An audit of dressing practice by occupational therapists in acute stroke settings in England

Introduction Dressing independence is commonly affected after stroke, with clinical guidelines recommending that dressing practice should routinely be provided for those with dressing difficulties. The aim of this study was to update the literature on current practice in the treatment of dressing problems in stroke rehabilitation units. Method A questionnaire survey of occupational therapists experienced in stroke care was sent to 157 stroke units in England. Results Responses were received from 70 stroke units. Frequency and duration of dressing practice varied substantially between units, with respondents typically providing dressing practice for six to 10 patients per week and spending 30 to 45 minutes per treatment session. Only 17 respondents (24.3%) stated that they regularly used standardised assessments of dressing ability. The functional approach was used more widely than the remedial approach. Service priorities, working environment and limitations of time and staffing were reported to influence dressing practice. Conclusion There is widespread variability in dressing practice. There is a lack of use of standardised dressing assessments, and therapists’ rationale for their choice of approach is unclear

What are the characteristics of patients with a stroke who are believed to need a pre-discharge home visit by occupational therapists?

Pre-discharge home visits are commonly completed by occupational therapists as part of the stroke rehabilitation care pathway. However, wide variations have been reported between stroke units in the number of home visits completed (Drummond et al 2012a; Royal College of Physicians 2006). This research aimed to identify the characteristics of those patients who are believed to need a visit by occupational therapists. Such a study is important as there is currently limited guidance to indicate when a home visit should be completed, or which particular patients should have a home visit. This has implications in terms of standardising practices between occupational therapists and provision of equitable services to patients. The research for this study combined qualitative and quantitative approaches. The qualitative research consisted of twenty interviews with senior occupational therapists working in in-patient stroke care across the United Kingdom. The interviews explored their views as to the types of patients who would and would not require a pre-discharge home visit. For the quantitative component, a comparative analysis was conducted on the characteristics of two groups of patients from a larger feasibility randomised controlled trial of Home Visits after Stroke (HOVIS). This analysis compared the characteristics of those patients whom the occupational therapists believed a home visit was ‘essential’ (n=33) and those for whom they did not (n=93). It also analysed the occupational therapists reasons for stating that a home visit was essential for each patient. Four key patient characteristics were identified as being particularly influential in the occupational therapists’ decision making process. These were: moderately severe physical disabilities, mild to moderate cognitive impairments, cortical strokes and living alone. Occupational therapists sought to balance characteristics relating to the patient’s level of ability to manage activities with details of the patient’s home environment, including the availability of support within the home environment. Although the presence of physical and cognitive impairments were important factors in the occupational therapists’ decision making, the findings suggest that they did not believe that the most physically and cognitively impaired patients were the most likely to need a visit. The main conclusion from this programme of work was that the home visit is multifaceted and individually reasoned for each patient, but that the four key characteristics outlined above are considered to be major factors in the decision making process by occupational therapists. It is suggested that future research on home visits for patients with a stroke should focus on those with moderately severe physical disabilities and on the role and importance of a patient’s cognition in occupational therapists’ reasoning process. A focus on the interactive relationship between these components would be fruitful. It is also recommended that future clinical guidelines should incorporate consideration of environmental and cognitive factors

What are the characteristics of patients with a stroke who are believed to need a pre-discharge home visit by occupational therapists?

