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Evaluation of pilot implementation of the Chronic Stroke Resource Kit
August 2014
Draft report
i
Table of Contents
Project Contributors....................................................................................................................... iii
Contact details for information about this report ................................................................ ii
Acknowledgements ......................................................................................................................... ii
Executive Summary ........................................................................................................................ iii
Introduction ....................................................................................................................................... 1
Background ........................................................................................................................................ 1
Aims ....................................................................................................................................................... 4
Methods................................................................................................................................................ 5
Study Design .................................................................................................................................................. 5
Setting ............................................................................................................................................................... 5
Participants .................................................................................................................................................... 6
Measures ......................................................................................................................................................... 6
Data Collection .............................................................................................................................................. 8
1. Clinician surveys ............................................................................................................................ 8
‘Train the trainer’ day ........................................................................................................................... 8
2. Stroke survivor and carers ........................................................................................................ 9
Audit of the Resource Kit review assessment and therapies and services received by
stroke survivors ....................................................................................................................................... 9
Survey of stroke survivors .................................................................................................................. 9
3. Focus group interview of stroke survivors and carers ............................................... 10
Data Management ..................................................................................................................................... 10
Data Analysis .............................................................................................................................................. 11
Survey and audit data......................................................................................................................... 11
Focus group data analysis ................................................................................................................ 11
Ethical Review ............................................................................................................................................ 12
Privacy ........................................................................................................................................................... 12
Results ................................................................................................................................................12
‘Train the trainer’ day ............................................................................................................................. 12
Clinician views on the format, content and useability of the Resource Kit ...................... 17
Audit of the utilisation of assessment and intervention components of the Resource
Kit .................................................................................................................................................................... 20
Survey of stroke survivors .................................................................................................................... 24
Focus group interview of stroke survivors and carers ............................................................. 26
Discussion .........................................................................................................................................28
References.........................................................................................................................................31
ii
Appendices
1. Chronic Stroke Resource Kit
2. Train the trainer day pre and post surveys
3. Data collection form for stroke survivors
4. Survey monkey questionnaire for clinicians
5. Long form comprehensive review assessment
6. Short form comprehensive review assessment
7. Stroke Survivor surveys
8. Consent forms
9. Summary of Assessment form findings
iii
Project Contributors
Affiliations of investigators and project staff 1 Physiotherapy Department, St Vincent’s Hospital, Melbourne. 2 Translational Public Health Unit, School of Clinical Sciences at Monash Health,
Monash University.
3 Public Health: Stroke Division; Florey Institute of Neuroscience and Mental
Health.
Project conceptulisation
Brock, K1
Birnbaum, M1
Graven, C
Project coordination Brock, K1
Birnbaum, M1
Ethics preparation Brock, K1
Birnbaum, M1
Cadilhac, D2,3
Purvis, T2 Development of the ‘train the trainer’
education session Brock, K1
Birnbaum, M1
Cadilhac, D2,3
Purvis, T2
Development of the ‘train the trainer’
evaluation tool
Brock, K1
Birnbaum, M1
Cadilhac, D2,3
Purvis, T2
Development of survey and database for
utilisation of assessment and
intervention components Brock, K1
Birnbaum, M1
Cadilhac, D2,3
Purvis, T2
Development of the focus group interview
schedule
Brock, K1
Birnbaum, M1
Cadilhac, D2,3
Purvis, T2
Moss, K3
Facilitation of focus group
Purvis, T2
Moss, K3
Data analysis
Purvis, T2
Moss, K3
Black, S1
Report compilation and editing
Purvis, T2
Moss, K3
Cadilhac, D2,3
Brock, K1
Birnbaum, M1
ii
Contact details for information about this report
St Vincent’s Physiotherapy Department
PO BOX 2900
Fitzroy, Victoria 3065
Ph: (03) 9288 2211 (page 947) Fax: (03) 9288 3825
Email: [email protected]
No part of this report may be reproduced without prior written permission from
Dr Kim Brock, St Vincent’s Physiotherapy Department. Any direct reference to
this work must be appropriately acknowledged.
Suggested citation: Brock K, Birnbaum M, Graven C, Purvis T, Moss K, Cadilhac
D (2014) Evaluation of the pilot implementation of the Chronic Stroke Resource
Kit. Department of Health, Victoria.
Acknowledgements
This project was supported by a grant from the Victorian Stroke Clinical Network
(VSCN).
We would like to thank the clinicians and the stroke survivors and their carers
who participated in the project.
We also acknowledge Megan Reyneke (Monash University) for her input with the
Access database and Genevieve Agostenelli for assistance with data collation.
iii
Executive Summary
The Chronic Stroke Resource Kit (Resource Kit) is a tool for health care clinicians
working in community settings to facilitate review and management of stroke survivors
and carers in the chronic phase (ie. more than six months) following stroke. Evidence
based guidelines were developed under ten specific domains, such as participation,
functional limitations and decline, mood status, carer support and goal setting. For each
domain, the Resource Kit includes a process for interdisciplinary review, identification
of “flags” indicating a need for intervention, and a summary of evidence based
intervention options and management plans. In Victoria, there are well established
community health resources in both community rehabilitation services, funded through
Subacute Ambulatory Care Services, Department of Health, Victoria and Community
Health Centres. Within these centres, there are allied health and nursing practitioners
who are well placed to implement recommendations for stroke survivors and their
caregivers. However, education and support is limited for clinicians undertaking this
role. The purpose of the Resource Kit is to facilitate these community organisations to
provide high quality care for stroke survivors in the chronic phase of recovery. In the
current project, a pilot implementation of the Resource Kit was conducted, inclusive of
evaluation from key stakeholders; clinicians who utilised the tool and stroke survivors
and their carers who participated in the assessment processes. The results of the
evaluation will be utilised for further development of the Resource Kit and to determine
the feasibility of state-wide implementation of the Kit.
Methods: The study was conducted at eight sites, including metro and rural services
and community rehabilitation and community health services. Two groups of
participants were involved: stroke survivors and carers; and allied health and nursing
clinicians providing community based services. Clinicians participated in “train the
trainer” workshops, provided feedback on use of the Resource Kit with individual stroke
survivors, and completed questionnaires about their experiences with the Kit. Stroke
survivors participated in comprehensive review assessments and completed
questionnaires about their experiences. A focus group of stroke survivors was
conducted. Data regarding interventions being delivered to stroke survivor participants
before and during the project were collected.
Results: Data were received from 22 clinicians and 37 stroke survivors. Clinicians found
that the Resource Kit was useful and they would recommend it to other clinicians.
Stroke survivors agreed that the domains included in the Kit were important to them.
