By Rebecca Winter- Occupational Therapist at NNUH
Research, Evaluation and Quality Improvement NICHE Scholarship
The relationship between occupation as purposeful, meaningful and
goal-directed doing, and health and wellbeing has been well
established in Occupational Therapy (OT) literature (Wilcock 2006,
Hocking, 2009). Engaging in creative and meaningful occupation can
impact positively on health and wellbeing (Ellis-Hill, 2019). Participating
in social and leisure activities are also legitimate goals of intermediate
care, as outlined by the NICE guidelines (NICE, 2017).
Creative arts-based therapies have been recommended for stroke
survivors, and have no adverse side-effects (Lo, 2018). Craft materials
can often be sourced for low-cost or from recycled materials, which is
essential given NHS budget restraints.
Creative arts therapies can be used to help reduce anxiety, depression
and isolation with stroke patients by helping them express internal
feelings through artwork (Kongkasuwan, 2015). Stroke survivors who
have received art interventions have been shown to improve their
spatial processing, attention, planning/sequencing, social expression
and increased use of affected limb (Reynolds, 2012). Improved spatial
improvement in brain connectivity may also be associated with
increased psychological resilience in adults, which is beneficial
following such a life-changing event such as stroke (Bolwerk, 2014).
Art-based therapies can be a useful supplement to existing stroke
rehabilitation programs that have a primary focus on functional
recovery. This comprehensive rehabilitation provides holistic care and
enhances the post-stroke quality of life for survivors (Lo, 2018).
Approximately two-thirds of stroke survivors in the UK are left with
some form of disability. Therapy is key to recovery and quality of life,
and evidence shows that intensity is key. Therefore the Stroke Sentinel
National Audit Programme (SSNAP) recommend 45 minutes of therapy
daily. However, this is rarely achieved and therapy is often infrequent.
Staffing levels are a contributing factor, along with the severity of the
stroke (Gittins 2020). Providing a group with activities for different skill
levels and allowing therapists to see multiple patients at once may
improve patient outcomes and the SSNAP targets for the department.
An ‘art’ based group was chosen by the OT team following
communication with other trusts about the groups they were running.
The resources were easy to obtain via community social pages,
meaning there would be no costs to the ward. Many patients
highlighted creative pursuits when asked about their hobbies by the OT
team.
The project aimed to increase the overall SSNAP rating score for OT
within Neurosciences, and to review the patient experience of being a
group participant to see if there were any additional benefits to offering
groups in an inpatient setting.
Quantitative Data: Patient Feedback:
A survey was developed which tracked: Quantitative data analysis showed mostly positive feedback, such as enjoying the opportunity
• The banding and amount of staff to run each session for social connection, enjoying the diversity of activities and the opportunity to have a change
• Patient attendance/drop-out rate of environment. Patients also reported self-rated improvement in hand function, however as
• Patients support needs the sessions are short and often patients move on from the acute environment to onward
rehabilitation it is difficult to formally measure functional change.
This data was then analysed using Excel to identify trends and connections.
While comments were mostly positive patients also mentioned finding creativity challenging,
Graph 1 shows that the mean total of staff to run the group over the four especially if it is not a usual occupation for them. Also comparing themselves to others can
months was 12 per month. The mean amount of attendance was 19.25 lead to personal frustration about how their abilities have changed post-stroke.
patients. This data is slightly affected by some months being longer than
others, so more sessions were run. Staffing Impact:
Qualitative data: Graph 2 shows the amount of staff vs. the total attendance of patients during the session.
Qualitative data analysis showed that occasionally high staff numbers were running the group.
