Co-designing organisational improvements and interventions to increase inpatient activity in four stroke units in England: A mixed-methods process evaluation using normalisation process theory

David Clarke, Karolina Gombert-Waldron, Stephanie Honey, Geoffrey Cloud, Ruth Harris, Alastair MacDonald, Christopher McKevitt, Glenn Robert, Fiona Jones

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11 Citations (Scopus)


Objective To explore facilitators and barriers to using experience-based co-design (EBCD) and accelerated EBCD (AEBCD) in the development and implementation of interventions to increase activity opportunities for inpatient stroke survivors. Design Mixed-methods process evaluation underpinned by normalisation process theory (NPT). Setting Four post-acute rehabilitation stroke units in England. Participants Stroke survivors, family members, stroke unit staff, hospital managers, support staff and volunteers. Data informing our NPT analysis comprised: ethnographic observations, n=366 hours; semistructured interviews with 76 staff, 53 stroke survivors and 27 family members pre-EBCD/AEBCD implementation or post-EBCD/AEBCD implementation; and observation of 43 co-design meetings involving 23 stroke survivors, 21 family carers and 54 staff. Results Former patients and families valued participation in EBCD/AEBCD perceiving they were equal partners in co-design. Staff engaged with EBCD/AEBCD, reporting it as a valuable improvement approach leading to increased activity opportunities. The structured EBCD/AEBCD approach was influential in enabling coherence and cognitive participation and legitimated staff involvement in the change process. Researcher facilitation of EBCD/AEBCD supported cognitive participation, collective action and reflexive monitoring; these were important in implementing and sustaining co-design activities. Observations and interviews post-EBCD/AEBCD cycles confirmed creation and use of new social spaces and increased activity opportunities in all units. EBCD/AEBCD facilitated engagement with wider hospital resources and local communities, further enhancing activity opportunities. However, outside of structured group activity, many individual staff-patient interactions remained task focused. Conclusions EBCD/AEBCD facilitated the development and implementation of environmental changes and revisions to work routines which supported increased activity opportunities in stroke units providing post-acute and rehabilitation care. Former stroke patients and carers contributed to improvements. NPT's generative mechanisms were instrumental in analysis and interpretation of facilitators and barriers at the individual, group and organisational level, and can help inform future implementations of similar approaches.

Original languageEnglish
Article numbere042723
Number of pages16
JournalBMJ Open
Issue number1
Publication statusPublished - Jan 2021


  • qualitative research
  • quality in healthcare
  • rehabilitation medicine
  • stroke

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