Both clinicians and stroke survivors supported the use of the comprehensive review
assessment, with clinicians indicating that it focused attention on areas of importance to
the stroke survivor. Clinicians reported increased confidence in exploring alterations in
mood and participation in valued activities with stroke survivors. The pilot
implementation did not show increased uptake of evidence based interventions
provided by community services. Areas identified for further development of the
Resource Kit include a greater focus on emotional changes after stroke and adjustment
to major life changes; community access to services; and issues about sexuality or
intimacy. Further research should focus on ways to improve access to evidence based
care for chronic stroke survivors living in the community.
1
Introduction
The Chronic Stroke Resource Kit (Resource Kit) is a tool for health care clinicians
working in community settings to facilitate comprehensive interdisciplinary
review and management of stroke survivors and carers following stroke. The
Resource Kit represents a summary of current evidence-based practice in
rehabilitation for the assessment, treatment, and overall management of chronic
stroke survivors. Guidelines for assessment and management were developed
under specific domains, such as participation, functional limitations and decline,
mood status, carer support and goal setting. The Resource Kit was developed by
a team of clinicians at St Vincent’s Hospital,Melbourne (SVHM), with additional
input from external experts and consumer representatives, and was funded by
the Victorian Stroke Clinical Network (VSCN). The purpose of the Resource Kit is
to facilitate community organisations to provide high quality care for stroke
survivors in the chronic phase of recovery, ie. more than six months post stroke.
Preliminary testing of selected individual components occurred as part of the
development of the Resource Kit. The purpose of this project was to detail the
pilot implementation and evaluation of the tool in community settings across
Victoria between January 2013 and May 2014.
Background
In Australia, stroke is a leading cause of long-term, permanent disability. In 2003,
more than 140,000 Australians were living with a disability as a result of their
stroke [1]. Most stroke survivors live at home, with half of these individuals
requiring assistance to complete some aspects of their daily life, such as
household chores, home maintenance and transport [1]. Informal carers provide
most of the assistance required for these, and many other activities. Given the
incidence of stroke is increasing due to an ageing population, and that close to 20
percent of all strokes occur in people under 55 years old, the need to optimise
the recovery of people with stroke is clear [2].
The initial acute and subacute phases post stroke usually involve an intensive
rehabilitation period that may include inpatient and outpatient based
rehabilitation, with improved outcomes evident if evidence based
recommendations for rehabilitation are followed [3]. As outlined in the Victorian
Stroke Care Strategy, on returning home, stroke survivors and their carers often
experience an intense and difficult lifestyle adjustment as they attempt to
resume their former way of living [4]. In the chronic phase of stroke, a high level
of unmet needs has been identified, with a recent Australian study providing
evidence that 84% of stroke survivors report unmet needs, with younger age and
higher disability levels being associated with greater unmet needs [5]. Lack of
access to community-based services and programs may be an important factor in
2
explaining the reported levels of unmet need. This is because stroke survivors
need to adjust to lifestyle changes and their loss of independence while
attempting to maximise their community reintegration and return to a healthy
and active lifestyle. There is also evidence that the needs of stroke survivors in
the chronic phase can change over time, particularly with regard to functional
decline [6,7].
Individuals who have had a stroke should have a review by a healthcare clinician
with expertise in stroke at least three, six, and twelve months after discharge
from hospital, with at least one review by a specialist medical practitioner [8,9].
The Australian Clinical Guidelines for Stroke Management recommend annual
reviews for people with ongoing impairments in order to determine current
health status and the merits of further intervention [8]. In addition, the person
who has had a stroke and their family/carer should have access to the details of a
relevant health care clinician who can act as a contact person within the
community setting [8].
In Victoria, we have well established community health resources in both
community rehabilitation services, funded through Subacute Ambulatory Care
Services, Department of Health, Victoria and Community Health Centres. Within
these centres, there are allied health and nursing practitioners who are well
placed to implement recommendations for stroke survivors and their caregivers.
However, education and support is limited for clinicians undertaking this role.
The Resource Kit (Appendix 1) was designed as an evidence based tool,
specifically to educate community based clinicians on the main issues for stroke
survivors. Key areas of focus are the risk of post stroke depression, indicators of
functional decline, and the need for a goal orientated and holistic approach to
enhance long term recovery and participation in valued life activities. The
Resource Kit includes a process for comprehensive interdisciplinary review for
10 domains (see Table 1); identification of “flags” indicating a need for
intervention; and a summary of evidence based intervention options and
management plans for each domain. The Resource Kit also includes
documentation options to provide stroke survivors and their carers with a
written summary of issues and personal goals identified and formats to promote
communication between clinicians, including general medical practitioners.
3
Table 1: Domains of the Chronic Stroke Resource Kit
Domain
Participation
Functional limitations and decline
Minimising risk of falls
Communication
Cognition
Mood Status / Depression
Health-related quality of life
Secondary stroke prevention and risk factor management
Carer support
Goal setting
The Resource Kit was developed by a team of clinicians at SVHM, funded by a
competitive grant through the VSCN in 2012. Input from external experts was
included, particularly in the areas of depression, falls and carer support.
Consumer representatives were involved in all stages of development. The
Subacute Committee of the VSCN were pivotal in review and refinement of the
Resource Kit. The Resource Kit has been presented at a number of professional
meetings, including workshops at events for clinicians sponsored by the VSCN,
and feedback from these sessions was incorporated into the Resource Kit. Key
assessment components of the Resource Kit relating to depression and
participation were pilot tested during development. However, no pilot testing of
the completed Resource Kit was undertaken prior to this project.
Project objective
The purpose of this project was to conduct a pilot implementation of the
Resource Kit, inclusive of evaluation from key stakeholders; clinicians utilising
the tool and stroke survivors and their carers who participate in the assessment
processes. Through this evaluation it is anticipated that further development of
the Resource Kit will be facilitated, and that the feasibility of state-wide
implementation to use the Resource Kit to improve management of chronic
stroke survivors will be determined.
Key issues for implementation and evaluation
The Resource Kit has a broader aim than provision of information. A main
intention in the development of the Resource Kit was to promote a culture shift
in community services. This was particularly around perceptions of the potential
of rehabilitation type activities to enhance the lives of stroke survivors and
carers in the chronic phase after stroke. There is a considerable body of evidence
4
to support the benefits of rehabilitation activities during the chronic phase (see
Appendix 1), but there are few indications of translation of this evidence into
clinical practice. The second main intention was to promote holistic care,
particularly with regard to stroke survivors and carers pursuing their personal
goals including the return to valued activities, thus driving the recovery process.
The third main intention was to assist clinicians to promote self efficacy and self
management during engagements with clients.
To promote a culture shift, it was required to consider the mode of
implementation. The Resource Kit is a 47-page document, inclusive of
assessment forms. Although the document is designed for easy navigation and
has a reader friendly layout, we were concerned that use of the Resource Kit may
be restricted to utilising the assessment formats only, with occasional reference
to the evidence based information. This would be unlikely to achieve the desired
culture shift. Therefore, the implementation was designed to include a “train the
trainer” module to ensure a focus on achieving the stated intentions.
