Results
Coding identified 1596 statements relating to the implementation of the SSCB which were distributed across all fourteen TDF domains. Sixty three percent of these (n=1005) were coded to six domains (Figure 1) which were prioritised for analysis.
[figure 1]
Reinforcement
Reinforcement related to anything that participants felt would or would not reinforce implementation of the SSCB and was the most frequently discussed domain (16% of statements). There was overwhelming agreement that the evidence base around the individual parts of the SSCB and positive patient outcomes encouraged implementation.
“they are actually based on good clinical evidence […], we know that these things actually make a difference to people.” (Interviewee 8)
Another commonly held view was that establishing and reviewing the reasons for any patient not receiving all elements of the SSCB was worthwhile. Most participants suggested that one way to motivate staff to attain SSCB compliance would be to regularly display information on ‘how we are doing’. Other individual areas were identified as positive reinforcers, for example the use of a ‘nurse coordinator’ which participants identified as increasing the likelihood of SSCB implementation.
Participants also identified negative reinforcers, the most prevalent of which was a belief that stroke care is not taken seriously enough at a macro level. The absence of noticeable political or organisational support was seen to contribute to the overall impression that stroke care is not considered to be an important field in modern healthcare and considered to be less important than other medical specialities. None of the staff interviewed felt that there was any real consequence for the organisation for either achieving or failing SSCB implementation.
“If we fail nothing really comes of it. We’ve had visits from the Scottish Government who told us to get a grip and what’s come of that […]” (Interviewee 5)
Environmental context and resources
Availability of resources along with the environment in which the SSCB is being implemented emerged as a key issue for this domain. Frequently discussed was lack of capacity across the system (NHS and social care perspectives) and the consequential pressures that this puts on the use of stroke beds.
Linked to this, participants frequently commented on staffing pressures both generally and in relation to availability of specialist stroke consultant staff. Some participants also discussed the increasing numbers of junior medical and nursing staff and reflected that their lack of experience and confidence made SSCB implementation challenging.
Two of the most striking barriers to SSCB implementation voiced across all eight interviews were environmental; firstly, an organisational culture that is not supportive of stroke care and secondly a lack of ownership of the SSCB. Relating to organisational culture, a commonly held view was that there was little managerial or organisational support for the efforts participants were making to improve the SSCB’s implementation and stroke care in general.
“I think there needs to be more involvement from higher up, I don’t know who higher up but people to help us meet the bundle” (Interviewee 3).
Linked to this, one participant suggested that a lack of political interest in stroke care directly influenced the organisation’s interest.
“The support at political level for stroke has dropped […] Fashions change and I think that the foot has been taken off the political gas […] but that will change again because something will happen, […] and the foot will go back on the gas because stroke is undoubtedly a major player in Scottish health […]” (Interviewee 1)
A commonly held view of participants was that stroke care is not taken seriously because it is not seen as a medical emergency.
“Stroke is an emergency. Unless you have people who believe that, […] until everybody treats stroke as a medical emergency […] We’re not able to do it.” (Interviewee 4).
One participant suggested that the reason for this is that stroke care is not a medical speciality in its own right.
The lack of SSCB ownership came through in all interviews. Participants highlighted that the SSCB is composed of elements that happen at differing times during the hyperacute care phase, so different staff groups are responsible for their implementation. Consequently, this impacts on the way other areas perceive their role in implementation. Participants regularly discussed the challenges faced in engaging staff from the other areas and all agreed that without this engagement consistent implementation was extremely challenging.