title: Introducing structured caregiver training in stroke care: findings from the TRACS process evaluation study.
abstract: OBJECTIVE
  To evaluate the process of implementation of the modified London Stroke Carers Training Course (LSCTC) in the Training Caregivers After Stroke (TRACS) cluster randomised trial and contribute to the interpretation of the TRACS trial results. The LSCTC was a structured competency-based training programme designed to help develop the knowledge and skills (eg, patient handling or transfer skills) essential for the day-to-day management of disabled survivors of stroke. The LSCTC comprised 14 components, 6 were mandatory (and delivered to all) and 8 non-mandatory, to be delivered based on individual assessment of caregiver need.
  
  
  METHODS
  Process evaluation using non-participant observation, documentary analysis and semistructured interviews.
  
  
  METHODS
  Patients with stroke (n=38), caregivers (n=38), stroke unit staff (n=53).
  
  
  METHODS
  10 of the 36 stroke units participating in the TRACS trial in four English regions (Yorkshire, North West, South East and South West, Peninsula).
  
  
  RESULTS
  Preparatory cascade training on delivery of the LSCTC did not reach all staff and did not lead to multidisciplinary team (MDT) wide understanding of, engagement with or commitment to the LSCTC. Although senior therapists in most intervention units observed developed ownership of the LSCTC, MDT working led to separation rather than integration of delivery of LSCTC elements. Organisational features of stroke units and professionals' patient-focused practices limited the involvement of caregivers. Caregivers were often invited to observe therapy or care being provided by professionals but had few opportunities to make sense of, or to develop knowledge and stroke-specific skills provided by the LSCTC. Where provided, caregiver training came very late in the inpatient stay. Assessment and development of caregiver competence was not commonly observed.
  
  
  CONCLUSIONS
  Contextual factors including service improvement pressures and staff perceptions of the necessity for and work required in caregiver training impacted negatively on implementation of the caregiver training intervention. Structured caregiver training programmes such as the LSCTC are unlikely to be practical in settings with short inpatient stays. Stroke units where early supported discharge is in place potentially offer a more effective vehicle for introducing competency based caregiver training.
  ISRCTN49208824.
authors.affiliation: Bradford Teaching Hospitals NHS Trust and University of Leeds, Bradford, UK.
authors.forename: David J
authors.initials: DJ
authors.lastname: Clarke
authors.forename: R
authors.initials: R
authors.lastname: Hawkins
authors.forename: E
authors.initials: E
authors.lastname: Sadler
authors.forename: G
authors.initials: G
authors.lastname: Harding
authors.forename: C
authors.initials: C
authors.lastname: McKevitt
authors.forename: M
authors.initials: M
authors.lastname: Godfrey
authors.forename: J
authors.initials: J
authors.lastname: Dickerson
authors.forename: A J
authors.initials: AJ
authors.lastname: Farrin
authors.forename: L
authors.initials: L
authors.lastname: Kalra
authors.forename: D
authors.initials: D
authors.lastname: Smithard
authors.forename: A
authors.initials: A
authors.lastname: Forster
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D017028:Caregivers / Q000193:education*; D004739:England; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D017064:Process Assessment, Health Care; D036301:Qualitative Research; D011788:Quality of Life; D000071939:Stroke Rehabilitation
keywords: Qualitative Research; Rehabilitation
references.citation: Lancet. 2011 Nov 12;378(9804):1699-706
references.pmid: 21996470
references.citation: Disabil Rehabil. 2009;31(2):61-72
references.pmid: 19152154
references.citation: Health Technol Assess. 2013 Oct;17(46):1-216
references.pmid: 24153026
references.citation: BMJ. 2006 Feb 18;332(7538):413-6
references.pmid: 16484270
references.citation: Qual Prim Care. 2012;20(3):179-89
references.pmid: 22828672
references.citation: Clin Rehabil. 2007 Oct;21(10):867-84
references.pmid: 17981846
references.citation: Patient Educ Couns. 2008 Mar;70(3):305-14
references.pmid: 18155388
references.citation: Cochrane Database Syst Rev. 2013 Sep 11;(9):CD000197
references.pmid: 24026639
references.citation: Milbank Q. 2004;82(4):581-629
references.pmid: 15595944
references.citation: BMJ. 2004 May 8;328(7448):1102
references.pmid: 15130978
references.citation: Lancet. 2013 Dec 21;382(9910):2069-76
references.pmid: 24054816
references.citation: Cochrane Database Syst Rev. 2012 Nov 14;11:CD001919
references.pmid: 23152210
references.citation: Implement Sci. 2013 Aug 23;8:96
references.pmid: 23972027
references.citation: Disabil Rehabil. 2013 Feb;35(4):315-24
references.pmid: 22686259
references.citation: Int J Nurs Stud. 2009 Aug;46(8):1122-33
references.pmid: 19329118
references.citation: Int J Stroke. 2012 Jan;7(1):94-9
references.pmid: 22111894