It was also important to capture the views of stroke survivors and carers
regarding their participation in comprehensive assessments and any goal
directed rehabilitation activities that may have resulted from the assessment.
We wanted to identify whether the domains considered in the Resource Kit
represented areas of concerns for consumers and whether the process of
assessment, was considered a useful experience.
With regard to clinicians involved in the implementation, we sought to capture
their views on the provision of care for chronic stroke survivors and carers in
Victoria, as well as feedback on the structure and contents of the Resource Kit.
We also sought to identify whether use of the Resource Kit improved knowledge
and confidence in dealing with recovery and reintegration issues for stroke
survivors, such as depression.
The planning of the implementation project was greatly facilitated by the
interest shown by allied health and nursing clinicians during the development of
the Resource Kit. Conducting presentations and workshops at professional
meetings gave us an opportunity to invite those present to provide an email
contact if they were interested in the further development of the Resource Kit.
This email list enabled us to identify clinicians and health services who were
prepared to trial the Resource Kit and participate in these evaluation activities.
Aims
The primary aim of the project was to obtain consumer and clinician
feedback regarding the content and processes of the Resource Kit, to guide
5
revisions to better meet the needs of consumers and clinicians. For
consumers, we sought their input on the appropriateness of the review
assessment; whether it covered the domains of interest for them, and the
quality of the experience of participating in the assessment. For clinicians,
we sought their input on the structure and content of the Resource Kit and
the utility of the review assessment.
Secondary aims were:
a) To describe clinician perceptions of current service provision in the
community for stroke survivors and their carers; and their
perceived competence in managing chronic stroke survivors.
b) To determine whether use of the Resource Kit improved clinician
knowledge and confidence in their ability to deliver a
comprehensive assessment and plan interventions for stroke
survivors and their carers.
c) To determine whether participation in a review assessment resulted
in changes to management of stroke survivors and carers.
Methods
Study Design
This project was based primarily on data from a prospective audit of review
assessments and related service utilisation by stroke survivors and carers.
Additionally, questionnaires for stroke survivors, carers and clinicians at varying
time points were undertaken, and a focus group was conducted with stroke
survivors and carers.
Setting
This study was conducted at eight sites, five metropolitan sites and three rural
sites. Five sites were community rehabilitation services (four metropolitan, one
rural), one site was a metropolitan community health service and one site was a
rural health service. The remaining site was a rural stroke care liaison service.
Key clinicians from each of these sites had indicated their interest in the
Resource Kit project prior to the commencement of the study and responded to a
group email asking for volunteers to participate in a pilot implementation of the
Resource Kit.
6
Participants
Two groups of participants were involved in this study: stroke survivors and
carers; and clinicians providing community based services to stroke survivors.
Stroke survivor and carer participants
Stroke survivors who were six months or more post stroke and attended the
participating sites were invited to participate. Prospective participants may have
been already attending the site when the study was commenced or commenced
at the sites at a later date. Sites were encouraged to include all those who met the
selection criteria. However, no registers were kept and the sample should be
viewed as a convenience sample. Clinicians were also encouraged to invite carers
to participate.
Stroke survivors and carers who attended either the SVHM Community
Rehabilitation Centres or Inner East Community Health Service were invited to
participate in the focus group.
Clinicians
Clinicians from allied health disciplines and nurses working at the participating
sites were eligible to participate in the study. Three modes of participation were
available for clinicians.
a) Clinicians who attended the introductory one day “train the trainer”
module at SVHM completed pre and post questionnaires. Each
participating site was encouraged to enroll two clinicians in this training
day.
b) Clinicians who conducted the review assessments at the sites were
invited to provide feedback on the utility of the assessment for individual
stroke survivors.
c) Clinicians who conducted the review assessments were invited to
complete a questionnaire about the utility of the Resource Kit at the
completion of the project.
Some clinicians may have participated in all three of these modes. Those who
attended the “train the trainer” day were tasked with orientating other
interested members of staff to the project, who may then have participated in
modes b) or c).
Measures
The measures in this study included information collected in audit, through
questionnaires and in the focus group. A summary of the measures for stroke
7
survivors and carers and clinicians is provided in Table 2. Figure 1 provides an
overview of the study design and evaluation methods.
Table2: Summary of measures Participants Measure Data type Stroke survivors & carers
Patient demographics and resource utilisation form
Quantitative
Chronic Stroke Assessment Forms
Quantitative & Qualitative
2 week stroke survivor and carer questionnaire
Quantitative & Qualitative
8 week stroke survivor and carer questionnaire
Quantitative & Qualitative
Focus group data
Qualitative
Clinicians Train the Trainer day pre and post questionnaires
Quantitative & Qualitative
Comments on assessments of individual stroke survivors
Qualitative
Survey monkey questionnaire at completion of the study
Quantitative & Qualitative
‘Train the trainer’ workshop
Pre and post survey of clinicians attending workshop to assess change in knowledge, and confidence in managing chronic stroke survivors and feedback on the workshop
Implementation- clinicians using Resource Kit assessment on chronic stroke survivors in community health settings
Clinicians conducted comprehensive screening assessments with stroke survivors/carers, recorded information about services/therapies survivors were receiving prior to the assessment and then at the end of the episode of care at the health service, and also provided comment about the utility of the Resource Kit for that individual
Focus Group with stroke survivors and carers at the end of the implementation period
Clinician survey completed at the end of the implementation period regarding the useability of the Resource Kit
Stroke survivor survey at 2 weeks post assessment, then 8 weeks post assessment
Evaluation of Resource Kit assessment
8
Figure 1: Overview of the study design and evaluation methods
Data Collection
A mix of quantitative and qualitative methods were used within a pre-post
evaluation design. The methods below outline these modalities in further detail.
1. Clinician surveys
As mentioned clinicians were asked to complete surveys at various time points
during the evaluation. These are further summarised below.
‘Train the trainer’ day
Clinicians who attended the ‘train the trainer’ day were asked to complete a
paper-based survey at the beginning (pre) and then at the end of the training
session (post) (Appendix 2). Surveys were de-identified, and an individual
identifying number was generated for each clinician to be used on both pre and
post surveys. Both open and closed questions were included. The initial baseline
(pre) survey captured basic demographic data, as well as quantitative
information regarding clinician’s beliefs and knowledge about the current care
they provide for chronic stroke survivors. Also included were closed questions
with various scales of response to rate the confidence of clinicians in managing
and treating patient with chronic stroke. The post survey administered at the
end of the training session included similar questions on knowledge and the
current care for chronic stroke survivors, and clinician confidence in managing
and treating issues associated with chronic stroke survivors. Feedback on the
content, presentation and usefulness of the training day itself was also elicited.
Open-ended questions were also included to capture additional information the
clinicians’ wanted to share on the training day.
Clinicians who used the Resource Kit in the community setting
Clinicians were provided with the opportunity to respond to open-ended
questions at completion of the data collection for each patient (Appendix 3)
regarding the usefulness of the Resource Kit for that individual patient; whether
it led to a change in focus or management, and suggested improvements to the
Resource Kit.