Pre-discharge home visits are commonly completed by occupational therapists as part of the stroke rehabilitation care pathway. However, wide variations have been reported between stroke units in the number of home visits completed (Drummond et al 2012a; Royal College of Physicians 2006). This research aimed to identify the characteristics of those patients who are believed to need a visit by occupational therapists. Such a study is important as there is currently limited guidance to indicate when a home visit should be completed, or which particular patients should have a home visit. This has implications in terms of standardising practices between occupational therapists and provision of equitable services to patients. The research for this study combined qualitative and quantitative approaches. The qualitative research consisted of twenty interviews with senior occupational therapists working in in-patient stroke care across the United Kingdom. The interviews explored their views as to the types of patients who would and would not require a pre-discharge home visit. For the quantitative component, a comparative analysis was conducted on the characteristics of two groups of patients from a larger feasibility randomised controlled trial of Home Visits after Stroke (HOVIS). This analysis compared the characteristics of those patients whom the occupational therapists believed a home visit was ‘essential’ (n=33) and those for whom they did not (n=93). It also analysed the occupational therapists reasons for stating that a home visit was essential for each patient. Four key patient characteristics were identified as being particularly influential in the occupational therapists’ decision making process. These were: moderately severe physical disabilities, mild to moderate cognitive impairments, cortical strokes and living alone. Occupational therapists sought to balance characteristics relating to the patient’s level of ability to manage activities with details of the patient’s home environment, including the availability of support within the home environment. Although the presence of physical and cognitive impairments were important factors in the occupational therapists’ decision making, the findings suggest that they did not believe that the most physically and cognitively impaired patients were the most likely to need a visit. The main conclusion from this programme of work was that the home visit is multifaceted and individually reasoned for each patient, but that the four key characteristics outlined above are considered to be major factors in the decision making process by occupational therapists. It is suggested that future research on home visits for patients with a stroke should focus on those with moderately severe physical disabilities and on the role and importance of a patient’s cognition in occupational therapists’ reasoning process. A focus on the interactive relationship between these components would be fruitful. It is also recommended that future clinical guidelines should incorporate consideration of environmental and cognitive factors

Can an occupational therapy intervention increase independence in activities of daily living (ADL) in people who use homecare re-ablement services?

Homecare re-ablement services have been widely implemented by local authorities in England, although there are widespread variations in relation to occupational therapy input within them. These services aim to improve users’ ability to manage independently at home and reduce the need for other health and social care services. It is not known whether outcomes are better for people who receive occupational therapy as part of their homecare re-ablement compared with those who do not. This thesis reports a programme of work investigating this, encompassing: a systematic review, a qualitative interview study, and a feasibility randomised controlled trial (RCT) of an occupational therapy intervention targeted at activities of daily living (ADL). For the systematic review, 11 databases were searched and 13 studies were identified comparing interventions to improve performance in ADL with routine homecare. The review found variability in the content of interventions delivered and the measures used for ADL ability. However, there was moderate evidence that the interventions led to improvements in ADL ability, although most effects were not statistically significant. Those interventions involving occupational therapists led to improvements in ADL, but the content of the occupational therapy input varied. Semi-structured qualitative interviews were completed with 12 occupational therapists working in re-ablement services and ten people who had received re-ablement services. Interviews covered experiences and opinions of the service, and were analysed using thematic analysis. Findings were categorised in three themes: (1) Re-ablement: Tasks and Activities (2) Re-ablement: Modalities and Strategies for Delivery, and (3) Facilitators and Barriers. The occupational therapists’ primary focus was delivering graded programmes to improve users’ ability to manage ADL, which they believed they were uniquely placed to provide and tailor to each individual’s needs. People using services valued this graded approach believing that it improved their confidence to manage activities. A feasibility randomised controlled trial (RCT) was conducted in which 30 re-ablement users were randomised to receive either: usual homecare re-ablement without routine OT input (control) (n=15), or usual homecare re-ablement plus a tailored OT programme targeted at ADL (intervention) (n=15). The OT programme was tailored for each participant and included: goal-setting; teaching or practising techniques; equipment and adaptations; and provision of advice or support. Outcomes were: personal and extended ADL; quality of life; falls; and health and social care service use. These were assessed at two-weeks, three and six months post re-ablement. Although there were methodological challenges due to service changes which affected usual care and trial recruitment, it was feasible to enrol and retain participants, deliver the intervention, and collect outcome data which were responsive to change. Participants in both groups showed improvements from baseline, although overall the OT group showed greater improvement; they also used homecare services less frequently and had fewer falls. However, confidence intervals were wide, reflecting the small sample. The intervention was acceptable to participants who particularly valued the tailored advice and support. The principal conclusions were that there is some evidence that interventions targeted at personal activities of daily living can reduce homecare service users’ dependency. Although the content of interventions is variable, those involving occupational therapists appear to be beneficial. Occupational therapists believed that their specialist skills and knowledge in ADL performance were essential facilitators implementing an approach which was suited to each individual’s needs and therefore to successful re-ablement. The RCT was feasible and a further powered definitive study is warranted, subject to methodological alterations. The favourable trends in the OT group indicate the potential benefits in this population group. This is the first RCT of occupational therapy in homecare re-ablement and it is therefore important in the development of the evidence base for this area of practice. A definitive RCT is needed given the widespread national and local government investment, and policy and legislation that continues to underpin the development of homecare re-ablement services