Patients were surveyed during their session to gain feedback on their As per the annotations on the graph this was often due to a multitude of factors, such as new
experience joining the groups. Questions included: students joining the team and training up new or returning staff. However, this would have
meant the group was less effective from a SSNAP perspective. The group takes 2 hours to
1. Do you feel that the group therapy session is of benefit to you? If so, Graph 1 run, including prep time and collecting patients. As it’s taking 12 staff on average to run the
how? group monthly there needs to be a minimum of 24 attendances to make it an effective use of
2. Are there any particular aspects of the group sessions that you enjoy? time. However, the general trend is that it is taking fewer staffing hours to run the group now
3. Are there any particular aspects of the group session that you dislike? that it has become more established, hopefully this trend will continue.
4. Do you feel your function has improved? If so, how?
5. Are there any changes you would make to the group? Graph 3 shows that there was only one week with no patient dropouts. This is a consistent
issue and contributes to the group being less effective from a SSNAP perspective as fewer
patients attend than anticipated. It was felt some of this was due to staff referring patients
Not all patients were able to respond to the feedback request, due to without having the chance to fully explain the group. A leaflet and poster (pictured left and
reasons such as aphasia or cognitive difficulties. below) were created for the patients to read in their own time, as this took some time to get
approval it is not yet known if this will have an impact on patient drop-out rates.
Graph 2 Staffing impact on attendance PDSA Developments:
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Training new High staff Multiple PDSA cycles were completed, mostly due to staff feedback that the group could be
staff sickness
7 Most patients
unwell or not
difficult to run if the usual OT staff were absent. This lead to the creation of a flowchart, altered
6 ready for referral form and ‘easy pickup’ activities to try and facilitate smoother running of the group, and
group
ensure sustainability as the group could then be continued if the leading OT’s were absent.
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4
3
2
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Implementing a therapy group in an acute setting can be a lengthy process to embed in a
busy environment. Fluctuations in patient motivation, attendance, support requirements and
0 staffing numbers can all have an impact on the effectiveness of group therapy.
Despite this the group received mostly positive feedback from a patient experience
Total 'Staffing' Total Attendances Poly. (Total 'Staffing') Poly. (Total Attendances) perspective, indicating that patients receive many social, mental and physical benefits from
having the opportunity to attend a group therapy session.
Graph 3 Referrals impact on attendance
12 Further study would benefit to establish the effectiveness of the new leaflet on patient drop-
New referral High staff out rates, also to compare data from other settings such as inpatient rehabilitation units
form created sickness
10 where patients may be more independent with less demands on staffing numbers- which
may show greater effectiveness from a SSNAP perspective.
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6 Acknowledgements: I would like to thank my mentors Rene Gray and Jonty Yazbek for all of their guidance and support with the
scholarship.
4 References: Bolwerk A, et.al. How art changes your brain: differential effects of visual art production and cognitive art evaluation on
functional brain connectivity. PLoS One. 2014 Jul 1;9. Ellis-Hill C, et al. HeART of Stroke: randomised controlled, parallel-arm,
feasibility study of a community-based arts and health intervention plus usual care compared with usual care to increase psychological
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well-being in people following a stroke. BMJ Open 2019. Gittins M, et.al. Delivery, dose, outcomes and resource use of stroke therapy:
the SSNAPIEST observational study. Southampton (UK): NIHR Journals Library; 2020. Hocking, C. (2009). The challenge of
0 occupation: Describing the things people do. Journal of Occupational Science, 16(3), 140–150. Intercollegiate Stroke Working Party;
SSNAP Acute Organisational Audit Report 2021. London: King's College London, 2022. Kongkasuwan R, et.al. Creative art therapy to
enhance rehabilitation for stroke patients: a randomized controlled trial. Clin Rehabil. 2016 Oct;30(10). Lo TLT, Lee JLC and Ho RTH
(2018) Creative Arts-Based Therapies for Stroke Survivors: A Qualitative Systematic Review. Reynolds, Frances. (2012). Art therapy
Amount of referrals Total Attendances Poly. (Amount of referrals) Poly. (Total Attendances) after stroke: Evidence and a need for further research. The Arts in Psychotherapy. 39. 239–244. Wilcock, A. (2006). An Occupational
Perspective on Health (2nd ed.), Thorofare, NJ: Slack.