All clinicians who used the Resource Kit during the implementation phase were
also asked to complete an online survey via SurveyMonkey
(http://www.surveymonkey.com) to provide feedback on the format, content
and usability of the Resource Kit. The survey was completed by clinicians at the
end of the implementation phase. In addition to demographic information about
the clinician, quantitative data regarding clinician confidence in managing and
treating patients with chronic stroke both before and after using the Resource
9
Kit were collected. Open-ended questions were also included to capture any
additional information about clinician’s views on the useability of the Resource
Kit (Appendix 4 ). All data were de-identified.
2. Stroke survivor and carers
Audit of the Resource Kit review assessment and therapies and services received by stroke survivors
All stroke survivor participants in the project had a Resource Kit comprehensive
review assessment at the commencement of their involvement in the project.
The findings of this assessment were recorded on either the Long Form of the
Assessment (Appendix 5) or the Short Form of the Assessment (Appendix 6),
according to the assessing clinician’s preference. In addition, clinicians recorded
therapies and/or services stroke survivors were receiving at the initial contact
point, and again at the end of the episode of care at the health service, or at the
eight week post assessment review in the Resource Kit, whichever occurred first
(Appendix 3).
Investigators also made regular contact with each site to check the progress and
offer further assistance in using the Resource Kit, as required.
Survey of stroke survivors
Stroke survivor participants who received the Resource Kit assessment were
asked to complete two paper-based surveys (Appendix 7). The first was sent two
weeks after their Resource Kit assessment to obtain their views of this
assessment. Like the post audit, the second stroke survivor survey was
completed eight weeks after the assessment, or at the end of their care provided
by the health service. This survey was intended to gain their perceptions on the
interventions and referrals resulting from the assessment. These surveys were
designed to be completed independently and could be sent as a postal survey.
However, it was considered that many stroke survivor participants would find
completing the survey difficult because of cognitive, communication or
community access issues. For each participant, the assessing clinician
determined the optimum mode of delivery of the surveys; as face to face
interviews, over the telephone or as a postal survey.
Closed questions were included, as well as open-ended questions which
provided stroke survivors with the opportunity to submit additional information
on services/therapies they felt were unnecessary, or conversely, that would have
been useful but weren’t offered. These open-ended questions also provided an
opportunity for the stroke survivor to raise any other issues associated with
services and support offered to chronic stroke survivors in the community.
10
3. Focus group interview of stroke survivors and carers
Survivors and their carers who had received the Resource Kit assessment were
invited to participate in a semi-structured focus group interview. Potential
interviewees were approached by a physiotherapist from SVHM or Inner East
Community Health and participation in the interview was voluntary.
Participation was offered to all stroke survivors who participated in a review
assessment, and their carers, where the person was deemed capable of taking
part in a focus group. The interview schedule comprised 18 primarily open-
ended questions covering the survivors’ and carers perceptions of recovery and
living with stroke, access to resources, any challenges/barriers that may have
been faced, and thoughts on the use of the Resource Kit assessment. The
interview schedule, although not specifically underpinned by a single theoretical
framework, covered each of the seven domains listed in the checklist recently
published by Flottorp and colleagues such as: ‘guideline factors’, ‘professional
interactions’, ‘resources’, ‘individual health professional factors’, ‘patient factors’,
‘social factors’ and ‘organisational characteristics [10].
The focus group interview was held at St. Georges Hospital in Kew from 1.30 pm
to 3 pm on 21/05/2014. Two research staff from Monash University and The
Florey facilitated the interview. Each researcher took notes during the interview
to ensure all major issues and views were recorded. With consent from the
participants, the interview was also tape recorded to aid with data transcription.
One survivor and carer were unable to attend the planned focus group. A
recorded telephone interview was conducted by one researcher (TP) with this
survivor and carer on 27/05/2014 using the same interview schedule. TP took
notes during the telephone interview, which were later verified using the tape
recording.
Data Management
An overview of the data management is provided in Table 3. Audit forms and stroke survivor survey
An individual identification number was generated for each stroke survivor and
used for the initial and post audits that were completed by a clinician. This
meant that all data were de-identified. The same individual identification
number was used on the stroke survivor survey so information could be tracked.
A random sample of 10% of the paper-based forms were double entered into the
database to assess data entry quality and over 96% of the data points were
consistent.
11
Table 3: Data management methods
Data Management Information collected
Access database Audit of the utilisation of the components of the Resource
Kit
Survivor survey- 2 weeks and 8 weeks post assessment
Excel (Microsoft
Corporation, 2010)
Train the trainer pre and post clinician survey
Focus group data
Comprehensive review assessment data
SurveyMonkey Clinician feedback at the end of the implementation project
Data Analysis
Survey and audit data
Data from the pre-post ‘train the trainer’ clinician survey were analysed in Excel
(Microsoft Corporation, 2010).
Data from the on-line SurveyMonkey database containing responses from
clinicians who had utilised the Resource Kit were downloaded and analysed
using STATA (statistical software) by the Monash University staff. Likewise, the
Access database containing audit data from the use of the Resource Kit and the
stroke survivor survey was converted to a STATA file for analysis. All data were
then cleaned and merged and then analysed by Monash University staff using
Intercooled STATA 12.0 for Windows (Stata Corporation,
http://www.stata.com/stata12/). Descriptive statistics are presented. Where
data were missing for a question, these data was excluded from the analysis for
individual questions.
The open-ended responses from surveys were subjected to thematic analysis. A
coding tree outlining the major themes and sub-themes was developed and used
to systematically code and then analyse the text responses. The coding was
verified independently by two researchers to ensure the interpretation and
meaning of the data was maintained.
Focus group data analysis
Qualitative data from the focus group were subjected to internal verification,
which involved two researchers reviewing and cross-checking responses and
other notes recorded at the focus group. Qualitative data analysis software QSR
NVivo 9 was used to identify and extract key themes and sub-themes that
emerged from the data transcript. Data for each of the key themes and sub-
themes were summarised, in order to provide an overview of the feedback
12
regarding respondents’ experiences of care for stroke survivors within the
community.
Ethical Review
Ethical review of the project was initially conducted by the SVHM HREC,where
the study was approved to be a Quality Assurance Project. Three sites did not
have formal associations with a HREC and these sites were added as external
sites to the SVHM Ethics Approval. The study was approved as Quality Assurance
at South West Healthcare and Goulburn Valley Health. Two sites required
submission of the project as a Low Risk Ethics Application and the study was
approved as such at Eastern Health and Southern Health. Consent forms for
stroke survivors and carers for SVHM are included in Appendix 8. In addition,
the focus group component of the study was approved as a Low Risk study by
the SVHM HREC; the consent forms for focus group are also included in Appendix
8.
