title: Why do patients with stroke not receive the recommended amount of active therapy (ReAcT)? Study protocol for a multisite case study investigation.
abstract: BACKGROUND
  Increased frequency and intensity of inpatient therapy contributes to improved outcomes for stroke survivors. Differences exist in the amount of therapy provided internationally. In England, Wales and Northern Ireland it is recommended that a minimum of 45 min of each active therapy should be provided at least 5 days a week provided the therapy is appropriate and that the patient can tolerate this. Sentinel Stroke National Audit Programme (2014) data demonstrate this standard is not being achieved for most patients. No research been undertaken to explore how therapists in England manage their practice to meet time-specific therapy recommendations. The ReAcT study aims to develop an in-depth understanding of stroke therapy provision, including how the guideline of 45 min a day of each relevant therapy, is interpreted and implemented by therapists, and how it is experienced by stroke-survivors and their families.
  
  
  METHODS
  A multisite ethnographic case study design in a minimum of six stroke units will include modified process mapping, observations of service organisation, therapy delivery and documentary analysis. Semistructured interviews with therapists and service managers (n=90), and with patients and informal carers (n=60 pairs) will be conducted. Data will be analysed using the Framework approach.
  
  
  BACKGROUND
  The study received a favourable ethical opinion via the National Research Ethics Service (reference number: 14/NW/0266). Participants will provide written informed consent or, where stroke-survivors lack capacity, a consultee declaration will be sought. ReAcT is designed to generate insights into the organisational, professional, social, practical and patient-related factors acting as facilitators or barriers to providing the recommended amount of therapy. Provisional recommendations will be debated in consensus meetings with stakeholders who have not participated in ReAcT case studies or interviews. Final recommendations will be disseminated to therapists, service managers, clinical guideline developers and policymakers and stroke-survivors and informal carers.
authors: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, UK.
authors: David J
authors: DJ
authors: Clarke
authors: Stroke & Vascular Research Centre, School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK.
authors: Sarah
authors: S
authors: Tyson
authors: Institute of Neuroscience, Newcastle University, Newcastle, UK.
authors: Helen
authors: H
authors: Rodgers
authors: Faculty of Medicine & Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
authors: Avril
authors: A
authors: Drummond
authors: Health Services Research, School of Health and Related Research, The University of Sheffield, Innovation Centre, Sheffield, UK.
authors: Rebecca
authors: R
authors: Palmer
authors: Physiotherapy Department, Bradford Teaching Hospitals NHS Trust, St Luke's Hospital, Bradford, UK.
authors: Matthew
authors: M
authors: Prescott
authors: Clinical Sciences Building, Manchester Academic Health Sciences Centre, Salford Royal Hospitals' NHS Foundation Trust, Salford, UK.
authors: Pippa
authors: P
authors: Tyrrell
authors: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, UK.
authors: Louisa
authors: L
authors: Burton
authors: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, UK.
authors: Katie
authors: K
authors: Grenfell
authors: Institute of Neuroscience, Newcastle University, Newcastle, UK.
authors: Lianne
authors: L
authors: Brkic
authors: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford, UK.
authors: Anne
authors: A
authors: Forster
mesh_terms: D002985:Clinical Protocols; D004739:England; D019983:Guideline Adherence; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D008485:Medical Audit; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D010358:Patient Participation; D012107:Research Design; D000071939:Stroke Rehabilitation; D017741:Survivors
keywords: QUALITATIVE RESEARCH; REHABILITATION MEDICINE