Stroke Event 13 Sep - Afternoon presentations

CLAHRC Impact-
Influencing change in practice.
Chair: Prof Avril Drummond
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
Collaboration for Leadership in Applied Health Research and Care for
Nottinghamshire, Derbyshire and Lincolnshire
CLAHRC NDL

Dawkins’ Law
Dawkins’ Law of the Conservation of
Difficulty states that obscurantism in
an academic subject expands to fill the
vacuum of its intrinsic simplicity.
Influencing change in practice
CLAHRC NDL

• My name is Fred Higton
• Age 65 - Retired (more or less)
• Over 35 years developing medicines and as a
pharmaceutical consultant
• Cartoonist and caricaturist for 40 + yrs
FRED’S STORY
CLAHRC NDL

Hobbies:
• Gardening especially vegetables
• Music. Classical and folk
• Played: Banjo, mandoline, mandola,
clarinet, crumhorn, dulcimer
• Art
FRED’S STORY
CLAHRC NDL

THE STROKE
• 11th Jan 2011 ca 4:00pm
• Lost all feeling and movement, right side
• Bleed
• Seacole ward City Hospital 7 weeks
• Moderate to Severe
FRED’S STORY
CLAHRC NDL

• Private physio once a week
• Use SAEBO brace every day
• Carer am to help me wash and dress
FRED’S STORY
CLAHRC NDL

Involvement in the Wii STAR project
• Initially involved in hospital
• Further work in Rehab Unit
• Work at Home
• Two television appearances
FRED’S STORY
CLAHRC NDL

PROGRESS:
• I can walk a little
• I have learned to draw left handed
• I drive a modified car
• I cook
• I now sing unaccompanied folk
• I volunteer
FRED’S STORY
CLAHRC NDL

LIVING WITH A DISABILITY IS A LOT BETTER
THAN THE ALTERNATIVE
FRED’S STORY
CLAHRC NDL

The Diffusion Fellow and the Service
Manager
Jane Terry - Occupational Therapist and CLAHRC Diffusion Fellow
Kate Hooban - Team Manager
Community Stroke Discharge and Rehabilitation Service
Nottingham CityCare Partnership

Background to Diffusion Fellow Role
• 2009 new DF role identified within CLAHRC which was highlighted as an
opportunity by Pip Logan (Research Lead for Nottingham CityCare) and
staff encouraged to apply
• Sought approval from Team Manager and organisation to apply
• Informal interview then began in post May 2009.
• Backfill for post secured (I day per week of Band 5 OT)
• Allocated to individual Stroke theme project (Return to Work)
• Project Lead (Kate Radford) identified from Nottingham University
• Initial training and development opportunities together with other
Diffusion Fellows took place
• Organisation mentor identified to guide role.

Intention of Diffusion Fellow role
• Crucial mediator between research and practice with dedicated
time, knowledge, motivation and support to get research findings into
practice
• Fully integrated member of RTW research team within stroke
rehabilitation theme.
• Help inform design and execution of the Return to Work (RTW) after
stroke project
• Identify relevant stakeholders and disseminate CLAHRC information to
healthcare partners and commissioners
• Translate information into appropriate language for all stakeholders

Diffusion Fellow Role- Return to Work 1
• Clinical knowledge and experience of working with stroke survivors helped
inform and shape the early development of the study e.g. questionnaire
• Using extensive clinical contact network as reference points
• Mapping key stakeholders in NDL for Phase I
• Commissioner focus group early in study
• Qualitative interviews with trial participants /employers /commissioners
/stakeholders

Diffusion Fellow Role-Return to Work 2
• Assisting with thematic analysis of qualitative interviews
• Contribution to publications and presentations
• Acting as member of Expert Panel and Steering Group
• Ongoing involvement in shaping the role of the CLAHRC Diffusion Fellow
• Assisting other stroke theme projects with recruitment
• Assisting with development of ideas for future research projects.

Benefits to Nottingham CityCare
Organisation
• Development of body of research aware staff (already championed by Pip
Logan in CityCare).
• Established body of clinicians and patients to inform and shape the
development of future research bids.
• Delivery of evidence based clinical interventions and best practice which
improves patient experience and more importantly OUTCOMES.
• Cost savings through working more effectively and moving away from non
proven traditional practices.
• Enhanced reputation of the organisation through DF contribution to
posters/presentations at national conferences and publications.