Normative puzzles for local government: Managing the introduction of single‐handed care in England

A crisis in social care is apparent across the developed world as ageing populations put unprecedented demand on understaffed social care workforces. A recent popular response to this ‘care crisis’ within the UK involves the ‘innovation’ of single‐handed care (SHC). SHC involves a care package with two or more homecare workers being reduced to one worker using advanced equipment and new moving and handling techniques. In this article, we explore how SHC is rendered in 245 documents from 52 local authorities in England. Using Actor Network Theory as an interpretative lens, we suggest documents attempt to satisfy three ‘duties of care’: to the individual wellbeing of citizens, morally and fiscally to the collective and to innovation. Each appeal to different stakeholder groups necessary for SHC to work, but the combination of duties can pose problems in enabling coherent stories of SHC. Duties can be kept apart in different documents, but at times they must be brought together in certain textual spaces to enact SHC as a coherent enterprise. Here, the potential tensions that emerge are routinely orientated to as (merely) problems of process that can and should be managed in and through a more refined approach to change management

Who should have a pre–discharge home assessment visit after a stroke? A qualitative study of occupational therapists' views

Introduction: The number of patients who have a pre-discharge home assessment visit following a stroke has been reported to vary nationally. The purpose of this research was to explore the factors influencing occupational therapists' decisions to complete such visits. Method: Semi-structured interviews were completed with 20 senior occupational therapists working with stroke in-patients, from a range of urban and rural locations in the United Kingdom. The interviews explored their views about those patients for whom a pre-discharge home assessment visit would and would not be required. The interviews were analysed using thematic analysis. Findings: Three themes were identified: the patient's level of physical, cognitive, or perceptual impairment and its impact on performance in activities of daily living; factors relating to the patient's home environment, including the availability of support within the home environment; and other influences on occupational therapists. The presence of a cognitive impairment was a particularly important factor. Conclusions: Occupational therapists balanced aspects from each of these themes in order to determine whether a visit was needed or not. Although the level of impairment was important, the most dependent patients were not necessarily those believed to be the most likely to need a visit

Interventions to reduce dependency in personal activities of daily living in community-dwelling adults who use homecare services: protocol for a systematic review

Background There is a growing demand for services whereby individuals receive assistance from care workers for personal care within the home. This has led to the development of re-ablement or restorative homecare services that provide time-limited input aimed at reducing dependency in personal activities of daily living, and preventing or delaying the need for further homecare support. However, little is currently known about how such interventions are configured, or how they may affect individuals’ ability to carry out personal care independently. Methods/Design We will seek to identify studies that compare an intervention designed to reduce dependency in personal activities of daily living with routine input or usual care as the control. We will include randomised controlled trials, nonrandomised controlled trials, and controlled before and after studies. We will also include interrupted time series studies. We shall search electronic databases in addition to searching for ongoing and unpublished studies, and where appropriate will contact key authors. Two reviewers will independently screen articles for inclusion; will assess risk of bias using quality assessment tools; and will carry out data extraction using pre-prepared forms. Any disagreements, at any stage, will be resolved by discussion and the involvement of a third reviewer if needed. We will produce a narrative summary of the results. A meta-analysis will be conducted if sufficient data are available of appropriate quality and comparability. Discussion The findings from this review will inform future practice within homecare re-ablement services; will inform policy decisions about the structure, organisation and content of such services; and will identify areas where further research is warranted

Bathing adaptations in the homes of older adults (BATH-OUT): protocol for a feasibility randomised controlled trial (RCT)