Privacy
All data that were collected have been de-identified in this report. All data, in
paper and electronic formats, are kept confidential and stored and secured at
SVHM, as required by the Australian Code for Responsible Conduct of Research
(National Health and Medical Research Council, Australian Research Council,
Universities Australia. Australian Code for Responsible Conduct of Research.
Canberra: Australian Government; 2007).
Results
For continuity, the results sections will be presented in a similar order to that
described in the methods.
‘Train the trainer’ day
In total, 16 clinicians from 10 health services participated in the ‘train the trainer’
day. Two of the 10 sites did not commence the study; one site had competing
projects and commencement at the other site was initially delayed by the need
for extended ethical review and then the primary contact had maternity leave.
Table 4 depicts the demographics of the clinicians who attended the ‘train the
trainer’ day.
Only four clinicians had previously received any prior training in managing
chronic stroke survivors. All clinicians unanimously felt there were
improvements to be made in the quality and comprehensiveness of services
13
offered to people with chronic stroke and their carers in Victoria, as well as
locally, at their site (Figure 2).
Figure 2: Clinicians perceptions of quality of services offered to chronic
stroke survivor’s and their carers in Victoria and at their centre (N=16)
Perceptions on service quality
The majority of the barriers clinicians felt impeded the management of chronic
stroke survivors at a local level were also identified at a State level. Many
clinicians perceived funding limitations affected resources, especially the
services available post the community rehabilitation phase, and staffing levels
alike. Several clinicians also stated that often patients with a chronic condition
become less of a priority compared to those with acute conditions, which was
perceived to be exaggerated by a lack of organisational management and
decreased awareness and knowledge of the issues this patient population faces.
Confidence, beliefs and knowledge in managing chronic stroke survivors
There was an improvement in confidence levels reported by clinicians in
managing all aspects of chronic stroke survivors after the train the trainer
education (Figure 3). This was especially the case for their ability to explore
alterations in mood (40% confident pre; 93% confident post), and being able to
explore options to improve stroke survivor participation in valued activities (73%
confident pre; 100% confident post).
14
Figure 3: Clinician changes in confidence in managing areas involved with
chronic stroke patients before and after the train the trainer day
After the training day, more clinicians were able to recognise more issues
commonly faced by chronic stroke survivors (Figure 4).
Figure 4: Clinician knowledge of the issues commonly faced by chronic
stroke survivors and their carers before and after the training day.
There was more awareness of the risk factors for post-stroke depression,
especially cognitive impairment, stroke severity and being female after the
training day (Table 4). Interestingly, more clinicians incorrectly recognised age
as a risk factor for depression after the training.
15
Table 4: Clinician knowledge of risk factors for post-stroke depression
before and after the training day
Correct Risk Factor Pre training day Post training day % change
Physical disability 15 (100%) 15 (100%) -
Cognitive impairment 11 (73%) 15 (100%) ↑ 27%
Dysphasia 15 (100%) 15 (100%) -
Stroke severity 13 (87%) 15 (100%) ↑ 13%
Female 4 (27%) 14 (93%) ↑ 66%
Social isolation 15 (100%) 15 (100%) -
Incorrect Risk Factor
Age 8 (53%) 12 (80%) ↑ 27%
Pre-morbid function 12 (80%) 11 (73%) ↓ 7%
Socioeconomic status 11 (73%) 9 (60%) ↓ 13%
Following the training, clinicians general knowledge of the majority of issues
surrounding chronic stroke improved (Table 5).
16
Table 5: Clinician general knowledge of chronic stroke before and after
training
Correct answers
Pre training
day N=15
Post training
day N=15
% change
Proportion of people experiencing
depression post stroke
73% 93% ↑ 20%
Proportion of chronic stroke
survivors experiencing a decline in
mobility
20% 20% -
How often should chronic stroke
patients be reviewed
27% 67% ↑ 40%
Most stroke survivors live at home 87% 100% ↑ 13%
Most stroke survivors have a
disability
100% 100% -
Stroke does not affect ability to
engage in social or leisure
activities
100% 93% ↓ 7%
Mood disturbances after stroke
are common
100% 100% -
Survivors with dysphasia are more
likely to experience depression
than those who don’t
87% 100% ↑13%
Long-term functional decline is
rare following stroke
100% 93% ↓ 7%
Community-dwelling survivors
have twice the risk of falling
60% 93% ↑33%
Stroke can lead to role changes
within the family
100% 100% -
Increasing social support can help
reduce depression in carers
100% 100% -
Stroke creates emotional and
identity issues
100% 100% -
Informal caregivers are rarely
affected by someone having stroke
if they have good social support
80% 93% ↑ 13%
Feedback on the ‘train the trainer’ day
Overall, the feedback on the ‘train the trainer’ session was favourable (Table 6).
Clinicians reported that the most useful aspects were the background
information on each domain, and the workshop tasks. There were some
17
clinicians who felt that having more time to talk about the actual implementation
of the Resource Kit would have been beneficial.
Table 6: Feedback on the ‘train the trainer’ day
N=15 1 2 3 4 5 6
The content of today’s
training was easy to
understand
11 4 0 0 0 0
The content of today’s
training was useful
7 7 1 0 0 0
The presentation of the
training was useful
7 8 0 0 0 0
The presentation of the
training was well paced
9 3 2 0 1 0
The group activities
during the training
session helped my
learning
6 6 1 0 0 0
The training manual
provided was excellent
8 6 1 0 0 0
Overall, the training
prepared me to manage
chronic stroke
survivors/carers well
8 6 1 0 0 0
1=strongly agree- 6=strongly disagree
Clinician views on the format, content and useability of the Resource Kit
Overall, 12 staff who had used the Resource Kit assessment on survivors in the
community completed the clinician survey at the end of the implementation
phase. The response rate could not be determined as it was unknown how many
clinicians at the Community Rehabilitation Centres/Community Health Centres
were involved in conducting review assessments with stroke survivors.
Nevertheless, of those who responded, six (50%) had completed the ‘train the
trainer’ day. Table 7 outlines the demographics and experience of these
clinicians who had used the Resource Kit assessments.