Opportunities for CityCare Stroke
Service
• Stronger links with researchers and Nottingham University
• Opportunities to engage with other CLAHRC Stroke theme projects (Wii
Star and ESDT consensus
• Raised profile of research which benefits patients
• Development of research culture within the service leading to new
research projects (RCAS)
• Commissioned Return to Work OT pilot service with I year funding and
evaluation by Nottingham University

Benefits for Nottingham CityCare Staff
• DF role developed communication channels between researchers and
clinicians and provided a conduit for information and innovation.
• Greater opportunities for clinicians to be involved in research projects by
contributing to recruitment to stroke projects. Formal and informal links
were fostered.
• Personal development for diffusion fellow through contribution to
posters, presentations and publications

Challenges
• Managing time within 2 roles and clinical caseload pressures. Difficult to
limit to one day a week.
• Working within two very different work cultures and environments.
• Demands of new training requirements in role.
• Pressure of achieving 2 sets of objectives.
• Practicalities of organising and managing backfill- extra supervision,
training
• Loss of Band 7 clinical knowledge, skills and expertise in team
• Organisational changes throughout period (TCS, new manager, new
mentor, several staff changes on RTW project, new commissioning
structures and commissioners)
• Uncertainty of time length of role (Extended towards end of period)

Going Forwards
Negatives:
• Lack of continuation of DF role due to end of CLAHRC
• No current opportunity to build on skills learnt and carry forward
experience and knowledge
• Time limited push of CLAHRC not continued . Research and practice links
could be lost.
Positives:
• Nottingham CityCare presentations were completed at strategic level to
raise profile of CLAHRC project and potential benefits to CityCare patients.
• Business case for pilot RTW service was developed in partnership with
Nottingham City commissioners and has been shared with Derbyshire to
support bid in that area.
• New Return to Work service commissioned as a one year pilot. OT
transferred skills and knowledge into this project.

• What is diffusion?
– In the CLAHRC context it is spreading research knowledge to aid take up of
evidence in practice
• How did CLAHRC try to do it?
– Diffusion Fellows
• Almost 30 people seconded by CLAHRC‟s partner organisations to be
attached to a CLAHRC study for 0.5 – 1 day a week for five years
• Included nurses, physiotherapists, managers, consultant
psychiatrists, psychologists, occupational therapists, City Council employees
Diffusion
CLAHRC NDL

• No
– Some diffusion fellows left early on
– Some study teams did not gel with their diffusion fellows
– Some studies didn‟t produce results to be diffused
– Some organisations didn‟t give enough support (e.g. backfill or
showing interest)
• Yes
– Success in developing networks
– Studies that made a difference to practice, e.g. Return to Work
and key role of diffusion fellow
Did it work as originally conceived?
CLAHRC NDL

• From „yes‟ and „no‟ we learned
– It helps to have a fit between diffusion fellow and study
– Getting to know each other is important and varied between themes
– Personal characteristics of diffusion fellows – no template but there are some
characteristics that help
– There are characteristics of study teams, managers and organisations that help
the process
– Support and development is important
– Diffusion happens both ways, into research as well as into practice
– It is a brilliant way to develop research receptiveness in organisations –
capacity, capability, knowledge, understanding, ensuring feedback
loops, engaging teams on the ground
Huge benefits beyond original idea
CLAHRC NDL

…… they are one part of a big system and other things
need to be in place:
• Timeliness
• Politics
• Mutual respect
• Relevant, quality evidence
• Support and interest from all parts of the system
Diffusion fellows are not the only answer
CLAHRC NDL

Thank you for listening
alison.seymour@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk
Twitter: @CLAHRC_NDL
CLAHRC NDL

Influencing cultural change; becoming a
clinical academic
Phillip Whitehead
NIHR Doctoral Research Fellow
phillip.j.whitehead@nottingham.ac.uk

Background
• Occupational Therapist
• Social Care - Nottingham City Council
• Researcher - Psychiatry, Business School
10/8/2013 26

