The checklist was an A4 summary of the LoTS care assessment sections, the purpose of which was to enable service users to prepare for their assessment. Both teams were keen to introduce the checklist into routine practice because of the benefits anticipated from its implementation. For example, an occupational therapist at service one commented that some individuals described the assessment as an ‘interrogation’ (S1OT1), as the process was lengthy and covered many areas. For this reason it was considered good practice to inform service users of the content of the assessment prior to the Coordinator’s visit. The manager at service one (S1SM) noted: ‘With the number of questions you’re asking them [service users], for them to have jotted things down and have thought about them and knew what was coming we thought that, that was quite a good tool really’, and this opinion was also shared by the manager at service two:
S2SM: It [the checklist] was something that we wanted to do in terms of
communicating and preparing the patients for the visit, so we kind of picked up on some of the things that had been started through the LoTS, in terms of at least being able to, at least when you come, you know, they’re not sort of hounded, they’ve had time to think about some of the issues or concerns for them so they can be prepared for the review in advance rather than being bombarded with lots of questions, and it also makes sure that actually you’re getting things from their perspective as well, rather than having things thrusted upon them, do you know what I mean?
Both services recognised that the assessment could be a negative experience for the service user if they felt ‘hounded’ or ‘interrogated’ during the process. Provision of the checklist could potentially alleviate these negative aspects through offering
service users an opportunity to prepare responses in the relevant domains. A further benefit of preparation, suggested by the manager at service two, was that the checklist might prioritise the ‘patient’s perspective’ i.e. if the individual had documented their concerns the Coordinator could focus the assessment on these points. Provision of the checklist was also valued as a source of support for the Coordinators. The senior occupational therapist (S10T1) at service one (who had taken a lead role in embedding the LoTS care components) commented:
S1OT1: There were some teething problems with it [using the system of care], that people didn’t like asking about sex. That was a big one. So, from that, we decided we were going to send out the patient questionnaire, although I did feel like I was the only person banging on about sending that out to be honest, as it’s all like, there is no admin, and it was just more work, but we should be doing that really and sending out a letter to someone to say, when we had a big waiting list, we need to write to the GP to tell them that we know about this patient as quite often we’d be in before they got their discharge letter from the hospital, or sometimes we’d be much later and people would be ringing up, and it’s important to communicate where you’re up to, so it made us be a bit more efficient.
Administration of the checklist may work to legitimise the coordinators’ coverage of the sensitive assessment domains i.e. sexual function, as service users would be aware that these questions were addressed as part of a standard assessment. The Coordinator (S1OT1) also revealed that there were some concerns over the administration of the checklist and that they had driven this change to improve communication with their service users. At the time of fieldwork, the waiting list for individuals to be seen by a Coordinator was up to eight-weeks. The occupational therapist commented that this led to uncertainty about whether the team had accepted the individual for a period of care. For this reason, a letter informing service users that their referral had been accepted and that they were on the waiting list to be seen was established. This provided a vehicle with which to administer the checklist. This finding also reflects the wider literature on diffusion of innovations, which describes that certain people can act as ‘champions’ of an intervention
facilitating their implementation in practice (Greenhalgh et al., 2004). In comparison to service one, service two corresponded with their service users to notify them of the date and time of their stroke review, and to ask them to complete the Hospital Anxiety and Depression Scale (HADS) (Snaith, 2003). The HADS was used to monitor service users’ mood and to inform referrals to the team psychologists. The checklist was easily incorporated with this as an additional form to complete.
Preparing service users for their assessment was an initiative that both services were keen to implement and they established new, or incorporated its administration with existing processes. The use of the checklist was not specifically explored further in this study. However, observations revealed that it was rarely used during the assessment process. The Coordinators discussed numerous barriers to its use in practice e.g. service users’ cognitive capabilities, poor literary skills, and confusion over its purpose. The Coordinators also reported that they often forgot to prompt its use during the assessment. Fieldwork supported these explanations. The majority of service users did not recall the checklist when prompted by the Coordinator. On the rare occasions when the checklist had been completed, the Coordinator did not use it to facilitate problem identification e.g. to target the individual’s problem areas. Therefore it was not observed to enhance the assessment process. At the service level the teams’ implemented the checklist as intended by the LoTS care team. However at the practitioner and patient level contextual barriers limited its ability to enhance the assessment process. This finding demonstrates the considerable task undertaken by some complex interventions, as their ideas and opportunities have to cascade through different levels before any benefits are realised in practice (Brady et al., 2011).