# Presentation: 043326

## Assessing organisational readiness for change prior to the introduction of clinical guidelines in multidisciplinary stroke care

- Dr Sharon Hamilton              	Professor S McLaren
- Reader in Nursing		Professor of Nursing
- University of Teesside		South Bank University
- Middlesbrough			London
- England			England

## All health professionals and managers want to provide high quality clinical care that produces the best outcomes for patients

- Assumption underpinning this study....

## But results from national audits and other studies of outcome following stroke in the UK showed that....Stroke care in the UK was suboptimal

*For example;*Not all hospitals in the UK had a stroke unitAssessment was fragmentedOnly half of patients had a swallow screening on admissionMultidisciplinary working was poorNeeds of carers not assessed in over 3⁄4 of patients

## Slide 4

## There was a need to influence clinicians to implement best practice 

- Early multi-disciplinary assessment is crucial for diagnosis and treatment but was not reflected in practice

***Key points***

## However

- Implementing research evidence into clinical practice is challenging
- A range of change management strategies are available but need to be adapted to address local barriers
- Diagnostic analysis is recommended for this purpose
- There is a paucity of recommended study designs

## The main study

- This presentation describes the first part of a larger study to evaluate the use of a multifaceted strategy for implement best evidence in stroke assessment
- Main study design: realistic evaluation framework incorporating a quasi-experimental design and elements of action research
- 		Stage 1: Diagnostic analysis
- 		Stage 2: Pre-intervention data collection
- 		Stage 3: Implementation of intervention (guidelines for stroke assessment)
- 		Stage 4: Post-intervention data collection
- 		Stage 5: Diagnostic evaluation

## Slide 8

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## Diagnostic analysis is recommended as a precursor to change 

*What is a diagnostic analysis?*
- Information gathering designed to identify complexities (barriers and facilitators) which can frustrate change – at the organisational and individual level
- Useful for engaging clinicians in change process
- This study tested the usefulness of a multi-method approach, informed by previous studies

## Diagnostic analysis: theoretical underpinnings

- Stage models of change, eg forcefield analysis (Lewin 1951)
- Social marketing (Kotler 2006)
- Precede/proceed model (Green *et al* 1980)

**Assumption that change is linear and can be planned**
**Contextualist models challenge this assumption (Pettigrew *****et al***** 1992)**

## Diagnostic analysis: study design

- South Thames Evidence into Practice (STEP)
- Promoting Action on Clinical Effectiveness (PACE)
- Assisting Clinical Effectiveness (ACE)

***None had used a diagnostic analysis for stroke care***

## Mixed method approach

- Analysis of hospital public documents n=6
- Interviews n=20 senior staff: n=6 patients
- Focus groups n=5 nurses: 3= doctors
- Team Climate Inventory questionnaire n=206

## Setting

- 			600 bed district general hospital
- No stroke unit
- 7 general medical wards
- Organisational instability due to merger

## Results: documents n=6

- The public face of the organisation:
*Five themes identified:*
- Evidence-based practice
- Management approaches/decision making
- Staff training
- Multidisciplinary working
- Support for the study

## Patient interviews n=6

- All patients were satisfied with their overall care at the hospital
- Food was poor
- Physiotherapy was a positive experience
- No occupational therapy in hospital
- Discharge home information poor

## Results: Team Climate Inventoryn=148/206 (72%)

- 7 nursing teams
- 1 medical team
- 1 therapy team
- Variability in team-working
- Team-working in 2 nursing teams and the medical team gave cause for concern

## Results: staff interviews n=28

- Four themes identified:
- Stroke assessment lacked structure
- Stroke services were generally poor
- The hospital as an organisation was medically dominated
- Past history of change in the hospital

## 		Barriers to change

- No clinical leadership for stroke care
- Low levels of multidisciplinary working
- Low levels of team-working in 3 teams
- Stroke assessment fragmented
- Organisational instability due to merger
- Severe shortage of permanent staff
- No stroke unit –  7 wards

## 		Facilitators for change 

- Positive working environment
- Positive support to improve stroke care
- Support from medical and nursing directors to change stroke care
- Positive past experiences of change
- Staff highly committed to hospital

## Change strategy: targeting barriers

- Opinion-leadership
- Identify influential clinical leaders
- Multidisciplinary professional advisory group
- Staff training sessions
- Variety of times and dates
- Provided in the classroom & on the wards
- Individual & group sessions
- Additional support for teams where team working shown to be low

## Conclusion

- The combination of qualitative and quantitative data captured multiple perspectives on the barriers and facilitators to change in this organisation
- The information gathered influenced the tailoring of the change management strategy to the needs of the specific hospital

## Slide 23

## Slide 24

## Dunning, M., Abi-Aad, G., Gilbert, D., Hutton, H., Brown, C. (1999) Experience, Evidence and Everyday Practice. London: Kings Fund Publishing.
Humphris, P. (1999) The Assisting Clinical Effectiveness (ACE) Programme. In Humphris, D., Littlejohns, P. (1999) Implementing Clinical Guidelines. Oxford: Radcliffe Medical Press Ltd.
Iles, V., Sutherland, K. (2001) Managing Change in the NHS. Organisational Change. A Review for Health Care Managers, Professionals and Researchers. London School of Hygiene and Tropical Medicine: National Co-ordinating Centre for NHS Service Delivery and Organisation Research and Development. 
NHS Centre for Reviews and Dissemination. (1999) Effective Health Care. 5(1): Great Britain: University of York. 
Ross, F., McLaren, S. (2000) The South Thames Evidence Based Practice (STEP) Project. Kingston University, St. George’s Hospital Medical School, Faculty of Health Care Sciences. 

Sharon.Hamilton@tees.ac.uk 

- Humphris, P. (1999) *The Assisting Clinical Effectiveness (ACE) Programme*. In Humphris, D., Littlejohns, P. (1999) *Implementing Clinical Guidelines.* Oxford: Radcliffe Medical Press Ltd.
- Iles, V., Sutherland, K. (2001) *Managing Change in the NHS. Organisational Change. A Review for Health Care Managers, Professionals and Researchers.* London School of Hygiene and Tropical Medicine: National Co-ordinating Centre for NHS Service Delivery and Organisation Research and Development.
- NHS Centre for Reviews and Dissemination. (1999) *Effective Health Care.* 5(1): Great Britain: University of York.
- Ross, F., McLaren, S. (2000) *The South Thames Evidence Based Practice (STEP) Project.* Kingston University, St. George’s Hospital Medical School, Faculty of Health Care Sciences.
- _[Sharon.Hamilton@tees.ac.uk](mailto:Sharon.Hamilton@tees.ac.uk)_

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