“There is evidence that it has a better outcome, I can’t remember all the figures but it does show that if it’s implemented straight away and properly then there is a better chance of recovery than there is if it isn’t” (Interviewee 7)
The importance of having the knowledge to correctly diagnose a stroke in the first place was repeatedly mentioned by all participants. This was seen to be essential to ensure appropriate SSCB application. Participants often reflected that general basic education about the SSCB was lacking and that if its importance was more widely understood and acknowledged then people would be more willing to ensure its implementation.
Optimism
Throughout the interviews the overwhelming feedback received was one of pessimism. Participants felt that consistent implementation of the SSCB for every person in the current climate was unachievable. Underpinning this was a lack of power to influence change.
“I think it is really challenging at times to feel that you have the power to make a difference to these things” (Interviewee 8)“that’s part of the challenge there is not one single thing that I think we can do now that is going to fix it….” (Interviewee 2)
Participants were extremely negative about their ability to get all relevant patients into a stroke unit in a timeous manner
“there isn’t enough beds and people don’t move quickly enough so there is no capacity” (Interviewee 1)
The challenges linked to discharging patients meant that participants could see no way to get patients moved when their stroke units had reached capacity.
Participants also repeatedly discussed the lack of support from management and the organisation in general which again led them to believe that they were powerless to influence changes which they felt were necessary. There was also a generalised belief that staff from other areas would never see the SSCB as a priority, given all the other competing priorities that they faced. Two participants went further, questioning the use of a bundle with targets and whether targets are helpful. They felt that each of the SSCB components should be a routine part of good quality stroke care, suggesting that if the care provided was good then the SSCB would be achieved.
On a positive note, all participants were optimistic that given the right organisational support it would be possible in the future to implement the SSCB consistently. This support included stroke care being prioritised, progressing direct access to stroke units, working towards a 24/7 stroke service and support with unblocking stroke units’ exit strategy issues.
Behavioural regulation
Participants identified specific ‘behavioural regulations’ at a national, organisational or clinical team level. At a national level the SSCA was generally seen as something that had a positive effect on raising awareness of the SSCB and promoting its implementation.
“because we know we are getting measured we do it and that probably is a big driver as much as the clinical care in terms of the fact you know you are going to get, […] judged on whether you do it.” (Interviewee 2)
However, there were mixed feelings about the Scottish Government’s annual stroke visit, during which the SSCA results and stroke care standards are reviewed. Participants acknowledged that it raises awareness of stroke at an organisational level but felt there was no subsequent action, compounding feelings of powerlessness and reinforcing the feeling that stroke and the SSCB were not taken seriously at a macro level.
At an organisational level participants discussed factors that influenced their behaviour. Any form of organisational support or interest was welcomed but most participants perceived a lack of this. This is relevant to behavioural regulation because of the multiple areas and professionals who are involved with SSCB implementation. Participants believed that the lack of support promoted a system wide belief that the SSCB was not important and consequently that this affected behaviours.
At a clinical team level, participants agreed that feedback on the SSCB’s implementation was important for practice. Those participants, in one hospital, who receive weekly feedback identified that this had a positive influence on SSCB implementation. Discussions revolved around exception reporting where any SSCB failures were investigated and followed up in an effort to drive improvement. Participants felt this could positively affect behaviour, but they recognised that grassroots staff do not routinely receive this feedback. When they do, behaviour change seems to be evident. All participants suggested that providing consistent feedback at a grassroots level, across the stroke pathway, could positively influence SSCB implementation.
One team was trying to identify a nurse to undertake a daily stroke coordination role, to promote compliance with the Scottish stroke care standards. This was found to be hugely influential in changing behaviour and increasing compliance. However, because of the current staffing complement the role was not consistently sustainable.
All participants agreed that direct admission to their stroke unit would ensure behaviour change because it would be specialist stroke staff driving SSCB implementation.
“I think we would need to admit straight to the stroke unit in an ideal world. I mean why are we putting patients through ED, AMU and here? Why are we doing that?” (Interviewee 4)
Noticeably, when discussing behavioural regulation participants started to suggest simple practical changes that could promote implementation. Given the opportunity to reflect on SSCB implementation prompted realisation that there were straightforward solutions, which might improve compliance.
Beliefs about consequences
When discussing their beliefs about the consequences of whether or not the SSCB was implemented the common theme was that stroke patients who did not receive the SSCB potentially suffered harm.
“I think not meeting these targets probably results in some harm. […] I’m sure there are people who come to harm because of this.” (Interviewee 5).
Three specific areas were highlighted: person-centred care; swallow screening and lack of stroke consultant cover. Given that the SSCB should be consistently applied to anyone suspected of suffering a stroke there were some concerns voiced that it reduced person-centred care i.e. on occasion people could be scanned unnecessarily or have an extra ward move in their patient journey. All who mentioned this nevertheless felt that the benefits of receiving the SSCB outweighed the risks posed. Of greater concern was that staff in both hospitals’ emergency departments refused to undertake swallow screening. This was raised as potentially harmful and was mentioned frequently by all participants.
“They may be […] kept nil by mouth when they could be allowed to eat and drink […], or they could be given water to drink when their swallow is unsafe, and they could be silently aspirating […] for years we have been trying to get them (ED) to do it (Swallow screening) and they won’t.” (Interviewee 5)
Finally, in one of the hospitals the lack of specialist stroke consultant cover was felt by the participants from that hospital as having negative consequences.
“I mean just now we don’t even have a consultant ward round every day […] I think just now I feel that patients are not getting the right interventions that they need at the right time” (Interviewee 4).
In relation to this domain personal consequences also emerged in the interviews. The overwhelming personal consequence for participants was emotional; they felt ‘bad’ and ‘guilty’. This related to times when the SSCB was not implemented, even though they were aware of the evidence based for its implementation and the potential harmful consequences to the patient. They also felt ‘frustrated’ because of feelings of powerlessness and their inability to make the changes they felt were needed to ensure consistent SSCB implementation. All participants suggested that there were no other personal consequences apart from perhaps occasionally being asked why a patient had not received the SSCB. Most participants also discussed feelings of satisfaction when their patients did receive it.