Introduction The Care Act 2014 has placed a responsibility on local authorities in England to provide services that prevent deterioration and minimise the use of other health and social care services. Housing adaptations have been identified as 1 of the 10 most promising prevention services for older adults, with bathing adaptations being the most requested. However, many local authorities have lengthy waiting times which may increase costs, reduce effectiveness and reduce the preventive effect. There is no robust evidence of the effect of these adaptations on: health, well-being and functional ability. Methods and analysis This is a feasibility randomised controlled trial (RCT) with nested qualitative interview study. The RCT will recruit between 40 and 60 people who have been referred for an accessible showering facility, and their carers, from 1 local authority in England. They will be randomised to either usual adaptations (∼3-month wait) or immediate adaptations (no wait). The primary outcome is the feasibility of conducting a powered study. The outcomes assessed will be: health and social care-related quality of life, independence in activities of daily living and bathing, falls and use of health and social care services. Outcomes will be assessed at 3 and 6 months. Preliminary health economic feasibility will be established. Ethics and dissemination Favourable ethical opinion was provided by the Social Care Research Ethics Committee (reference number 16/IEC08/0017). The results of this study will lay the foundations for a further powered study. This would investigate the effect of bathing adaptations on quality of life and whether increased waiting times are associated with poorer outcomes and increased costs. The results have further potential to inform trials of other housing or social care interventions using the novel waiting list control method. Dissemination will include peer-reviewed publications and presentations at national and international conferences. Trial registration number ISRCTN14876332; Pre-results

Occupational Therapy in HomEcare Re-ablement Services (OTHERS): results of a feasibility randomised controlled trial

Objectives: The objective of this study was to test the feasibility of conducting a randomised controlled trial (RCT) of an intervention targeted at activities of daily living (ADL), delivered by an occupational therapist, in homecare reablement. Design: Feasibility parallel group RCT. Setting: Single-site local authority homecare reablement service. Participants: People referred for homecare reablement with ability to consent. Exclusion criteria were as follows: inability to speak English, receiving other community therapy services, needing two or more to assist transfer and receiving end-of-life care. Control: ‘Usual care’ was 6 weeks of homecare reablement delivered by social care workers (no routine health professional input). Intervention: A targeted ADL programme, delivered by an occupational therapist incorporating goal setting, teaching/practising techniques, equipment/adaptations and provision of advice/support. This was in addition to usual care. Outcome measures: Aspects of feasibility including eligibility, recruitment, intervention delivery, attrition and suitability and sensitivity of outcome measures. Participant outcomes were personal and extended ADL, quality of life, falls and use of health and social care services. Results: 30 participants were recruited, 15 to each arm, which was 60% of those eligible. Data from 22 (73%) were analysed at 6 months. Of the 15 participants, 13 (86%) received the intervention and were able to set one or more ADL goals. There were improvements from baseline in both groups, although overall improvements were greater in the occupational therapy (OT) intervention group. The biggest threat to feasibility was a change in service configuration during the trial, involving additional occupational therapy input, affecting usual care and recruitment. Conclusions: Despite the service reconfiguration, it was feasible to recruit and retain participants, deliver the intervention and collect outcome data that were responsive to change. The choice of primary outcome measure remains unclear. A further powered study is feasible and warranted; however, the design will require careful consideration because of ongoing national changes in service configurations

Biopsychosocial Intervention for Stroke Carers (BISC): protocol for a feasibility randomized controlled trial

Introduction Reducing length of hospital stay for stroke survivors often creates a shift in the responsibility of care towards informal carers. Adjustment to the caregiving process is experienced by many carers as overwhelming, complex and demanding, and can have a detrimental impact on mental and physical health and wellbeing. National policy guidelines recommend that carers’ needs are considered and addressed; despite this, few interventions have been developed and empirically evaluated. We developed a biopsychosocial intervention in collaboration with carers of stroke survivors. Our aim is to determine whether the intervention can be delivered in a group setting and evaluated using a randomised controlled trial (RCT). Methods and Analysis Feasibility randomised controlled trial (RCT) and nested qualitative interview study. We aim to recruit up to 40 stroke carers within one year of the stroke onset. Carers are randomised to usual care or usual care plus biopsychosocial intervention. Each intervention group will consist of five stroke carers. The intervention will focus on: psychoeducation, psychological adjustment to stroke, strategies for reducing unwanted negative thoughts and emotions, and problem solving strategies. The main outcome is the feasibility of conducting an RCT. Carer outcomes at six months include: anxiety and depression, quality of life, and carer strain. Data is also collected from stroke survivors at baseline and six months including: level of disability, anxiety and depression, and quality of life. Ethics and Dissemination Favourable ethical opinion was provided by East Midlands – Nottingham2 Research Ethics Committee (14/EMI/1264). This study will determine whether delivery of the biopsychosocial intervention is feasible and acceptable to stroke carers within a group format. It will also determine whether it is feasible to evaluate the effects of the biopsychosocial intervention in an RCT. We will disseminate our findings through peer-reviewed publications and presentations at national and international conferences