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Thayabaranathan T, Immink MA, Hillier S, Stolwyk R, Andrew NE, Stevens P, Kilkenny MF, Gee E, Carey L, Brodtmann A, Bernhardt J, Thrift AG, Cadilhac DA. Co-Designing a New Yoga-Based Mindfulness Intervention for Survivors of Stroke: A Formative Evaluation. Neurol Int 2021; 14:1-10. [PMID: 35076591 PMCID: PMC8788460 DOI: 10.3390/neurolint14010001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/19/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Movement-based mindfulness interventions (MBI) are complex, multi-component interventions for which the design process is rarely reported. For people with stroke, emerging evidence suggests benefits, but mainstream programs are generally unsuitable. We aimed to describe the processes involved and to conduct a formative evaluation of the development of a novel yoga-based MBI designed for survivors of stroke. We used the Medical Research Council complex interventions framework and principles of co-design. We purposefully approached health professionals and consumers to establish an advisory committee for developing the intervention. Members collaborated and iteratively reviewed the design and content of the program, formatted into a training manual. Four external yoga teachers independently reviewed the program. Formative evaluation included review of multiple data sources and documentation (e.g., formal meeting minutes, focus group discussions, researcher observations). The data were synthesized using inductive thematic analysis. Three broad themes emerged: (a) MBI content and terminology; (b) manual design and readability; and (c) barriers and enablers to deliver the intervention. Various perspectives and feedback on essential components guided finalizing the program. The design phase of a novel yoga-based MBI was strengthened by interdisciplinary, consumer contributions and peer review. The 12-week intervention is ready for testing among survivors of stroke.
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Affiliation(s)
- Tharshanah Thayabaranathan
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC 3168, Australia; (M.F.K.); (A.G.T.); (D.A.C.)
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Correspondence: ; Tel.: +61-3-8572-2646; Fax: +61-3-9902-4245
| | - Maarten A. Immink
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia;
| | - Susan Hillier
- IIMPACT, Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia;
| | - Rene Stolwyk
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC 3800, Australia
| | - Nadine E. Andrew
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Peninsula Clinical School, Monash University, Frankston, VIC 3199, Australia
| | | | - Monique F. Kilkenny
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC 3168, Australia; (M.F.K.); (A.G.T.); (D.A.C.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3052, Australia
| | - Emma Gee
- Survivor of Stroke, Inspirational and Motivational Speaker, Cotham, VIC 3101, Australia;
| | - Leeanne Carey
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3052, Australia
| | - Amy Brodtmann
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3052, Australia
| | - Julie Bernhardt
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3052, Australia
| | - Amanda G. Thrift
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC 3168, Australia; (M.F.K.); (A.G.T.); (D.A.C.)
| | - Dominique A. Cadilhac
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC 3168, Australia; (M.F.K.); (A.G.T.); (D.A.C.)
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Heidelberg, VIC 3084, Australia; (R.S.); (N.E.A.); (L.C.); (A.B.); (J.B.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3052, Australia
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Fisher RJ, Chouliara N, Byrne A, Cameron T, Lewis S, Langhorne P, Robinson T, Waring J, Geue C, Paley L, Rudd A, Walker MF. Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.
Objectives
To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.
Design
A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.
Setting and interventions
Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.
Participants
Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.
Data and main outcome
Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.
Results
A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.
Limitations
Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.
Conclusions
The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.
Trial registration
Current Controlled Trials ISRCTN15568163.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca J Fisher
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Adrian Byrne
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Trudi Cameron
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Justin Waring
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Claudia Geue
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Anthony Rudd
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Marion F Walker
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
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Langhorne P, Audebert HJ, Cadilhac DA, Kim J, Lindsay P. Stroke systems of care in high-income countries: what is optimal? Lancet 2020; 396:1433-1442. [PMID: 33129394 DOI: 10.1016/s0140-6736(20)31363-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/31/2020] [Accepted: 06/09/2020] [Indexed: 01/19/2023]
Abstract
Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Royal Infirmary, Glasgow, UK.
