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The research presented within this thesis utilised a mixed methods research design to explore self-management practices specific to stroke within four studies: 1) a systematic literature review of trials on stroke self-management; 2) a feasibility randomised controlled trial (RCT) exploring the Bridges stroke self-management programme (SSMP) in addition to community rehabilitation versus usual rehabilitation; 3) a qualitative study conducted with participants from the feasibility RCT to explore their experiences of the Bridges SSMP and, 4) a comparative study exploring the Bridges SSMP with an alternative self-management programme currently offered within Northern Ireland. Study 1 identified relatively few published studies on stroke self-management programmes. The types of programmes explored in these studies varied and results were mixed but findings suggest some effect on functional recovery, quality of life and confidence in recovery post stroke. Study 2 established that the Bridges SSMP appeared feasible to implement within the clinical rehabilitation setting, however, further exploration of the reasons behind relatively low recruitment needs further evaluation. Study 3 found that the Bridges SSMP was acceptable to all stakeholders and helped illuminate key mechanisms of change involved in the Bridges SSMP such as the personalised nature of goal setting which resulted in the perception by participants that they were better able to manage their progress. Study 4 suggested that the Bridges SSMP was equally as acceptable and feasible to deliver as the Taking Control self-management programme currently offered by Northern Ireland Chest Heart and Stroke but highlighted key issues related to the delivery of both programmes that need further exploration. The findings of this research suggest that self-management programmes may offer potential benefit to stroke participants and indicate that it may be feasible to deliver the Bridges SSMP in both the clinical rehabilitation and voluntary sector. Further research is needed to improve the understanding of the mechanisms and context of delivery.

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The development of collaborative interdisciplinary working is a key element of contemporary health policy. Future healthcare workers will need to work. individually, collaboratively and in teams if they are to meet the complex and changing needs of the patients they serve. The literature related to health professional team working identifies many barriers and sources of potential conflict, but there is also evidence that effective interdisciplinary teamwork can be achieved and is associated with improved health outcomes. The specialised and co-ordinated multidisciplinary team care provided in stroke units was considered to contribute directly to the improved patient outcomes seen in these units. However, the ways in which stroke unit team members co-ordinate their work was not clearly understood. This study utilised a grounded theory approach to develop an explanation of the ways in which health professionals in two stroke rehabilitation units in the North of England achieved teamwork. Data were generated through over 200 hours of participant observation and thirty four semistructured interviews with a range of team members. The findings of the study identified a basic social process which was common to team working in both stroke units; this process was termed 'opportunistic dialogue'. This represented an interactional process through which the division of labour in respect of specific rehabilitation activities was worked out and agreed by team members on a day-to-day basis. Co-location of most team members in both units led to repeated engagement in sharing and validating patient information and in exploring different perspectives. Opportunistic dialoguing contributed to mutual learning in the stroke unit teams and explained the shift in thinking and team culture which occurred as team members moved from concern with discrete disciplinary actions to dialogue and negotiations focused on collaboration to meet the needs of stroke patients. Negotiations played a major role in opportunistic dialogue and coming to agreement on the teams' rehabilitation work. The study findings emphasised the interrelatedness and interdependence of these concepts as core interactional processes contributing to the achievement of teamwork in stroke units. The study confirmed the utility of the negotiated order perspective in understanding and explaining workplace interactions, but identified that whilst negotiations were a key feature of opportunistic dialogue, other processes also contributed to achieving and maintaining teamwork. Focussing on dialogue demonstrated that patterned talk-in-interaction processes maximised the contribution of opportunistic dialogue to coordinating the skills and knowledge of the different disciplines participating in stroke rehabilitation. The achievement of teamwork in these units occurred through access to and participation in opportunistic dialogue.

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The onset of a stroke provides a unique set of challenges and complex experiences for the person and carer, which are particularly evident during transition to home. Previous studies from a family or couple’s perspectives underline the role of interdependence between the person post stroke and the partner for recovery and adaptation process. Moreover, longitudinal findings suggest that the path of adaptation continues to present challenges to both. However, the literature is sparse on interrelations of both people post stroke and carers’ needs, how they manage the new situation and its implications over time, as well as how health professionals may support their adaptation to a new life situation after stroke. Additionally, research on adaptation and coping post stroke in the Portuguese context is almost non-existent. Therefore, this thesis explores the topic of adaptation and coping process during transition to home and rehabilitation after stroke. In particular, it asks: 1) How do Portuguese people, who have experienced a stroke and their carers, cope with the demands of stroke and rehabilitation? and 2) How are roles perceived within the triad (person post stroke, carer and health professional) to facilitate the adaptation and coping process during rehabilitation and transition to home? By undertaking a longitudinal and multi-perspective design this thesis contributes to the literature mainly with: 1) a metasynthesis of qualitative research focusing on people post stroke and carers’ views about coping throughout the first year, including 22 studies and a total of 596 participants, and 2) an understanding of how people who have had a stroke and their carers cope after stroke and during rehabilitation in the first six months at home in a Portuguese context, involving 24 participants (8 triads) in a total of 33 interviews. Additionally, service users and other stakeholders (18 members) were included by organising meetings with advisory groups in order to provide comments and advice on recommendations from the thesis findings and the dissemination of results. This thesis provides a new perspective about the support and interrelations within the family. The importance of a balanced and reciprocal support between the person post stroke and carer(s) over time was emphasised, helping both people post stroke and carers to find their own way of managing their new life situation. A unique contribution was achieved from studying a Portuguese context. With time, Portuguese participants seemed to move from a point when future plans were avoided to a time when they changed their view of the future and life goals, which seemed also to be better achieved within the family. Furthermore, new insights resulted from the methodological approach selected. By undertaking a multi-perspective study involving a triad, similarities and differences were found, with a gap between perspectives of both people post stroke/ carers and health professionals giving additional insights to the need of moving rehabilitation away from the predominant functional and paternalistic approach. Findings from the empirical study suggest the importance of gradually increasing the people post stroke and carers’ active engagement in the adaptation and rehabilitation processes in a dyadic perspective. Moreover, it would also suggest the need for gradual change and adjustment of the health professionals’ approach throughout rehabilitation, according to both people post stroke and carers’ needs and expectations.

Background Stroke is the leading cause of long-term neurological disability in adults and the third most common cause of death in Britain. It is well known that in addition to the patient characteristics of age and severity, the treatment a stroke patient receives in hospital signifcantly affects outcome. The effectiveness of complex service interventions, how the benefits of these interventions are achieved and the economic impact of different types of service delivery were explored. Methods The Stroke Unit Trialists' Collaboration systematic review was updated and currently contains 31 clinical trials (6936 subjects). The aims were explored using various basic frequentist and Bayesian meta-analysis techniques as well as more complex meta-analysis ideas. These more complex ideas include: meta-regression where covariate information is incorporated into the model; and network meta-analysis where direct and indirect information is used in a mixed treatment comparisons model while also incorporating covariate information. Results Organised inpatient (stroke unit) care showed reductions in death, death or dependency and death or institutional care compared to general medical wards. Stroke unit care appears to reduce the risk of adverse outcomes through prevention and treatment of complications. Acute, comprehensive and rehabilitation stroke unit care appeared to be most effective and acute stroke unit care appeared to be the most cost-effective. However, acute followed by rehabilitation stroke unit care, if required, appears to be the most cost-effective pathway of care compared to the other pathways analysed. Discussion Future research should focus on rehabilitation, acute and comprehensive systems of inpatient care, and explore the best ways of preventing and managing specific complications. Effort should be made to make individual patient data and information on the care pathway of a stroke patient available for meta-analysis.