Introduction
Methods
Study design
Theoretical domains framework
Participants
Data collection
Analysis
Ethical approval and participants’ informed consent
Results
Variable | Number (%) | |
---|---|---|
Age (years) | 21–30 | 1 (4.2) |
31–40 | 8 (33.3) | |
41–50 | 12 (50.0) | |
51–60 | 3 (12.5) | |
Sex | Male | 10 (41.7) |
Female | 14 (58.3) | |
Profession | Stroke consultanta | 5 (20.8) |
Nurse | 4 (16.7) | |
Allied health professional | 9 (37.5) | |
General practitioner | 6 (25.0) | |
Healthcare setting | Secondary care | 9 (37.5) |
Primary care | 6 (25.0) | |
Community care | 6 (25.0) | |
Secondary & community care | 3 (12.5) | |
Years of experience | < 5 | 3 (12.5) |
5–10 | 5 (20.8) | |
11–20 | 11 (45.8) | |
> 20 | 5 (20.8) |
TDF domain | Theme (Barrier [B], Enabler [E], Mixed [M]) | Quote |
---|---|---|
Lack of standardised follow-up care pathway | ||
Environmental context and resources | Variability in follow-up pathways (M) | “So we found that with some TIA clinics they offer a follow up appointment around six to eight weeks, sometimes it’s consultant led and sometimes it’s nurse led so you can imagine that those appointments would be very different depending on who they speak to whereas other TIA clinics don’t have that option at all so there’s a very disjointed follow up pathway which people are getting...” [H8, GP, 17 Years of experience] |
Restricted access to early supported discharge (B) | “So, for the TIAs obviously we don’t do that [Early Supported Discharge] there’s no follow up.” [H17, Stroke consultant, 8 Years of experience] | |
Intentions | Variability in consultants use of nurse-led follow-up (M) | “We do have a, for follow-up we do have a nurse lead follow-up clinic. Which I have access to, but I don’t use a lot. And again, there’s some variation in practice amongst the five stroke physicians about how much they use that clinic.” [H20, Neurologist, 22 Years of experience] |
Variability in GPs having an active vs passive approach to follow-up (M) | “…personally I quite like to see patients particularly when patients have been started on a whole bunch of new tablets… So, I like to get them to come and see me.” [H11, GP, 18 Years of experience] “…it wouldn’t be feasible for every specialist letter we get for strokes and everything else to contact the patient to sort of go through the [medication], we wouldn’t do anything else really. So we add the medication to the repeat prescription” [H13, GP, 13 Years of experience] | |
Interface between healthcare settings | ||
Environmental context and resources | Restricted communication between healthcare settings (B) | “So, I think for me part of the problem is sometimes the access to the specialist. And yeah, we can fax over letters and we can make phone calls and we can try and bleep people and we can email and all this sort of thing, but you know my experience generally is that we don’t get a lot of information back.” [H11, GP, 18 Years of experience] |
Variability in content and speed of discharge letters (M) | “Communication is quite good. It’s quick. The turnaround on letters is quick…” [H3, AHP, 23 Years of experience] “We’re still relying on old paper letters, which, you know, we probably shouldn’t be anymore and communication is very slow, so it takes us six weeks often to get a clinic letter and if something’s urgent then we can’t afford to wait that long.” [H13, GP, 13 Years of experience] | |
Intentions | Variability in how GPs engage with discharge letters (M) | “And we tend to just wait for the [discharge] letter, act on it… It’s very much been directed by the secondary care rather than doing a massive amount off our own backs.” [H12, GP, 7 Years of experience] “And certainly the discharge letters are quite ‘protocolised’ again in that… And there’s things that they will put on there that you just think ‘well, there’s no need for that to be on there’ in terms of giving me advice here…” [H11, GP, 18 Years of experience] |
Social Influences | GPs have difficulty accessing imaging results and specialist stroke advice (B) | “But obviously it’s a bit hard to give them [patients] absolute reassurance because in terms of the scan reports or the results on the investigations, may not be entirely with us…” [H9, GP, 6 Years of experience] |
TDF domain | Theme (Barrier [B], Enabler [E], Mixed [M]) | Quote |
---|---|---|
Approaches to identifying needs | ||
