two ways 1) by comparing the implementation activities performed in day-to-day practice against those anticipated by the intervention architects, and 2) by testing two CMO propositions. Data from the observations, interviews and service documents reviewed were brought together to provide a detailed account of the extent to which the system of care produced the desired outputs i.e. enhanced service practice.

Data from observations and informal discussions were organised into frameworks at two levels, 1) the service and 2) the Coordinator. At the service level the analysis framework categorised contextual differences in the structure and organisation of the teams e.g. their eligibility criteria, the allocation of the Coordinator role, the number of stroke reviews performed and details of the assessment tools used prior to the LoTS care system of care. This framework also recorded details of how the LoTS care components had been embedded in service practice established through observations. These areas are described further in chapter five. At the Coordinator level the frameworks highlighted the professional’s background and experience, and details of their assessment observed e.g. their use of the client checklist, assessment booklet, the LoTS care manual and their approach/ interaction with the service user.

Interview data was organised separately. A tentative analysis framework was developed based on the questions guiding the research, and the theories of change prioritised for investigation. For example, ‘the implementation process’ was an overarching theme within which a further three sub-themes were identified from the theory elicitation process; ‘provision of reviews’, ‘monitoring processes’, and ‘care planning’. The themes and sub-themes were refined, where necessary, through data collection and allocated codes. The codes were then applied to the transcripts and

the coded chunks were cut and paste into a data matrix developed using Microsoft Word.

The frameworks organised the data and facilitated the exploration of themes within and across each case. The analysis process compared the theories of change prioritised for investigation (described further in chapter four) against service practice. The implementation of the system of care was examined first. Data from observations and informal discussion during fieldwork quickly revealed that the services’ monitoring and review processes differed from the expectations of the LoTS care team (these findings are described in detail in chapter six). Interview data provided evidence that explained the observations and supported the informal explanations provided during fieldwork. The different sources were used to describe how and why the implementation of the system of care differed from the expectations of the intervention architects. This analysis provided insight into the extent to which the system of care enhanced the amount and type of contact provided to the service user by the Coordinator.

The realist propositions explored focused on the extent to which the system of care promoted evidence base service responses and a comprehensive post-stroke assessment (clarified in chapter four). The first step in the analysis process was to establish the extent to which these outputs were realised in practice. Data from the LoTS care assessment booklet provided some insight into this. The assessment booklets recorded whether an assessment domain had been addressed, the type of problems identified by the Coordinator, and the service response employed. The data revealed whether the Coordinators had documented a comprehensive assessment (according to criteria established by the LoTS care team) and the extent to which their service responses adhered to or deviated from the recommendations in the LoTS care manual.

Establishing the extent to which the outputs of interest were realised in practice, the next point of inquiry was whether these linked to the hypothesised causal mechanisms underpinning the intervention. Observational data provided insight into the extent to which the LoTS care components were used in day-to-day practice and

for what purpose. Interview data provided insight into the extent to which the Coordinators felt they had been informed by the system of care’s components, which was not observable. This part of the analysis was undertaken with consideration of the particular contexts (service and Coordinator level) that were thought to trigger the desired mechanisms i.e. to refine the starting CMO proposition.

The multiple methods provided a detailed account of how the system of care was implemented in practice, the influence its components exerted on the Coordinators practice and the extent to which these factors represented an enhancement in service practice. The preliminary analysis was discussed with the Coordinators as part of respondent validation. Extracts from the focus group discussions are presented in boxes throughout the thesis and were used to elaborate upon the findings from the initial stages of fieldwork.

3.14.1 Interpreting trial outcomes

Exploring the implementation of the system of care and the mechanisms of change provided insight into the contribution it made to the outcomes measured as part of the LoTS care trial. This provides: ‘an increased understanding of why observed results have occurred (or not) and the roles played by the intervention and other factors’ (Leeuw and Vaessen, 2009). The role of the system of care in identifying and addressing post-stroke problems was reflected upon in each of the findings chapters.

3.15 Summary

This chapter has described the methodology and methods used to answer the research questions. An overview of the methodology is provided in figure 8 below, for clarification. To address some limitations in the trial design a theory-driven approach was applied drawing on the principles of realist evaluation. The aim was to examine the implementation of the system of care in context and whether the system generated changes that enhanced service delivery. Two services were

selected as case studies based on the premise of maximum variation, and multiple methods were employed to provide a detailed account of the complex processes under examination. The study was small and focused on a set of sub-theories prioritised for investigation from the wider theory of change; these are clarified in the following chapter.

Figure 8: Methodology Overview

Theory  refinement  

What  has  worked,  for  whom,  how  and  in  what  circumstance   Respondent  valida7on:  findings  discussed  with  par7cipants   Individual  Feedback     Focus  Group  Disucssion  

Preliminary  analysis  

Framework  approach  used  to  organise  data  and  facilitate  analysis  process   Theory  tes7ng:  Methods  

 Observa7ons  of  prac7ce   Document  Review   Interviews     Theory  tes7ng  performed  at  two  interven7on  sites  (case  studies)  

Case  studies  chosen  based  on  varia7ons  in  service  context  and  pragma7c  considera7ons   Theory  elicita7on