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dominique A Cadilhac
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
| | - Joosup Kim
- Monash University, Department of Medicine, School of Clinical Sciences at Monash Health, Clayton, VIC, Australia
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Chouliara N, Fisher R, Crosbie B, Guo B, Sprigg N, Walker M. How do patients spend their time in stroke rehabilitation units in England? The REVIHR study. Disabil Rehabil 2019; 43:2312-2319. [PMID: 34315309 DOI: 10.1080/09638288.2019.1697764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM To examine how patients spend their time in stroke rehabilitation units in England. METHODS We recruited 144 patients within a month after stroke from four stroke rehabilitation units and observed their activity type, interactions and location. Each participant was observed for 1 min every 10-minutes, for a total of 20 h, over three consecutive days. Multilevel modelling was performed to assess differences across sites. RESULTS Across the four sites a total of 12,248 observations were performed. Patients spent on average 37% of the observed time inactive and 60% alone. A health care professional was present for 18% of the observations and patients' most frequent contact was with family members (19%). Patients were mainly physically active in the presence of therapists, but they practiced self-care activities of daily living most frequently in the presence of nursing staff. There were limited opportunities for activity away from the bedside. Significant differences were found between the units, including patients' level of contact with rehabilitation assistants and nursing staff, but not in their time with occupational therapists and physiotherapists. CONCLUSIONS Stroke patients in England spend a large proportion of their day inactive and alone. Opportunities to promote a rehabilitation focused environment may include: a) enhancing the role of rehabilitation assistants, b) supporting nursing staff in maximising opportunities for the practice of activities of daily living and c) involving family members in the rehabilitation process.IMPLICATIONS FOR REHABILITATIONClinicians need to consider stroke patients' activity levels and rehabilitation experience outside formal therapy.The role of rehabilitation assistants and nursing staff can be key in promoting patient activity and practice of self-care ADL tasks.Pragmatic strategies to encourage family involvement in the rehabilitation process need to be developed.
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Affiliation(s)
- Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rebecca Fisher
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Brian Crosbie
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Boliang Guo
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingha, UK
| | - Nikola Sprigg
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Marion Walker
- Division of Rehabilitation, Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
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Purvis T, Middleton S, Craig LE, Kilkenny MF, Dale S, Hill K, D'Este C, Cadilhac DA. Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread. Implement Sci 2019; 14:87. [PMID: 31477125 PMCID: PMC6721322 DOI: 10.1186/s13012-019-0934-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the Quality in Acute Stroke Care (QASC) trial undertaken in stroke units (SUs) located in New South Wales (NSW), Australia (2005-2010), facilitated implementation of a nurse-led care bundle to manage fever, hyperglycaemia and swallowing (FeSS protocols) reduced death and disability for patients with stroke. We aimed to determine subsequent adherence to the bundled FeSS processes (reflective of the protocols) between 2013 and 2017 in Australian hospitals, and examine whether changes in adherence to these processes varied based on previous participation in the QASC trial or subsequent statewide scale-up (QASCIP-Quality in Acute Stroke Care Implementation Project) and presence of an SU. METHODS Cross-sectional, observational study using self-reported organisational survey and retrospective clinical audit data from the National Acute Services Stroke Audit (2013, 2015, 2017). Mixed-effects logistic regression was performed with dependent variables: (1) composite outcome measure reflecting compliance with the FeSS protocols and (2) individual FeSS processes, including the year of audit as an independent variable, adjusted for correlation of outcomes within hospital. Separate models including interaction terms between the year of audit and previous participation in QASC/QASCIP and year of audit and SU were also generated. RESULTS Hospital participation included the following: 2013-124 hospitals, 3741 cases; 2015-112 hospitals, 4087 cases; and 2017-117 hospitals, 4192 cases. An 80% increase in the odds of receiving the composite outcome in 2017 compared to 2013 was found (2013, 30%; 2017, 41%; OR 1.8; 95% CI 1.6, 2.0; p < 0.001). The odds of FeSS adherence from 2013 to 2017 was greater for hospitals that had participated in QASC/QASCIP relative to those that had not (participated OR 2.1; 95% CI 1.7, 2.7; not participated OR 1.6; 95% CI 1.4, 1.8; p = 0.03). Similar uptake in adherence was evident in hospitals with and without an SU between 2013 and 2017. CONCLUSION The use of the FeSS protocols within Australia increased from 2013 to 2017 with the inclusion of these care processes in the National Audit. Greater uptake in hospitals previously involved in QASC/QASCIP was evident. Our implementation methods may be useful for other national initiatives for improving access to evidence-based practice.
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Affiliation(s)
- Tara Purvis
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, Victoria, 3168, Australia.
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne, Sydney, New South Wales, Australia.,School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia
| | - Louise E Craig
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne, Sydney, New South Wales, Australia.,School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia.,Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, Victoria, 3168, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne, Sydney, New South Wales, Australia.,School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, New South Wales, Australia
| | - Kelvin Hill
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.,Stroke Foundation, Melbourne, Victoria, Australia
| | - Catherine D'Este
- National Centre for Epidemiology and Population Health, Research School of Population Health, ANU College of Health and Medicine, Canberra, Australian Capital Territory, Australia.,School of Medicine and Public Health, University of Newcastle, Sydney, New South Wales, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Level 3, Hudson Institute Building, 27-31 Wright Street, Clayton, Victoria, 3168, Australia.,Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia
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