Social professional role and identity | Perceived role in follow-up care influences approaches to identifying needs (M) | “I: So, do you see that a part of your role to ask about things like people’s social activities and their mood and cognition and the more holistic side? IV: Yeah, I think it is part of our role…” [H22, nurse, 13 Years of experience] “Usually it’s pretty much a one-stop clinic so if they need a carotid scan they get it there. If they need a brain scan urgently they get it there. We give them the medication that they need to prevent further events, book any other tests which are non-urgent but still need to be done and then we discharge them. So it’s a one-stop medical clinic.” [H24, consultant, 12 Years of experience] |
Professional training influenced approaches to identifying needs (M) | “As an OT, obviously we’re dual trained in physical and mental health.” [H14, AHP, 17 Years of experience] | |
Knowledge | Knowledge/ lack of knowledge of potential patient needs (M) | “…but there might be a lack of education, medical education about the, yeah, the long-term consequences really.” [H13, GP, 13 Years of experience] “…and that can affect you, you know you can’t drive, you maybe can’t work, can’t watch TV, can’t read, it’s a very small minor stroke but it’s had a big effect.” [H4, nurse, 37 Years of experience] |
Goal | HCPs had different perceptions on the goal of their follow-up (M) | “In the review clinic, we make sure two things, one, that all investigations have been completed. Secondly all the risk factors have been addressed and thirdly they’re on the right medications for the conditions. So, we just see them one more time after being seen in the TIA clinic.” [H7, consultant, 20 Years of experience] “And it’s quite a holistic type clinic so we look at them although obviously we’re focussing on the stroke, we’re looking at the whole person.” [H4, nurse, 37 Years of experience] “…so the follow up that I offer tends to be just checking that they’re ok, that they’re sort of getting on with their medications that they have recently been prescribed and just ensuring that they are kind of informed about you know what the process is and any further results that are coming back through and I guess sort of just general support about you know ongoing risk factors and risk reduction…” [H8, GP, 17 Years of experience] |
Intentions | Active vs passive approach to identifying needs (M) | “I don’t actively ask for it, I don’t actively for sleep and emotional problems, not things that I tend to ask about…” [H20, consultant, 22 Years of experience] “So, there’s an element of tailoring. But we do always generally check mood, fatigue, confidence as well, as part of what we’re doing.” [H22, nurse, 13 Years of experience] |
Social influences | Personal experience of TIA/minor stroke (E) | “…but it almost seems like there is a kind of post TIA syndrome and certainly I probably first became aware of that through personal experience really rather than in the practice.” [H8, GP, 17 Years of experience] |
Beliefs about capabilities | Confident/ not confident in identifying needs (M) | “I: Do you feel quite confident in being able to identify what their [patients’] needs are? IV: Yeah. yeah, I think I definitely…” [H16, AHP, 4 Years of experience] |
Use of checklists and screening tools | ||
Environmental context and resources | Checklists/ screening tools used/ not used to facilitate identification of needs (M) | “We use formal mood screens in [location]… the HADS, the DISC, those types of things. In terms of fatigue we use self-rating scales for fatigue. Obviously, cognition we’ve got a whole host of standardised assessments that we use, alongside functional assessments as well. Anxiety again, would be self-rating. And fear of falling would be self-rated. We don’t use every single one with every single patient but we have those.” [H14, AHP, 17 Years of experience] We don’t, at the moment, do a formal mood assessment and we don’t do a formal cognitive screen within clinic.” [H3, AHP, 23 Years of experience] |
Lack of time to use screening tools (B) | “…in a clinic setting, there isn’t really time to do lots of formal screening.” [H3, AHP, 23 Years of experience] | |
Beliefs about consequences | Checklist/ screening tools considered useful/ not useful (M) | “I mean the screen tools don’t always pick up on these things and sometimes we’ve found that, you know, at home they answer that everything’s alright on the PHQ’s but actually when you see them they are clearly upset about something.” [H8, GP, 17 Years of experience] “It [checklist] just gets a good, overall idea of what they’re doing and then identifies then at the end of it what they need to be referred to.” [H1, AHP, 5 Years of experience] |
