Summary of the impact

Bridges is a novel programme for self-management of stroke. Training in this programme has been delivered to health and social care practitioners across England, and has recently begun to be taken up in New Zealand. This has resulted in significant changes to the practice of post-stroke practitioners who have incorporated the Bridges programme into their practice, towards using more person centred and self-management approaches. Bridges is the first social enterprise spin out from Kingston University, and was successfully launched in 2013 following development grants from Unltd.

Underpinning research

In 2006, no post-stroke self-management programmes existed in the UK, despite evidence of people having reduced quality of life, high levels of depression and a sense of abandonment after discharge from stroke rehabilitation. A qualitative study published by Fiona Jones in 2008 showed that patients attributed much of their progress to their individual beliefs and confidence [3]. This research directly informed the development of the Bridges programme. Research in 2008 by Jones also led to the first stroke self-efficacy questionnaire which provides a method of measuring confidence and self-management after stroke [2]. A research programme carried out by Jones, starting in 2006 and continuing to the present, resulted in development of the first individualised stroke-specific self-management programme — and Bridges (previously known as Stepping Out) was launched in 2008/9. Bridges consists of a unique programme of training for professionals to support self-management skills and self-efficacy in people post stroke, using an interactive stroke workbook and a set of defined strategies with individuals at any stage post stroke [4]. A systematic review published by Jones in 2011 was the first review of self-management and self-efficacy in stroke in the UK, and has added to knowledge about the role of supporting self-efficacy in stroke rehabilitation [5].

The underpinning research for Bridges has employed several different methods and methodologies in order to explore the experiences of stroke practitioners using the programme. A key finding from the research is that practitioners trained to use Bridges have changed their attitudes, beliefs and practice towards using a self-management approach [6]. This research evaluated the use of the Bridges programme across a whole stroke pathway (hospital and community) and also showed there was greater communication and consistency in how self-management was integrated into rehabilitation. Findings from further research have revealed distinct areas of changes such as use of self-efficacy principles, and a different approach to goal setting in order to better support patients' self-management and confidence to continue to progress after discharge from rehabilitation [6].

Early proof of concept work showed a change in self-efficacy in stroke patients using the programme [4]. A later research trial carried out by Jones in collaboration with University of Ulster in 2010, which tested the feasibility and acceptability of Bridges in a community stroke team, also showed favourable changes in self-efficacy and quality of life (for up to 3 months) in patients randomised to the "Bridges" group [1].

All the underpinning research leading to Bridges was conducted by Fiona Jones [Reader in Rehabilitation, employed 2002- present]. Jones was employed throughout this period on a Kingston University contract as a member of the Kingston University / St George's, University of London Joint Faculty of Health, Social Care and Education.

References to the research

The majority of research outputs below have been published in peer reviewed journals. Output [1] is the result of external grant funding which has been peer reviewed. [Northern Ireland Chest Heart and Stroke Association funded study: `Stepping Out: promoting self-management for stroke survivors' (£40,168), 2008-2010, awarded to S. Lennon]

Details of the impact

The development of the Bridges programme has changed practice among stroke practitioners in London and Surrey, and has recently been taken up in New Zealand.

The first vehicle for achieving impact was a programme of Bridges workshops that commenced in 2008. Since then, the Bridges stroke self-management programme and training has been delivered to more than 1200 health and social care practitioners, and remains the only stroke specific self-management programme accredited by the Stroke Specific UK Forum for Training [1]. The programme has advanced the understanding of how to deliver a self-management programme for stroke and directly addressed the guidance in the National stroke strategy in 2007 which stated `There is scope to expand the range of `self-management' activities available for people with stroke' ([2] chapter 3, p39).

The Bridges programme was adopted as a priority project by the National Stroke Improvement plan in 2009 (under its previous title of "Stepping Out") [3], and Bridges was cited as an exemplar case study in the `Life after Stroke' commissioning guidance for London in 2010 [4]. As a direct result of Bridges being included in the Life after Stroke commissioning guidance, the programme has been commissioned in stroke pathways such as Islington, London, where over 70 stroke practitioners were trained to use the programme. An evaluation of the impact of Bridges training in Islington and three other stroke pathways in 2011 (Newcastle, Wandsworth and Worcestershire), involving 82 stroke practitioners from 6 different professional groups found that 99% changed their practice to include a greater focus on self-management as a result of the training [5]. The results showed that practitioners are now more knowledgeable in the use of methods to support self-management, and now integrate Bridges into their practice [6]. Evaluation carried out by Dr Meriel Norris (Brunel) has also demonstrated changes in beliefs, attitudes and practice after training in the Bridges programme [5]. As a consequence these teams are able to show they are addressing the key priorities to promote self-management confidence and increase control as outlined in the UK Stroke strategy (2007) and Kings Fund report (2012).