18
Table 7: Demographics and experience of those clinicians who had used the Resource Kit
Demographics Clinicians who
attended the train-
the-trainer day
N=16 n (%)
Clinicians who used
the Kit
N=12
n (%)
Gender
Female 15 (94) 11 (92)
Age (years)
<24 2 (13) 0 (0)
25-34 8 (50) 7 (58)
35-44 2 (12) 2 (8)
45-54 3 (19) 2 (17)
55-65 1 (6) 2 (17)
Professional background
Physiotherapist 5 (31) 5 (42)
Occupational therapist 8 (50) 6 (50)
Nurse 1 (6) 1 (8)
Speech pathologist 2 (13) 0 (0)
Worked in profession
<1 year 1 (6) 0 (0)
1-2 years 1 (6) 0 (0)
2-5 years 3 (19) 4 (33)
5-10 years 8 (50) 3 (25)
> 10 years 3 (19) 5 (42)
Work setting*
Community rehabilitation
centre
10 (63) 7 (70)
Community health centre 4 (25) 3 (30)
Both 2 (12) 0 (0)
Experience in current setting
<1 year 2 (12) 0 (0)
1-2 years 3 (19) 2 (18)
2-5 years 6 (38) 6 (55)
5-10 years 2 (12) 2 (18)
> 10 years 3 (19) 1 (9)
Experience with chronic stroke
survivors
Regularly work with this
patient group
10 (63) 5 (42)
Occasionally work with this 5 (31) 6 (50)
19
patient group
Rarely work with this patient
group
0 (0) 0 (0)
No previous experience 1 (6) 0 (0)
Other^ 0 (0) 1 (8)
*2 with missing data for clinicians who used Kit; ^Other included someone who delivers stroke self-management program
Figure 5 outlines the clinicians’ perceptions of their confidence in managing
aspects of care for their patients with chronic stroke before and after using the
Resource Kit assessment. After using the assessment, 92% compared to 50%
(before using the assessment) were confident to provide options to improve
participation, and almost twice as many felt confident exploring alterations in
mood (42% before; 83% after). This is a similar representation to the change
seen before-after the ‘train the trainer’ day.
Figure 5: Clinician changes in confidence in managing areas involved with
chronic stroke patients.
After using the assessment, the majority (92%) of the clinicians would
recommend the use of the Resource Kit for all chronic stroke survivors (Figure
6).
20
Figure 6: Clinician’s perceptions on the benefits of the Resource Kit From the qualitative responses, the feedback from clinicians regarding the
useability of the Resource Kit was generally positive. They valued the structure
and guidance that the questions provided, and the fact that it covered a variety of
scenarios that chronic stroke survivors experienced. A couple of clinicians raised
concerns that it may duplicate some already existing assessment tools being
used at certain sites. It was also felt that the Resource Kit may be strengthened
by including additional areas such as community access and sexuality. In terms
of useability, some clinicians felt it was easy to use and follow the layout, while
others commented that may be it could be condensed to reduce the time taken to
deliver the assessment.
Audit of the utilisation of assessment and intervention components of the Resource Kit
Between March 2013 and Jan 2014, the Resource Kit assessment was used on 37
stroke survivors at the eight participating sites. Appendix 9 summarises the
findings from the review assessments received (n= 33).
Clinicians filled in the assessment and service utilisation components of the audit
on various numbers of survivors. The available audit data for each section are
outlined in Table 8.
21
Table 8: Number of survivors with Resource Kit assessments and completed data at each site
Site
number
Location/ type
Number Resource
Kit used on
N= 37
Completed assessment
forms submitted
N = 33
Demographic data
completed by clinicians
N=30
Data on current services
N=27
Data on services
post assessment
N=20
Survivor survey
completed (2 weeks)
N=31
Survivor survey
completed (8 weeks)
N=25
1 Metro CRC 9 9 8 7 5 7 5
2 Metro CRC 5 5 5 5 4 5 5
3 Metro CRC 2 2 2 2 0 2 2
4 Rural Stroke Liaison
10 10 10 10 9 9 8
5 Rural CRC 3 0 2 0 0 3 0
6 Metro CHS 4 4 0 0 0 2 2
7
Rural CHS 3
3
3
3
2
3
3
8 Metro CRC 1 1 0 0 0 0 0 CRC- Community Health Centre; CHS- Community Health Service
22
Table 9 outlines the demographics of the stroke survivors who received the Resource Kit assessment. More than half were male and the majority had an ischaemic stroke. Table 9: Demographics of survivors who received the Resource Kit assessment
Demographics N= 30
n (%)
Gender
Male 19 (63)
Age (years)
Median (Q1, Q3) 60 (53, 75)
Stroke type^
Ischaemic 17 (63)
Haemorrhage 8 (30)
Both 2 (7)
Time since stroke (months)
Median (Q1, Q3) 12 (9, 21)
Living arrangements
Alone 8 (27)
With Family/Friend 21 (70)
Supported Residential Facility 1 (3)
Availability of carer#
Physical assistance 24 hours 9 (31)
Supervision 24 hours 3 (10)
Physical assistance part time 6 (21)
Supervision part time 3 (10)
Daily check 1 (4)
None 7 (24)
Existing patient at service* 19 (83)
Q1, Q3- 1st and 3rd quartile; ^3 cases missing/unknown; #1 cases missing/unknown; * 7 cases missing/unknown
While somewhat difficult to quantify, the data in Table 10 outlines the
services/therapies survivors were receiving prior to the Resource Kit assessment, and
then after use of the Resource Kit assessment.
23
Table 10: Comparison of interventions recorded before and after the Resource Kit assessment^
Domain Interventions pre
assessment
N=27 Interventions
post assessment
N=20
Participation/
Functional limitation
/fatigue/falls
Physiotherapy 41% Physiotherapy 30%
Occupational
therapy
41% Occupational
therapy
5%
Various exercise
groups+
22% Exercise group 10%
Orthotists 4% Podiatry 5%
Botox 5%
Volunteer
programs
(vocation)
5%
Continence Continence clinic 4% Continence
clinic/nurse
20%
Communication Speech therapy 7% Speech therapy 10%
‘Talk and Tea’
group
5%
Cognition/mood/qual
ity of life*
Neuropsychology 7% Neuropsychology 5%
Psychology/psychiat
ry
11% Psychology/psych
iatry
5%
Self-Management
Program
22% Counselling and
support group
30%
Stroke education
program
5%
Secondary prevention GP involvement 30% GP involvement 10%
Rehabilitation
physician
7%
Carer Social worker 11% Social worker 5%
Home Care 7%
Respite 7%
^There is much overlap in the domains for which services/activities relate. An attempt has been made to categorise these; *Occupational therapy also linked with cognition/mood; +includes upper limb classes, balance classes, fatigue management classes, hydrotherapy
Clinician feedback for individual stroke survivors
In 56% of patients (n=14), clinicians felt that the assessment with the Resource Kit led
to some kind of change in focus for services that the patient was already receiving
(Figure 7). Importantly, this was on an individual patient basis rather than globally. The
24
additional feedback from clinicians was that using the Resource Kit assessment tended
to focus on areas that may not have been followed up previously, or was more focused
on areas of importance to the survivor. It was also suggested that it would be beneficial
to complete the Resource Kit assessment annually as stroke survivor needs may change
over time.
Figure 7: Clinician responses about results of Resource Kit Assessment
Survey of stroke survivors
Two weeks post assessment In total, 31 of the 36 (86%) stroke survivors responded to the survey request two
weeks after their Resource Kit assessment. Of these, 17 (55%) reported the assessment
to be ‘very worthwhile’ and 14 (45%) felt it was ‘somewhat worthwhile’. Stroke
survivors agreed that the domains included in the resource kit were important (Figure
8). Other useful areas survivors felt could have been covered in the assessment included
Religion and further inquiry and information on changes in emotions.