Reinforcement | Content of primary care long-term conditions template is influenced by performance-based incentives (Quality and Outcomes Framework) (B) | “Cause one of the things we have at present in our clinical systems is templates… I think they tend to be very much QOF kind of based. So, it’ll probably be addressing things like cholesterol, blood pressure, their sugar etc. etc. Medication, making sure they are on the appropriate medications… I don’t think it actually addresses the kind of psychological aspects.” [H10, GP, 31 Years of experience] |
Screening tool mandated by local Clinical Commissioning Group (B) | “…the Barthel Index is obviously the Clinician Commissioning Group level, so I don’t think that will change…” [H2, AHP, 3 Years of experience] | |
Memory, attention and decision processes | Checklist/ screening tool used to inform decision making (E) | “…then we’ll use it [screening tool] to set the goals and then we’re doing it to give them to focus. What we want to do is improve their score and also so that we can monitor that what we’re doing is effective as well.” [H5, AHP, 16 Years of experience] |
Skill | Skilled/ not skilled in use and interpretation of screening tools (M) | “…we’ve trained the physios to do MOCAs, so, we provide weekend service on the wards. Unfortunately not in ESD at the moment, so, if a physio is working at the weekend, they can do a MOCHA over the weekend, so, there isn’t that delay.” [H14, AHP, 17 Years of experience] |
Patient factors | ||
Social influences | Cultural/ language barriers (B) | “The obvious one is language and non-English speaking patients where you may not know that until they come to clinic and you’re really then stuck…” [H3, AHP, 23 Years of experience] |
Patients not wanting to “bother” doctor or raise non-medical issues (B) | “…especially elderly people they don’t pester their GP for things, my mum says that, I don’t want to trouble the GP.” [H4, nurse, 37 Years of experience] | |
Family members as facilitators/ barriers to identification of patient needs (M) | “The other one is just normally again partners coming in and it tends to be men who come in and they don’t say a great deal and then the partner or wife mentions they’re worried that the patient’s been like this for a long time and then they tell me everything.” [H12, GP, 7 Years of experience] “…people can be quite proud and not want to sort of, they want to put a good front on it for other family members and things and not admit it.” [H6, AHP] |
TDF domain | Theme (Barrier [B], Enabler [E], Mixed [M]) | Quote |
---|---|---|
Stroke prevention | ||
Social professional role and identity | HCP did/ did not perceive prescribing stroke prevention their role (M) | “I: Do you see that as part of your role as well, around the stroke prevention, diet and exercise? IV: Totally. So, in terms of stroke prevention, we do lots of education with our patients that come through to ESD.” [H14, AHP, 17 Years of experience] “I think for TIAs it would be more kind of about prevention, wouldn’t it, really. Lifestyle and education and prevention, which wouldn’t really be our role.” [H5, AHP, 16 Years of experience] |
Belief about capabilities | Confident/ not confident in prescribing stroke prevention medication (M) | “…But certainly, blood pressure always worries me, I don’t think we treat blood pressure well. I don’t treat it, I don’t manage it because I’m a Neurologist by training. So, I think I lack expertise…” [H20, Neurologist, 22 Years of experience] |
Environmental context and resources | Lack of time to address lifestyle change (B) | “So, we talk about stopping smoking and healthy diet and exercise but it’s a fairly brief discussion and don’t really feel I have time in the clinic to do that in great depth.” [H20, consultant, 22 Years of experience] |
Information leaflets used to address lifestyle change (E) | “Again, we use a lot of the Stroke Association’s resources, like leaflets about exercise after stroke, prevention and risk of stroke which we tend to give out to patients.” [H1, AHP, 5 Years of experience] | |
