El desarrollo humano

therapists’ decisions about treatment options and modes of delivery for the hemiplegic upper limb after stroke.

4.2.2 Phase 2 aims

To explore the process through which therapists collect data about movement after stroke and the rationale underpinning their selection of treatment options.

4.2.3 Phase 2 Objectives

1. To describe the assessment process through which therapists collected information about movement of the hemiplegic arm after stroke.

2. To explore the rationale which therapists employed in order to identify and understand key components related to movement of the hemiplegic arm after stroke.

3. To explore the rationale which therapists employed in order to formulate decisions about treatment for the hemiplegic arm after stroke.

4.3 Method

4.3.1 Study design

Design: Descriptive Qualitative approach based on semi structured

interviews; open questions and reflective discussion. This approach aims to understand the complexity of human experiences through exploration of personal aspects of the experience (Burns & Grove, 2009).

153 4.3.2 Overview

In this phase of the study telephone interviews were conducted to explore the content and rationale underpinning the examination and selection of interventions by participating physiotherapists for treatment of clients with movement problems of the hemiplegic upper limb after stroke. Interview questions were derived from literature review and responses to phase 1 of this study. Purposive, convenience sampling was used to recruit a sub group of ten physiotherapists from phase 1 participants who provided contact details in order to indicate their interest in participating in phase 2. Nine of the ten participants were in current practice with a stroke client base and one had retired from practice in the previous 12 months but had extensive

experience treating clients after stroke; all were members of a post-graduate specialist interest group, The Association of Chartered Physiotherapists in Neurology (ACPIN).

This permitted access to a group of therapists who had relevant experience in the area of interest and facilitated the possibility of data saturation.

However, a self-selected sub group may possess specific characteristics which are not shared by other neuro-therapists and the convenience may be offset by limitations in the range or type of data provided (Cresswell & Plano Clarke, 2011) (please see section 6.6).

Participants were drawn from senior NHS staff grades six (specialist

physiotherapist), seven (highly specialist physiotherapist) and eight (Service Lead physiotherapist) and comparable roles in private practice and had a range of postgraduate experience in neurological rehabilitation for individuals who had sustained stroke. Participants worked with clients in the acute, sub- acute and chronic phases of stroke rehabilitation (definitions based on ISWP: RCP, 2012) although the practice of any therapist included clients at varying stages of recovery.

154 4.3.3 Interview schedule design

This study was explorative, interview questions were based on extant literature about factors related to clinical presentation and decisions about interventions during neurological physiotherapy practise for assessment and treatment of the hemiplegic upper limb after stroke. This process was based upon descriptions provided by previous studies (Edwards et al., 2004; Smart & Doody, 2007; Wallin et al., 2008; Quinn et al., 2009; Skjaerven,

Kristoffersen & Gard, 2010; Haas et al., 2012;Kristensen, Borg & Houndsgaard, 2012).

Information was synthesised by the author from review of recently published research papers, medical and physiotherapeutic texts and National Institute for Health and Care Excellence (NICE, 2010) and Intercollegiate Stroke Working party: Royal College of Physicians (ISWP: RCP, 2012) guidelines for stroke in order to construct questions intended to explore participants’ opinions of the process through which therapists collect data about movement after stroke and the rationale underpinning their selection of treatment options. This list was discussed with a senior (neurological) physiotherapist and a senior (neurological physiotherapy) academic prior to designing the interval protocol/schedule.

The draft interview protocol/schedule was piloted with two physiotherapists (one academic: one clinician) to check for face validity, to ascertain that the questions were understandable and un-ambiguous and to determine and refine timing. Modifications (in question sequence and wording) were made in response to their suggestions. Data collection via telephone interview/ digital recording was discussed with experienced research associates and the protocol refined further (simplified) based on their advice. Involvement of both academics and clinicians in review of the interview design and content ensured face and content validity and that the questions were relevant to the themes of the study.

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The final schedule (see Appendix viii) comprised themes and suggested questions which represent the principal components of the interview:

1. Demographic and service based information: participants post- graduate clinical and educational experiences and influences, structure and clinical remit of participants working environment (staffing, Multi-professional team availability and working practice). 2. Reflective and belief driven information: participants’ opinions and

observations of the effect of stroke on the hemiplegic upper limb, the type of interventions which could be used during treatment and the factors which influence their decisions about selection of

intervention.

4.3.4 Ethical approval

The physiotherapists who consented to take part in this phase of the study worked in both the private and public sector within the United Kingdom and participated in the study in their capacity as members of the Association of Physiotherapists in Neurology (ACPIN).

Ethical approval for this study was obtained from Northumbria University Research and Ethics Committee (28.11.11) and the Integrated Research Application System (City Road and Hampstead; Project number:

12/LO/0819: received 19.09.12) (Appendix ii).

All participants were given written and verbal information about the study and consent was gained before the start of each interview (Appendix ix).

4.3.5 Sample size

Sample size was limited by the use of purposive sampling from the

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studies generate extensive material (Huberman & Miles, 2002; Alreck & Settle 2004, Saldana, 2009) and on discussion with research supervisors and associates it was anticipated that because the questions were about specific aspects of clinical practice it was acceptable to recruit a small group of participants (n=10) and to monitor the interview responses for “saturation” of emerging data. Review of similar studies supported the size of the

participant group (Edwards et al., 2004, n=12; Smart & Doody 2007, n=7; Wallin et al., 2008, n=11; Quinn et al., 2009, n=9; Skjaerven, Kristoffersen & Gard, 2010, n=15; Haas et al., 2012, n=24Kristensen, Borg & Houndsgaard, 2012, n=14).

4.3.6 Recruitment

Recruitment for phase 2 (n=10) was from participants (n=143) in phase 1 who had indicated their willingness to take part in a semi structured interview in order to expand on the information they had provided in response to the questionnaire. This selection bias of a subgroup from a specific group of physiotherapists working in neurology may have impacted on the range and transferability of the data collected (Edwards et al., 2004; Larsson & Gard, 2006; Plummer et al., 2006).

Potential participants were contacted by email and information about phase 2 (participant letter and information sheet – see Appendix) was provided.

Potential participants were asked to contact the researcher by email or telephone if they were still interested and in order to arrange a convenient time for a telephone interview. Twelve potential participants were contacted and interviews were arranged with ten; it was not possible to coordinate a time with the remaining potential participants because of limitations imposed by their family or work.

Potential participants were assured that the time devoted to the interview was under their control; all participants were very generous with their time and interviews lasted between 30 and 60 minutes. Consent to record,

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transcribe and analyse the interview data for themes was obtained by email prior to contacting participants by telephone at the time arranged,

participants email replies were considered as tacit consent to participation, the researcher did not have mail addresses for participants; further verbal consent was given at the beginning of each telephone conversation.

Participants were assured of anonymity and transcriptions were returned to each participant to edit, amend and expand further in order to ensure their discussion with the researcher was accurately represented and that they had conveyed the information which they wished.