25
Figure 8: Outline of stroke survivor perceptions of the importance of the domains
of the Resource Kit Assessment
Eight weeks post assessment (or end of episode at the health service)
Twenty-five survivors completed the follow-up survivor survey. At this time, 60%
(n=15) stated that they remembered receiving advice from a health professional or
referral to other therapies after the Resource Kit assessment. Overall, 21 (84%)
survivors felt that having a comprehensive assessment as part of the Resource Kit
assessment was helpful. The stroke survivors perceptions on the services/therapies
available are listed in Table 11.
26
Table 11: Stroke survivor’s perceptions on recommended services/therapies as a
result of the assessment
Survivor perceptions N=25
n (%)
Services
Referred to services or
therapies that were helpful*
19 (83) Therapies, including physiotherapy,
occupational therapy and speech
therapy
Referred to services or
therapies that were not
helpful*
2 (9) Recommended change in medication,
and advice to cease smoking
Referred to services or
therapies you chose not to
receive*
8 (35) Continence clinic, botox injections,
counselling and support and
psychological services
Services you felt you
required but did not receive
6 (24) Counselling and support,
physiotherapy for longer duration
Services you were unable to
access, and why
7 (28) Physiotherapy, hydrotherapy
Not locally available 2 (29)
Too expensive 1 (14)
Lack of transport 2 (29)
Other 2 (29)
*2 cases missing
Focus group interview of stroke survivors and carers
In total, the focus group and telephone interview comprised six participants, four were
stroke survivors (50% male) and two were carers (100% male). The average age (of all
participants) was 68 years. The average time since stroke was 16 months. Two of the
stroke survivors were living with family, one was at home with a carer and one was at
home alone.
The following section provides a summary of the main themes that arose from the focus
group interview.
Physiotherapy was considered the first step and the most important and beneficial
step in recovery. However, there were concerns raised that the services were limited
and difficult to access long-term:
“Need more access to therapy. I go backwards when not in therapy”.
27
“Need to resolve anger issue about the system. How can we achieve these goals in eight
weeks? The system is set up to fail. No way in six weeks can I climb stairs sequentially and
be comfortable to be able to use my left hand for light switches and shaving for example”.
Respondents reported a need for more information about emotional changes after
stroke.
“Not once was my partner warned of changes after the stroke, that I might have some
difficulty emotionally. Need additional information about mood changes before discharge
for the carer. No discharge planning should take place until the significant other is present.
Family meetings would be good”.
Respondents felt that their needs had changed one year post-stroke and that they had
become more physically independent.
“My needs are less now. I can do more things now. I can read now and concentrate more, I
can sleep now”.
“We all need help and depend on someone but being independent helps us to go on. I try to
make my own lunch. I push the trolley when shopping with my wife which I couldn’t do
before. Of course I am tired when I go home”.
Carers reported a need for more information about what to expect after stroke. In
particular, the emotional aspects and mood changes post-stroke such as anxiety and
depression.
“[There is] nothing to educate you about what you’re going to come up against. No-one
said changes in personality might happen”. (Carer)
Also from the carer’s perspectives, more information was wanted about eligibility for
allowances and services:
“There's no system in place to handle such a major change in life. No-one gives you
assistance to say this is what's going to happen, this is what you're going to do. No -one
assists you. Centrelink is hopeless.”
More access to disabled parking at rehabilitation centers was also deemed important,
along with the recurring theme of the need for access to longer term rehabilitation and
physiotherapy.
“At St. Vincent’s there’s a five hour wait and see a different person every time. The main
thing is seeing when [stroke survivor] does physio[therapy] she can do more. When the
eight week stint finishes you have to wait before you can go back”.
28
Responses regarding the Resource Kit assessment were varied in that some
respondents did not readily recall having been given the assessment. One stroke
survivor said: “I get asked a lot of questions by people”. Another stroke survivor who
remembered the assessment task said they had taken the paperwork home to complete
it. They stated that: “It was useful for the new physio[therapist] to have an idea of where
I'm at” and “…it was good to go back over things”. Another respondent remembered the
task as “…a goal-focused instrument with questionnaire follow-up to see if these goals
have been achieved”. This respondent felt that the questions asked in the Resource Kit
assessment were relevant and were comprehensive.
Discussion
The primary objective of this project was to obtain consumer and clinician feedback on
the usefulness of the Chronic Stroke Resource Kit, including the comprehensive review
assessment embedded in the tool. With regard to the assessment, the results of the
study support the value of this assessment, with stroke survivors finding the experience
to be worthwhile and that the domains included in the assessment were important to
them. Similarly, clinicians also agreed that the Resource Kit was useful and they would
recommend it to other clinicians. Clinicians indicated that the review assessment
focused attention on areas of importance to the stroke survivor and identified areas that
may not have been followed up in previous assessments.
The main areas of focus within the Resource Kit include the high incidence of
depression, the difficulties experienced by stroke survivors in returning to valued
activities and the importance of individualised goal setting. Prior to using the Resource
Kit, clinicians indicated a lower level of confidence in exploring alterations in mood,
compared to other domains of the Resource Kit, with an increased rate of confidence
following utilisation of the Resource Kit. A similar pattern was observed for exploring
participation in valued activities with clients, with improvements in confidence
following use of the Resource Kit. Clinicians had high levels of confidence in their ability
to explore meaningful goals with clients, prior to and following use of the Resource Kit,
and this perhaps reflected the current strong focus on this area of practice in
community care.
Several areas were identified in the study as limitations to the Resource Kit in it’s
current form. Of particular interest is the focus on emotional changes after stroke and
the impact of this on families of stroke survivors. Another main theme was the need for
services to help stroke survivors and families cope with such a major change in their life;
with access to counselling specifically identified and also self management programs,
support groups and stroke education programs. These later aspects were not included
in the original version of the Resource Kit due to a number of studies being concurrently
conducted utilising these interventions. The updated version of the Resource Kit should
29
include a comprehensive review of strategies to assist with coping. Other areas
identified as gaps in the Resource Kit include community access and sexuality.
Some clinicians noted that the review assessment may duplicate some already existing
assessment tools utilised at their sites. It may be that the Resource Kit tool should be
used to supplement current assessments in these settings to prevent stroke survivors
from having to participate in repeated assessments. Alternatively, the more targeted
and comprehensive assessment in the Resource Kit could replace the standard initial
assessment for stroke survivors. While the assessment tool in the Resource Kit has
overlap with other tools, particularly those developed for the care of the older person
[11], there is benefit in having condition specific tools. Some assessment components
are specifically targeted at the needs of stroke survivors and the evidence for
interventions and management is condition specific. Ideally, the review assessment
embedded in the Resource Kit would form the first assessment when a person with
chronic stroke is referred to a community service. One clinician participant suggested
that the Resource Kit be used annually as survivor needs may change. This is certainly
the view of the investigators involved in the development of the Resource Kit and is
consistent with National Stroke Foundation guidelines [8].