Intentions | GPs actively reviewed patients’ medication vs issuing repeat prescriptions from secondary care (M) | “Usually what would happen is we get a letter from the specialist and we add the medication that they’ve suggested onto the person’s repeat medications.” [H13, GP, 13 Years of experience] “…personally I quite like to see patients particularly when patients have been started on a whole bunch of new tablets… So, I like to get them to come and see me.” [H11, GP, 18 Years of experience] |
Lifestyle change not meaningfully addressed or actively supported (B) | “Diet maybe we could improve, I don’t talk a lot about diet I’ll just say generally healthy diet and that’s all I’ll say. Smoking, I’ll tell people to stop smoking but I won’t talk about medication for that…” [H20, consultant, 22 Years of experience] | |
Goal | Stroke prevention was/ was not considered a goal of HCPs’ follow-up (M) | “The whole point [of a TIA clinic] is that they’re at increased risk early, so the whole point to come and see them early is to get treatment started early.” [H21, consultant, 24 Years of experience] |
Beliefs about consequences | Lifestyle change considered important for stroke prevention (E) | “I’m very passionate about how lifestyle can change your life or has an effect on your life.” [H17, consultant, 8 Years of experience] |
Residual impairments | ||
Knowledge | Knowledge/ lack of knowledge of residual impairments (M) | “I don’t think there is an awareness that there are these long-term sequalae... So there’s probably a bit of a lack of, well speaking personally, I don’t know what my colleagues would say, but there might be a lack of education, medical education about the, yeah, the long-term consequences really.” [H13, GP, 13 Years of experience] “But actually, from our experience, we see a lot of patients who have had a TIA and you know, they may only have had symptoms for 10 min but actually, there are a lot of other, what we call sort of hidden effects that I think are missed.” [H22, nurse, 13 Years of experience] |
Beliefs about capabilities | Confidence/ lack of confidence in addressing residual problems (M) | “I don’t think I will bring back somebody to manage their mood and fatigue because I don’t feel competent in doing that and probably I’m not.” [H17, consultant, 8 Years of experience] “Yeah, I feel confident being able to then draw from that whether they needed directing to further psychology referral or whether it’s maybe just providing that sort of information with regards to prevention or what they’ve actually been through. I’d feel quite confident being able to do that, from having talked to them.” [H1, AHP, 5 Years of experience] |
Intentions | Stroke prevention prioritised over residual problems (B) | “I guess I prioritise things which I think are extremely important, so smoking advice, cessation advice, exercise, restrictions into what they can do... The things which are absolutely mandatory to make sure that they completely understand the importance of their medication and why they’re taking it and what side effects they may get, that sort of thing; things which are commonly going to arise. I guess I probably don’t spend so much time, unless they specifically ask, about the slightly more quality of life activities of living questions that they may have.” [H24, consultant, 12 Years of experience] |
Skill | Some AHPs/nurses had the skills to actively addressed residual needs (E) | “As an OT, obviously we’re dual trained in physical and mental health. So, we do have a certain basic training in terms of anxiety management skills, anger management, those types of things.” [H14, AHP, 17 Years of experience] |
Beliefs about consequences | AHPs/ nurses believed in the value of a “supportive chat” which involved active listening, acknowledging patients’ needs and reassurance (E) | “But then a lot of the time spent with them doing the supportive chat will be reassurance wouldn’t it you know. I think a lot of people I think supportive chat and reassurances is a big thing that people perhaps require and then if they don’t have that that’s when things build up and the stress levels and stuff are worse.” [H4, nurse, 37 Years of experience] |
Education about diagnosis, stroke risk and medication | ||
Intentions | HCP provided/ did not provide education (M) | “Rightly or wrongly I think we have to really make the assumption that the patient has been counselled adequately about that medication and why they’re being put on it in secondary care, yes, because otherwise it’s duplication of work” [H13, GP, 13 Years of experience] “We do a lot of education on exercise and basically, the benefits of keeping active, diet, alcohol and smoking.” [H1, AHP, 5 Years of experience] |
