Therapy on stroke units : an ethnographic study

Taylor, Elizabeth Rose (2017) Therapy on stroke units : an ethnographic study. (PhD thesis), Kings College London, .


Background: Guidelines and audit have been widely adopted as quality improvement strategies in healthcare. A recent stroke guideline states that 45 minutes of each relevant therapy, 5 days per week, should be provided to patients deemed appropriate. National audit data suggest variation across teams in the proportion of patients deemed appropriate, and the quantity and frequency of therapy provided. Reasons for these variations are unknown. Aim: To investigate the ways in which policy, professional judgement and patient need influence the delivery of therapies in stroke units (SUs) in the era of the 45 minute guideline. Method: An ethnographic study, including participant observation and interviews, was conducted in three SUs. Results: Drawing on theoretical concepts of audit society and street level bureaucracy, the study found that the 45 minute guideline was limited in its ability to influence delivery of therapies. The attempt to standardise therapy time was undermined by variation in the roles and remits of SUs and therapists, and varied understandings of ‘what counts’ as therapy. Thus they had different approaches to assessing therapy needs, and adopted different audit reporting practices. In line with the claims of street level bureaucracy, therapists developed routines of practice to simplify and manage their caseloads. In one example, the audit had become a way of categorising patients’ need for therapy and justifying resource allocation. The thesis identifies the role of ‘Street Level Leaders’ in guiding therapists’ attitudes and practices. The thesis provides empirical data to support the theoretical concept of audit society, showing how changes to therapy standards and practice took place in a wider economic and social context. Conclusions: The 45 minute guideline was one of many factors influencing delivery of therapy and was diversely interpreted and implemented. The study’s findings suggest that, in the context of the quasi-marketisation of healthcare, audit may become a tool of commissioner-centred, rather than patient-centred care. Ongoing engagement between strategic leaders, patients and clinicians is needed, to ensure that quality of care does not become secondary to ‘playing the numbers game’.

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