Delivering evidence-based rural community stroke services: a realist evaluation

Howe, Joanne (2022) Delivering evidence-based rural community stroke services: a realist evaluation. PhD thesis, University of Nottingham.

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Strong evidence exists relating to the efficacy of Early Supported Discharge (ESD) which has been synthesised in several Cochrane systematic reviews. National clinical guidelines recommend that ESD be offered to all eligible stroke survivors, however service models vary significantly and there are still areas of England where ESD has not been commissioned. Additionally, some services, particularly in rural areas, report challenges in delivering evidence-based services. The organisational core components necessary for evidence-based service implementation have been identified, informed by international consensus and randomised controlled trials. It is unknown if or how these organisational components facilitate the delivery of evidence-based community stroke services in rural areas.


A theory building realist evaluation case study of community stroke services delivering ESD in rural areas of England was conducted. Three exemplar rural services were identified from the post-acute phase 2 stroke sentinel national audit programme as fulfilling key evidence-based criteria as identified in the national clinical guidelines for stroke. Incorporating evidence from the randomised controlled trials and a panel of expert advisors, five initial candidate programme theories were developed to explain how the core components underpin evidence-based service delivery in rural services. These programme theories were iteratively tested and refined during a 12-month data collection period taking place from June 2017 to May 2018. Evidence from realist interviews, observations, and several informal conversations, and documents were interrogated to identify hidden causal mechanisms and corresponding contextual features influencing evidence-based service delivery in line with national clinical guidelines. Data analysis incorporated inductive, deductive, abductive and retroductive inferencing to generate context-mechanism-outcome configurations for each programme theory under evaluation.


Programme Theory One: The multidisciplinary team and interdisciplinary working identified the importance of a comprehensive team composition including service leads, rehabilitation assistants and administrators with staffing levels adjusted for rurality. A supportive interdisciplinary team culture alongside service leads who empower skill development were also identified as important factors of teamworking. Working in an inter and transdisciplinary manner was identified as a key mechanism to facilitate the delivery on evidence-based services resulting in improved service efficiency and delivery of holistic inter and transdisciplinary care. The lack of psychologists within the stroke services was thought to impede the level of interdisciplinary working and resulting in unmet needs for patients. This negatively impacted upon the self-confidence of staff who did not possess sufficient knowledge or skills to appropriately treat patients with psychological needs.

Programme Theory Two: Inter and transdisciplinary training was inextricably linked with programme theory one and identified the importance of providing formal and informal opportunities for all staff, including administrators, to develop inter and transdisciplinary skills. Training was provided in house and delivered by staff within the service. Comprehensive competency-based training for rehabilitation assistants equipped these members of staff with appropriate knowledge, skills and confidence to engage in transdisciplinary working. Training also facilitated interprofessional trust associated with the delegation of specialised rehabilitation tasks.

Programme Theory Three: Multidisciplinary Meetings found that weekly MDMs facilitated shared decision-making, inter and transdisciplinary working and increased the likelihood of adhering to key Stroke Sentinel National Audit Programme governance criteria and national clinical guidelines. For services with high caseloads, meeting effectiveness was facilitated through effectively chaired and formally structured meetings. Given that rural community stroke services have reduced opportunities for communication, meetings provided a forum for interdisciplinary discussions which occurred in supportive team climates and enabled staff to develop a shared understanding of patient and service objectives.

Programme Theory Four: Care Transitions identified that functional proximity between services, collaborative working and good interpersonal relationships between service leads facilitated smooth, timely and appropriate care transitions between services. Cross-service collaboration encouraged the development of trust, role clarity and shared understanding of patient and service needs. Conversely, hard organisational boundaries created barriers to cross-service collaborations and negatively impacted upon care transitions.

Programme Theory Five: Visit Scheduling was identified during data collection and suggested that implementing structured visit scheduling facilitated the delivery of equitable and efficient services. This was particularly true for the services with high caseloads operating over large geographical areas.


This realist evaluation has provided a valuable insight into how stroke service organisation, coordination and teamworking facilitates the delivery of evidence-based services in line with national clinical guidelines in rural areas of England. The revised programme theories highlight the importance of supportive service leads, collaborative inter and transdisciplinary working from all staff including administrators, the use of highly trained transdisciplinary rehabilitation assistants to deliver rehabilitation and structured visit scheduling as essential components to the successful delivery of services with large caseloads. Given that some services in rural areas have found it difficult to deliver evidence-based services, it is hoped that these findings provide some meaningful detail for service leads and healthcare providers to adapt and implement within their own stroke services both in rural and urban areas.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Fisher, Rebecca
Walker, Marion
Clarke, David
Keywords: ESD, CRT, Stroke Rehabilitation, Service Delivery, Early Supported Discharge, Community Stroke Team, Implementation, Rural, England, Integrated Stroke Teams
Subjects: W Medicine and related subjects (NLM Classification) > WL Nervous system
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 69295
Depositing User: Howe, Joanne
Date Deposited: 01 Aug 2022 04:40
Last Modified: 01 Aug 2022 04:40

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