Beliefs about consequences | Belief that it is difficult for patients to retain information provided at the acute stage (M) | “in the acute phase when patients are seen [patients get] an awful lot of information ... And so the amount of information that they absorb is tricky...” [H11, GP, 18 Years of experience] |
Use of support services and resources | ||
Environmental context and resources | HCPs used/ did not use support services (M) | “Smoking cessation I have to say I don’t often refer them to a smoking cessation clinic. I’m guilty of not doing that…” [H24, consultant, 12 Years of experience] “The main ones that we do refer to tend to be the Stroke Association... There’s a Recover group, I think, for alcohol and drug substance misuse. We’ve got referral forms for quite a different few and various links for different reasons and we would refer if necessary.” [H1, AHP, 5 Years of experience] |
Lack of support services (B) | “The other side of the problem is that there is very little to refer to.” [H3, AHP, 23 Years of experience] | |
Barriers to accessing support services, including long wait times, referral processes, transport issues and geographical boundaries (B) | “I mean at the moment, again, it’s the waiting times, a lot of people complaining, that I’ve been told, I’ve rung them, but they see they can’t see me for eight weeks, ten weeks, something like that.” [H7, consultant, 20 Years of experience] “I always feel like there are big geographical gaps. [H3, AHP, 23 Years of experience] “I think transport is a huge issue.” [H3, AHP, 23 Years of experience] | |
Directories used to facilitate identification of support services (E); however, these were often outdated (B). Successful directories had someone delegated to update them (E) | “We have our own directory … and basically what people do, what’s the name, how do you refer and how do you access. We already have an inhouse directory... We have an admin person that manages that directory, any new updates, any new differences to the referral pathway, any different forms, that is updated by our admin staff…” [H9, GP, 6 Years of experience] “…but I must admit in the past when I’ve been sent little directories of support services, they are useful but it suddenly becomes limited after about six or twelve months because a lot of these organisations are they don’t sustain… they just change or they move or whatever…” [H8, GP, 17 Years of experience] | |
In primary care, access to social prescribers or community champions facilitated identification of support service (E) | “…locally we’ve got something called Community Information Champions and I think a couple of our staff are trained, so a couple of receptionists, our healthcare assistant, they get additional training and normally it’s about accessing services, it’s our healthcare assistant she’s really good at that…” [H8, GP, 17 Years of experience] | |
Knowledge | Knowledge/ lack of knowledge of support services (M) | “I’d say good knowledge of what’s available but it’s probably not a very in-depth knowledge of what the service, potentially, will always offer.” [H1, AHP, 5 Years of experience] “I don’t have knowledge of what services are there.” [H20, consultant, 22 Years of experience] |
Memory, attention and decision processes | AHPs proactively searched for services to meet specific patient needs (E) | “…the other day I saw a patient who might benefit from maybe like a befriending type scheme. So, I’m going to look into that for her… if I feel that there’s something a patient would benefit from, just come away and do my own kind of internet searching.” [H16, AHP, 4 Years of experience] |
Patient factors | ||
Social influences | Patients refusing referral to support services, denial, low education, IT illiteracy and comorbidities were barrier to addressing needs (B) | “I think some people, not all, but they don’t really want that ongoing support. Cause obviously that’s a barrier in itself. Cause sometimes there’s patients where you feel that they would benefit more from it but if they’re not consenting then there’s nothing you can do.” [H16, AHP, 4 Years of experience] |
Family members often supported patients to access services or online resources, and relayed/ repeated information (E) | “Family are usually very good at helping. If family are available and around, they usually can be really good with directing or helping patients to work out what they need to access.” [H1, AHP, 5 Years of experience] |