Staff’s views of delivering patient-led therapy during inpatient stroke rehabilitation: A focus group study with lesson for trial fidelity

Background: Fidelity to the treatment protocol is key to successful trials, but often problematic. We report staff’s views on delivering a complex rehabilitation intervention; patient-led therapy during in-patient stroke care. Methods: Focus groups with staff involved in a multi-centred (n=12) feasibility trial of patient led therapy were undertaken. Purposive sampling was used to ensure that participants represented sites with both high and low recruitment rates. Data analysis used a framework approach. Results: Five focus groups were held involving 30 participants. Five main themes emerged; the effect of the interventions; practical problems; patient-related factors; professional dilemmas and skills. Staff felt the main effect of the therapies was on patients’ autonomy and occupation; the main practical problems were patients’ difficulty getting in the correct position and a lack of space. Staff clearly identified characteristics which made patient-led therapy unsuitable for some patients. Most experienced dilemmas over how to prioritise the trial interventions compared to their usual therapy and other clinical demands. They also lacked confidence about how to deliver the interventions, particularly adapting it to individual needs. For each barrier to implementation, possible solutions were identified. Of these, involving other people and establishing a routine were the most common. Conclusions: Delivering patient-led therapy during stroke rehabilitation is a complex task, which requires suitable patients to be identified, treatments to be delivered and adapted effectively and confidently and other workload demands to be managed and given appropriate priority. Staff require time and support to develop these skills and strategies to resolve professional dilemmas.