In 2011, a project funded by the South West London Academic, Health and Social Care Systems (SWL AHSCN) evaluated the introduction of Bridges in the stroke pathway in Kingston, Surrey. The results showed that the Bridges programme changed attitudes to self-management and improved cross team working [6]. These findings led to a further award from SWL AHSCN and HIEC in 2012 to explore the `Sustainability of Bridges one year on'. This was the first evaluation of the impact of Bridges in the longer term, and led to a new programme of training for `Bridges champions' which was launched in 2012 and delivered by Jones at Kingston University, in which senior stroke practitioners are supported to use a whole systems approach to self-management [7].

Further funding has also been awarded in 2013 by SWL AHSCN to develop and evaluate the use of Bridges with care support workers — this is responding to feedback from teams trained in Bridges to extend the training to a wider group of care staff that plays an important role in supporting self-management post stroke.

Stroke practitioners in an East London trust have reported a number of changes to their practice after introducing Bridges, which have been beneficial to service delivery. These include introducing Bridges in the acute/hospital setting, innovative ways to use Bridges with Bengali stroke survivors, and involving service users in an evaluation of the programme [8]. 75 practitioners have been trained since 2011, and have used Bridges with more than 200 patients across acute and community teams. The impact of Bridges in the East London stroke pathway was presented at the UK stroke forum 2012 [8].

Bridges has led to changes in the way in which stroke rehabilitation is delivered in stroke teams, towards using more person centred and self-management approaches. This impact on practice has been recognised through an `excellence in stroke care' award received by Jones from the Stroke Association in 2009 [9], and a Fellowship from the Chartered Society of Physiotherapists for the contribution to advancement in neurorehabilitation in 2010 [10].

The effectiveness of Bridges has received international recognition. Feedback from attendees of a workshop and series of invited keynotes presentations by Jones in 2011 highlighted the need for such a programme in New Zealand. 12 stroke professionals and academics from an Otago district health board were trained by Jones to deliver the programme in August 2012 [11]. The programme is also being piloted for young stroke survivors by the Laura Fergusson Trust in Canterbury, New Zealand [12].

Sources to corroborate the impact

[1] http://www.ukfst.org/courses/15/

[2] http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdf

[3] http://www.improvement.nhs.uk/stroke/CommunityStrokeResource/CSRLifeafterstroke/CSRLifeafterstrokeselfmanagement/tabid/227/Default.aspx
http://www.slcsn.nhs.uk/stroke-npp-steppingout.html South London Cardiac and Stroke network website.

[4] "Life After Stroke: Commissioning Guide" (NHS guidance document)
http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Stroke%2fNational%2fNational%20Project%2fStroke%20Community%20Resource%2fservices%20supporting%20the%20rehab%20process%20and%20life%20after%20stroke%2flondon%20life%20after%20stroke%20guidelines.pdf page 15

[5] Lecturer in Physiotherapy, Brunel University (Corroboratiing Contact Identifier: 1)

[6] Jones F., Bailey N. How can we train stroke practitioners about self-management? Description and evaluation of a pathway wide training programme. European Journal for Person Centered Healthcare, vol 1, no 1 (2013) pp 246-254, http://dx.doi.org/10.5750%2Fejpch.v1i1.660.
http://ubplj.org/index.php/ejpch/article/view/660

[7] http://www.swlondonsystem.org/our-work/stroke-helping-people-make-progress-on-their-own-after-a-stroke

[8] Clinical Lead Neuro Team , Royal London Hospital, Barts Health (Corroborating Contact Identifier: 2)
http://www.acpin.net/EMN2013/Baird%20Community%20stroke%20services.pdf
http://onlinelibrary.wiley.com/doi/10.1111/j.1747-4930.2012.00961.x/pdf Abstracts 108, 058, 068, 156

[9] The Stroke Association UK-Tony.Banks@stroke.org.uk
http://www.csp.org.uk/news/2009/05/12/physio-excellence-stroke-care-award-winner

[10] Chartered Society of Physiotherapy UK.
www.csp.org.uk/sites/files/csp/secure/csp_awards_2010_programme.pdf

[11] Associate Dean of Research, School of Physiotherapy, Otago University, Dunedin (Corroborating Contact Identifier: 3).

[12] Chief Executive Officer, Laura Fergusson Trust (Corroborating Contact Identifier: 4)