How do you combine a clinical and
research career?
10/8/2013 27

CLAHRC – The HOVIS Study
• Excellence in Occupational Therapy Research
• Methods: RCT, Qualitative Interviews, Survey
• Ethics, Research Governance, Research Procedures
• Publications and Conference Presentations
• MPhil
• BESTS – Travel Scholarship
10/8/2013 28

NIHR Fellowship Scheme
• Personal Awards
• Health Research - Clinical and Generic
• Person, Project, Place, (Training) Plan
• Highly competitive application and interview process
10/8/2013 29

Project – Occupational Therapy in
Homecare Re-ablement - OTHERS
• Homecare Re-ablement Services “in-vogue”
• Social Care Institute for Excellence
• Systematic Review
• Qualitative Interviews
• RCT

Training
• Building research skills
• University of Nottingham Modules/Courses
• National Courses (e.g. Oxford University, DLF)
• Conferences
• Collaborations/Networks
• International Travel

Place
• Reputation of Institution
• Mentorship
• Departmental Links
• Networking Opportunities
• Developing New Links

• PhD
• Develop clinical and research skills
• Practitioners involvement in research
• More collaborations with Social Care
• Challenges

What have we achieved in
stroke rehabilitation
through CLAHRC NDL?
A partnership between
Nottinghamshire Healthcare NHS Trust
and the University of Nottingham
CLAHRC NDL

Four successful projects
CLAHRC NDL

What are our learnings?
CLAHRC NDL

Doing things differently
CLAHRC NDL

• Existing expertise in stroke rehabilitation research
• Consultation with patient partnership group
• Consultation with NHS and social care service providers
and commissioners
How were stroke projects decided?
CLAHRC NDL

• Innovation
– Addressing issues that are key in the NHS
– Exploring feasibility/acceptability of specific stroke rehab interventions
• Homevisits
• Return to work
• Upper limb
• Implementation
– Moving what we know into what we do
• Early Supported Discharge
Innovation and implementation
CLAHRC NDL

 Direct input into service specifications e.g ESD service
specification
 Meaningful contribution to reviews of service provision
 Trust and respect......stronger synergy
 Inter dependency absolutely crucial!
Output
CLAHRC NDL

Key ingredients for success
CLAHRC NDL

• Publications
– 25 publications
• Conference/meeting
Presentations
– >60
Traditional research output
CLAHRC NDL

International collaboration (Int J Stroke)
CLAHRC NDL

• Phillip Whitehead – MPhil
• Karen Fellows – Mphil
• Matt Horrocks – MSc
• Louise Bramley – PhD
• Kate Hooban – MPhil
• Andy Richardson – MPhil
• Phillip Whitehead – NIHR Fellowship award
• Kate Threapleton – Senior Stroke Association Fellowship Award
• Christine Cobley – Clinical Psychology Training
• Clare Edwards – Clinical Psychology Training
• Emma Ford – Clinical Psychology Training
• Hazel Sayers – PRINCE2 Foundation and Practitioner (Project Management) & City and Guilds
Senior (Level 4) award in Professional Practice (HE Administration
• Karen Fellows – CLAHRC RIPPLE award
• Rachel Tomasevic – CLAHRC RIPPLE award
Increasing capacity
CLAHRC NDL

• Research Into Practice people
• Fully funded places to:
– Conduct original research
– Evaluate practice
– Service Review
• 13 days over 6 month period
• Mentored by lead researchers
• Additional £500 to work with patients and public
RIPple
CLAHRC NDL

First cohort of RIPples
CLAHRC NDL

• Local Health Trusts and Social Care partnerships also
providing funding
• Funded secondments
• Examples of current stroke projects
– Implementing a return to work intervention
– Cognition and TIA
– Homevisits
• Rehab staff embarking on research degree’s
Success is catching
CLAHRC NDL

BITES - Engagement
CLAHRC NDL

Diffusion Fellows
CLAHRC NDL

• What is expected of me?
• What skills do I have to offer the CLAHRC?
• I don’t understand the language used
• How much time will it take?
• Who will I be working with?
• Will I have a desk within CLAHRC?
• Where is the CLAHRC stroke theme based?
• What happens when the research project ends?
• What’s in it for me?
What is my role?
CLAHRC NDL