The study results did not indicate an increased uptake of evidence based interventions
and management plans, with a general decrease observed in rehabilitation
interventions between the two week and eight week assessments. Forty-one percent of
stroke survivors were receiving physiotherapy and/or occupational therapy prior to
participating in the review assessment. These stroke survivors were likely to be already
engaged in a comprehensive rehabilitation program, with less potential to add
interventions. In addition, 28% of stroke survivors indicated that they were not able to
access services they required, including counselling and support, rehabilitation and
physiotherapy for longer durations and hydrotherapy. Further investigations need to be
conducted to identify the level of need for interventions in chronic stroke survivors and
access to appropriate services.
Limitations to the study include the sample recruited as a representation of the
population of people with chronic stroke. All stroke survivor participants were within 2
years post stroke, with a median of 9 months and many were already receiving
comprehensive rehabilitation prior to recruitment. Stroke survivors at a later stage
post stroke are not represented in this sample. The sample was also characterised by
younger age (mean age of 60 years) and a predominance of males (63%). A large
number of stroke survivor participants had incomplete data, particularly data acquired
at the eight week point.
The study protocols included a postal survey for stroke survivors, however, this was felt
to be difficult for many of the participants to complete. Clinicians were given the option
of conducting the survey by phone or in person, if this was deemed necessary and was
30
feasible within resource capabilities. This decision was made to facilitate involvement of
people with cognitive and communication disabilities or difficulty with hand writing
commonly observed post stroke, to gather the viewpoints of those who may not have
been included if support was not available to complete questionnaires. However,
participants may have given more positive responses to questions because of their
relationship with the clinician. We also sought to gather carer perspectives, however,
very little data was received from carers. Future studies should consider using clinicians
not involved in the care of the person to collect data, while still providing support and
guidance to those who require it to participate. Strategies to increase carer responses
should be investigated.
With regard to clinician participation in the study, twelve clinicians responded to the
final survey. The number of clinicians who were involved in delivering the assessments
at the eight centres is unknown, so the response rate can’t be calculated. There is a
possibility that clinicians who found the Resource Kit less useful didn’t respond to the
survey. It should also be noted that all of the sites volunteered to participate, without
financial recompense, indicating that the clinicians at these sites already had a
commitment to improving care for chronic stroke survivors. The views of the clinicians
from these sites may not be representative of other clinicians working in community
settings.
Considering barriers and enablers for this project, a difficult aspect to the project was
the varying response of the Ethics Committees at the sites. The project was accepted as
a quality assurance activity at the host site SVHM on the basis that the purpose of the
project was to enhance evidence based practice through provision of information
regarding current evidence and structured formats to improve assessment processes.
Informed consent was obtained from stroke survivor participants and implied consent
was utilised for clinicians participating in the anonymous questionnaires. However,
three potential sites required full ethical review of the proposal, adding a considerable
delay to commencement, with only two of these sites commencing data collection. The
primary enabler to the project was the interest in the study from the clinicians and their
commitment to data collection over a prolonged period of time, adding an extra
component to their workloads.
Most of the stroke survivors in the study were in the first year post stroke, with no
participants more than two years post stroke. It is notable that only one service reached
the goal of recruiting ten people to the study, despite a six month extension of the
timeframe for data collection. Reports from the centres indicated that there were few
clients with chronic stroke attending, making it difficult to recruit to the study. Given
the large numbers of people living with chronic stroke in our community, with high
levels of remediable conditions such as depression and low levels of community
participation, it is disappointing to find that few stroke survivors are accessing the
expertise in these sites beyond the subacute phase post stroke. It is important that
31
barriers to people with chronic stroke accessing services are identified. The high level of
unmet need in stroke survivors has been clearly identified by Andrew et al (2014) [5].
Future studies investigating methods to improve access to evidence based interventions
in chronic stroke should focus on stroke survivors with ongoing disability, who are
more than two years post stroke and are not linked in to community rehabilitation or
community health services.
Conclusion The pilot implementation of the Chronic Stroke Resource Kit has provided evidence that
clinicians working in community settings are supportive of the introduction of the Kit
and would recommend it to their colleagues. The comprehensive review assessment
embedded in the Resource Kit was utilised for stroke survivor participants and
clinicians reported that this often led to a change in focus for ongoing care. Stroke
survivor participants reported that taking part in the comprehensive review
assessment was worthwhile, and the assessment covered domains of interest that were
relevant for them. Clinicians reported improved confidence in exploring alterations in
mood and participation in valued activities with stroke survivors following the
introduction of the Resource Kit.
Areas identified for further development of the Resource Kit include emotional changes
after stroke, adjustment to major life changes, community access to services and a
greater focus on sexuality and intimacy. The pilot implementation did not show
increased uptake of evidence based interventions provided by community services .
Further research needs to be directed towards stroke survivors who are not currently
utilising community based services, to identify the evidence based interventions that
they may benefit from, and processes for improving access to community based services.
References
1. Senes S (2006) How we manage stroke in Australia. Australia: Australian Institute of
Health and Welfare.
2. Australian Institute of Health and Welfare (2004) Australian Facts: Heart, stroke and
vascular diseases. Australia: Australian Institute of Health and Welfare.
3. Hubbard I, Harris D, Kilkenny M et al. (2013) Adherence to clinical guidelines
improves patient outcomes in Australian audit of stroke rehabilitation practice.
Arch Phys Med Rehabil ;93:965-71.
4. Victorian Government Department of Human Services (2007) Stroke Care Strategy
for Victoria. Australia: Department of Health, Victoria.
5. Andrew N, Kilkenny M, Naylor R et al. (2014) Understanding long-term unmet needs
in Australian survivors of stroke. Int J Stroke 15 Jul 2014, DOI: 10.1111/ijs.12325
6. Dhamoon, M, Moon Y, Piak M et al. (2009) Long-term functional recovery after first
ischaemic stroke: the Northern Manhattan study. Stroke;40:2805-11.
32
7. Van de Port I, Kwakkel G, Wijk I, Lindeman (2006) Susceptibility to deterioration of
mobility long-term after stroke: a prospective cohort study. Stroke;37:167-71.
8. National Stroke Foundation (2010) Clinical guidelines for stroke management.
Melbourne
9. Lindsay P, Bayley M, Hellings C et al. (2008) Canadian best practice recommendations
for stroke care. Can Med Assoc J179:S1-S25
10. Flottorp S, Oxman A, Krause J et al. A checklist for identifying determinants of
practice: A systematic review and synthesis of frameworks and taxonomies of
factors that prevent or enable improvments in healthcare professional practice.
Implementation Science. 2013; 8:35)
11. Department of Health, Victoria, (2012) Best care for older people everywhere: The
toolkit. Australia: Department of Health, Victoria.