A realist approach investigating hidden mechanisms underpinning implementation of community based rural stroke services

Informed by evidence from randomised controlled trials, national stroke guidelines recommend early supported discharge (ESD) from hospital is offered to patients with mild to moderate stroke. ESD is a complex intervention... [ view full abstract ]

Informed by evidence from randomised controlled trials, national stroke guidelines recommend early supported discharge (ESD) from hospital is offered to patients with mild to moderate stroke. ESD is a complex intervention comprising multiple components that are delivered by stroke specialist multidisciplinary teams. A core tenant of ESD is that patients receive rehabilitation in their own homes at the same intensity as they would have been received in hospital. Although commissioning of ESD services has increased, the models of service delivery vary and there is inequity in service provision across England. It has been questioned as to whether it is possible to fully implement ESD in practice. Rural multidisciplinary teams implementing ESD face practical difficulties covering the large geographical areas they serve. Also, given that the original clinical trials were conducted in urban settings, it remains currently unclear how to successfully implement clinical guidelines within a rural context.

This PhD, currently in its first year, will adopt a realist approach and focus on uncovering the mechanisms facilitating or hindering implementation of ESD within rural community stroke services. It is envisioned multi-disciplinary team working will be central to the successful implementation of the ESD guidelines and the current research will focus on identifying Context – Mechanisms – Outcome configurations (CMOc) of team working which facilitate the implementation of ESD guidelines. Previous research investigating provision of stroke care in acute stroke settings identified 13 mechanisms central to multi-disciplinary team working. This research will investigate whether similar mechanisms are found within provision of rehabilitation by rurally based community stroke services. Also the aim will be to identify new mechanisms, unique to either community or rurally based services.

A multi-case study approach will be undertaken which has the benefit of complimenting a realist approach as both methods advocate using multiple sources of data collection and recognise the role of context. To increase the generalisability of any findings “cases” (individual community rural stroke services) will be identified from publicly available sentinel stroke national audit programme (SSNAP) data and used for evaluation. Sources used to gather data will be integrated and scrutinised to determine patterns and explanations for any CMOc’s.

Due to the complexity of ESD, the environment within which it operates, the multi-disciplinary team working within it and the interactions with the patient receiving the intervention, it is highly probable that many CMOc’s will be embedded and interlinked. It may also be the case that many distinct mechanisms will need to be activated in succession in order for a specific outcome to be realised. This poster will focus on developing a potential framework for guiding data capture in order to uncover CMOc patterns of team working within community based rural stroke teams and will invite discussion around the complex concept of interlinking and embedded mechanisms.