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 maintenance of the role was compromised due to a lack of staffing
resource
- when these roles were adequately staffed then guidelines were
successfully implemented and sustained
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.