• Act as crucial mediator between research and practice with the
time, knowledge, motivation and support to get research findings into
practice.
• Takes time to grow into this role!!!
• Fully integrated into the stroke rehabilitation theme
• Help inform the design and execution of research in the NHS
• Four key roles…………
Diffusion Fellow ……….
CLAHRC NDL

• Passionate about building a research friendly
culture
• Sustainability of research beyond life of CLAHRC
– Take lessons learnt and experiences gained during
their involvement in CLAHRC to act as champions for
future change and innovation
Capacity Builder
CLAHRC NDL

• Lead implementation activities in clinical
setting
– Facilitate workshops
– Chairing and leading sessions
– Regular update review meetings
Change Agent
CLAHRC NDL

• Spread the work of the CLAHRC and the project to healthcare partners and
commissioners
• Translate it into appropriate language
• Identify and recruit appropriate CLAHRC Associates
• Access point for clinical staff to
discuss research and CLAHRC activities
Public Ambassador
CLAHRC NDL

• Become involved in capturing data
– E.g. conducting interviews, helping recruit patients,
gathering data, conducting follow –up assessments.
• Helping with analysis
• Writing up for publication
• Presenting research findings
Hands on research
CLAHRC NDL

Academic Health Science Network
CLAHRC NDL
15 AHSN’s throughout England
In set up
Accelerating Adoption and Diffusion
‘Getting evidence into practice’
Older people and stroke rehabilitation
East Midlands budget
£3 million per year
Pop 4.8 million

• Two projects determined from strategic clinical network objectives
• A checklist for the regular follow-ups for stroke survivors
• National Stroke Strategy Quality Marker 14
All stroke survivors should have a regular follow up at 6 weeks, 6
and 12 months.
• CCG required to return data on „People with stroke who are
reviewed at 6 months.‟
• Development of post stroke checklist – endorsed by WSO
• National Survey
• Roll out of 6 month reviews across East Midlands
AHSN Stroke rehabilitation
CLAHRC NDL

• Build on CLAHRC and Health Innovation Education Cluster (HIEC)
• To equip MDT in the community to monitor quality and demonstrate
their effectiveness.
• Interactive workshops – focus on data collection, data sharing
across organisations and analysis.
• HIEC pilot project
Effectiveness programme for CS services
CLAHRC NDL

• Caring for older people and stroke survivors
• Research to Implement EVidence Based In-Hospital Stroke
Rehabilitation (REVIHR)
AIM :
Develop and evaluate a change programme designed to facilitate the
delivery of evidence based stroke rehabilitation in hospitals across the
East Midlands
East Midlands CLAHRC
CLAHRC NDL

• Robust evidence exists
– Early/ High intensity/Task specific/Specialist
• Challenges in implementation
– Delivery interventions vague
– Benefit in trials found in practice?
• Clinical Guidelines go some way to addressing but…….
• Behavioural change
• Organizational context
• Structure and resources of the institution
• Economic and political context etc
REVIHR
CLAHRC NDL

• Phase 1
What is evidence based rehabilitation in a hospital setting? (SSNAP
2 high achieving hospitals)
• Phase 2
How and why is rehabilitation delivered? (Behavioural and
qualitative mapping)
• Phase 3
Improving delivery of rehabilitation – Construct theory of change
• Phase 4
Pilot and evaluation of change programme.
REVIHR
CLAHRC NDL

• High quality research output that has informed service delivery
• Developed a research active workforce in the NHS
• Developed a culture of joint collaboration addressing key issues in
NHS and social care.
• Focus, Time and Resource to make it happen!!
Summary
CLAHRC NDL

Thank you for listening
Marion.walker@nottingham.ac.uk
www.clahrc-ndl.nihr.ac.uk
Twitter: @CLAHRC_NDL
CLAHRC NDL
This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research
and Care for Nottinghamshire, Derbyshire and Lincolnshire (NIHR CLAHRC NDL). The views expressed in this presentation are
those of the speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Stroke Event 13 Sep - Afternoon presentations

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