Discussion
The main purpose of this study was to explore the enablers and barriers to the implementation of the SSCB in one Scottish Health Board. This is the first study to specifically consider staffs’ perceptions and experiences of SSCB implementation. The key areas that emerged during the analysis as increasing the likelihood of patients receiving the SSCB in this Health Board relate to knowledge, resources and organisational culture.
The significance of knowledge
Knowledge was a key theme throughout all interviews and was discussed by participants across several domains. The most surprising finding was the lack of knowledge amongst participants of precisely what the SSCB consisted of. Although all participants knew the four component areas none described all the targets and timescales accurately. Van Achterberg et al suggest that there is frequently a gap between knowledge and practice.8 An important example of this was that during the analysis it was clear that participants were not, unless prompted, discussing ‘getting patients to the stroke unit’. It seemed that they lacked knowledge about this component of the SSCB. However, initially they had all discussed admission to a stroke unit as being part of the SSCB and most had also highlighted its importance. This gap between knowledge and practice appears to be due to the lack of control participants had over ‘entry to stroke units’; they simply forgot about this being a key component of SSCB implementation.
When looking for evidence to support this everything appeared to link forgetfulness to stress though there was no evidence noted during the interviews or analysis to support this theory. This could potentially be an interesting area for further research.
An enabler often suggested by participants was the development of regular short training sessions to raise awareness of the importance of the SSCB. The importance of training in stroke care is nationally recognised in Scotland and Priority 4 of the ‘Stroke Improvement Plan’ states that staff should be trained to an appropriate level.9 The e-learning Stroke Training and Awareness Resources (STARS) ‘Core Competencies’ are considered to be the minimum nationally approved courses4 however, the SSCB is only mentioned very briefly in STARS. The lack of recognition of the SSCB in the national training database may in itself be compounding the general lack of knowledge and priority placed on the SSCB. This would be a relatively easy area to address with the development of a core competency around the SSCB and the current research base for stroke care.
Knowledge was also sought by participants in terms of their eagerness to receive consistent feedback at a ward level on how they were doing with implementing the SSCB. As most participants felt that grassroots feedback, would enhance SSCB implementation. The necessity of knowledge is also recognised in other areas e.g. The Report of the Mid Staffordshire NHS Foundation Trust which highlighted the importance of care being provided by those with relevant knowledge.10
The influence of resources
Resources were a recurring theme throughout all interviews and across all 14 domains. Discussions focussed on three main areas: staffing, the current stroke pathway and general system capacity. In terms of staffing the commonly discussed barriers related to a general lack of availability of specialised stroke care staff and particularly medical stroke specialists. Lack of appropriate staffing is a commonly discussed key barrier in much of the stroke and evidence-based practice literature (EBP). 11, 12, 13 Furthermore the Vale of Leven14 and Mid Staffordshire11enquiries emphasise the unacceptability of the lack of appropriate staffing, in relation to quality of care and patient safety.
Participants suggested that a nurse coordinator who would identify stroke patients on admission to hospital would ensure that they received the SSCB. Drury et al15 found that three quarters of the stroke units they studied had a member of staff whose role was the dissemination and implementation of stroke guidelines, highlighting that:
The findings from Dale’s11 study mirror the findings of this study and consequently a key improvement area should be consideration of how to develop this role in a sustainable way.
The current stroke pathway was highlighted repeatedly as a key barrier to SSCB implementation because of the number of services and staff involved. Participants suggested that the current pathway encouraged a lack of ownership of the SSCB, contributing to a lack of collaboration and encouraging an organisational culture that did not prioritise its importance. All participants considered direct admission to their stroke units as the obvious solution to this and moreover direct admission was the most discussed enabler to the implementation of the SSCB. Improving the pathway to allow direct admission to the stroke units would require a substantial amount of organisational change which may or may not be financially viable. Donnellan et al found that finance for the development and maintenance of stroke services was a barrier in their healthcare setting.16
Locally stroke patients admitted via AMU are the same patients who would be directly admitted to the stroke units. If they then consistently received all the elements of the SSCB Turner et al’s evidence suggests that their outcomes would be improved thus potentially offering a cost saving over the longer term.17 This is particularly relevant as this evidence of improved outcomes is the only evidence to date on the SSCB.
The third area most discussed in resources related to capacity and flow in the stroke units with lack of beds and exit strategies regularly cited as barriers. The Scottish Government has signed up to a ‘Whole Systems Patient Flow Improvement Programme’ aimed at adopting an approach to patient flow which will ensure patients receive ‘the right care at the right time in the right place by the right team every time.’ Locally, in this Health Board area, one of the key transformation programmes is Capacity and Flow however stroke was not part of this Programme. Purvis et al cite limited stroke unit beds as a key barrier to getting patients into their stroke unit.18 This was often also highlighted in this study in relation to the use of stroke unit beds for boarders and delayed discharges
The influence of organisational culture
Organisational culture was the area that presented itself most strongly as a barrier to the implementation of the SSCB. Participants consistently discussed the lack of support they experienced as leading to feelings of helplessness as to how things could be improved. This lack of support manifested itself at both a national and local level. Medical staff wondered whether the concentration on an acute care bundle was diluting the importance of stroke care in general and none of the staff had experienced any genuine form of recognition whether or not the SSCB was achieved. This links to a key finding in both the Vale of Leven and Mid Staffordshire enquiries. They found organisational cultures which accepted poor standards of care and tolerated the risk this posed to patients.10, 14 T he Vale of Leven enquiry found a “mismatch between expectation and implementation” and highlighted a management approach that demonstrated an organisational culture that viewed infection prevention and control as being of low priority. In this study participants frequently verbalised their frustration that stroke care and the SSCB were seen as low priority. Other studies into implementation of stroke standards and EBP also found lack of support to be a major barrier.15,19 Hardy et al found that when leaders prioritised EBP by promoting organisational culture that EBP improved.20
This lack of support led to feelings of helplessness, powerlessness and frustration alongside pessimism about their ability to influence the changes required to ensure consistent SSCB implementation. Kanter suggests that powerlessness is caused by an organisations inability to provide three key components of power, namely: information, resources and support21 and Gary believes that disempowerment follows when any of these three components is missing as this leads to an inability to provide adequate patient care.22Interestingly these three components are the three key themes which emerged as the areas which appear to have considerably influenced the effectiveness of the implementation of the SSCB in this Health Board area.