Age and Ageing 1999; 28: 433–440 q 1999, British Geriatrics Society

Observing the process of care: a stroke

unit, elderly care unit and general
medical ward compared
PANDORA POUND, C AROLINE SABIN, SHAH EBRAHIM
Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, Rowland Hill Street,
London NW3 2PF, UK

Address correspondence to: P. Pound, Department of Public Health Sciences, GKT, 5th Floor, Capital House, 42 Weston
Street, London SE1 3QD. Fax: (+44) 171 403 4602. Email: p.pound@umds.ac.uk

Abstract
Background and purpose: patients on stroke units have better outcomes but it is not known why. We
investigated the process of care on a stroke unit, an elderly care unit and a general medical ward.
Methods: comparison of the three settings was by non-participant observation of 12 patients in each. Data were
analysed using multi-level modelling methods.
Results: stroke unit patients spent more time out of bed and out of their bay or room, and had more opportunities
for independence than patients on the medical ward. There were more observed attempts on the stroke unit
than on the general medical ward to interact with drowsy, cognitively- or speech-impaired patients. Stroke
unit patients spent more time with visitors. Most of these aspects of care were also found on the elderly care unit,
where patients also spent less time asleep or ‘disengaged’, more time interacting with nurses, and were given
appropriate help more often than those elsewhere. Stroke unit patients received less eye contact, were ignored and
treated in a dehumanizing way more frequently and had more negative interactions or activities than those
elsewhere.
Conclusions: we have identified some aspects of the process of care which may help explain the improved
outcomes on stroke units. These aspects were also observed in the elderly care unit.

Keywords: elderly people, stroke, stroke unit

[19–25]. Only two studies compared stroke units with

Introduction
Patients on stroke units have improved outcomes
compared with those on general wards [1–9]. A
systematic review of 19 trials found that stroke units
were associated with long-term reduction of death,
dependency and institutionalization, with benefits
being independent of age, sex or stroke severity [10].
However, we still do not know why stroke units
improve outcomes. It is unlikely to be the amount of
therapy given, since this is not much greater on stroke
units [11]. Perhaps stroke units manage secondary
complications better [12].
It is difficult to get information about the process
of care. One way is to review case notes retrospec-
tively [13], but a more accurate method is to observe
what happens to patients. This approach has been
used to study rehabilitation [14, 15], health care for
elderly people [16–18] and the care of stroke patients
conventional care: one [20] found that stroke unit
patients spent more time in treatment (nursing,
therapy and medical care) while the other [23] found
they interacted more with nurses and therapists and
that limb positioning was better. None explored
the quality of the interactions or activities. Further-
more, none compared stroke units with elderly care
wards.
In randomized controlled trials of stroke units,
elderly care units tend to be combined with general
medical wards to form a ‘conventional care’ compar-
ison group [4], thus obscuring any contribution that
interdisciplinary care might make. For this reason, we
compare the process and quality of care between a
stroke unit, elderly care unit and general medical ward.
The aim was to identify aspects of the process of care
which may help explain the improved outcomes
associated with stroke unit care.

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P. Pound et al.

Methods information about the patient’s location, position (bed,

chair, other), activity, who they were with and what
type of interaction (if any) was occurring. Assessments
Settings of the quality of each activity/interaction were also
The elderly care unit and general medical ward were in recorded [for example, whether the patient was given
one inner-city teaching hospital and the stroke unit was the chance to be independent (if appropriate)]. Some
in another teaching hospital in the same city. The of these assessments of quality were subjective. In
stroke unit offered rehabilitation to stroke patients of particular, one item recorded whether the researcher
all ages, with the exception of those receiving terminal felt the activity or interaction to be ‘dehumanizing’ (for
care and those likely to be discharged quickly. It was example, if a patient was wheeled from one room to
run by an interdisciplinary team headed by a con- another without any explanation).
sultant physician with an interest in stroke. It had 24
beds and was 3 years old at the time of the study. The Data collection
elderly care unit consisted of an acute ward (18 beds)
Permission to observe was sought from staff and
and a rehabilitation ward (22 beds), both of which
patients involved, or from the carers of those patients
were run by interdisciplinary teams headed by the
with cognitive impairment. Access was freely per-
same consultant physician. The general medical ward
mitted and no-one refused. Pre-stroke Barthel index,
had 32 beds. Nine consultants had patients on this
diagnosis and the Barthel score and conscious level on
ward. Although stroke patients were referred to
admission were obtained from the medical notes.
therapists, there were no interdisciplinary team meet-
Barthel score upon observation was assessed by the
ings. At the time of the study there were 1.8 patients to
observer, while clinical assessments of conscious level
every nurse (including nursing assistants and student
and cognitive and speech impairment upon observation
nurses) on the stroke unit, 1.7 per nurse in the elderly
were made by a doctor.
care unit and 2.9 per nurse in the general medical
Stroke patients already in each setting when the
ward.
study began were observed and further patients
recruited consecutively as they were admitted. The
The observational schedule observer sat no more than 3 m away from the patient.
Non-participant observation was used. The items on Each patient was observed for three consecutive 5-min
the observation schedule were developed after several periods in every hour of an 8 h shift. Consequently,
weeks of observing stroke patients in one setting. The each patient provided 24 ‘units’ of observation. Twelve
schedule was then piloted and modified slightly. The patients were observed in each setting, generating
final version (see Appendix) consisted of a form 288 units of observation in each setting and 864 units
for each patient, enabling the researcher to record of observation in total. In each setting, 72 units of

Table 1. Patient characteristics

Stroke unit Elderly care unit General medical ward
(n = 12) (n = 12) (n = 12) Pa
..................................................................................................................................................................................................

Median age (range) 70 (43–90) 80 (74–84) 72 (47–91) 0.12

Female 6 (50%) 9 (75%) 6 (50%) 0.36
Median pre-stroke Barthel index (range) 20 (8–20) 20 (17–20) 20 (2–20) 0.54
Impairment of consciousness on admission 2 (17%) 3 (25%) 3 (25%) 0.91
Right hemisphere stroke 3 (25%) 5 (42%) 8 (67%) 0.12
Median Barthel index (range)
On admission 5 (0–9) 0 (0–20) 2 (0–20) 0.23
On observation 7 (0–16) 6 (0–20) 5 (0–20) 0.98
Impairment of consciousness at observation 2 (17%) 3 (25%) 2 (17%) 0.35
Cognitive impairment on observation 4 (33%) 1 (8%) 2 (17%) 0.19
Speech impairment on observation 7 (58%) 5 (42%) 5 (42%) 0.85
Median length of stay (range) 61 (4–134) 31 (2–307) 24 (2–155) 0.51

a
Mann–Whitney U-test (continuous data) or x2 test/Fisher’s exact test (discrete data) as appropriate.

434
 Observing the care of stroke patients

observation were made between 0730 h and 1530 h, possibility, multi-level modelling methods (which allow
120 between 0930 h and 1730 h and 96 between the hierarchical nature of the data to be exploited)
1430 h and 2230 h. were used where possible. Using these methods [26],
the variance structure of the data can be more precisely
Reliability defined and measurements within individuals can be
assumed to be correlated. The advantages of these
The researcher and an independent observer simulta-
methods have been described [27].
neously recorded 96 5-min observational sessions to
For each variable, a multi-level logistic model was
test the inter-observer reliability of the schedule.
fitted using the NONLIN macro in the statistical
package MLn [28]. The primary questions addressed
Data analysis
were: (i) were there any differences in the process of
The unit of analysis was not the patient, but the care between the three settings and (ii) could these
observations generated by each patient. Because each differences be explained by differences in the type of
patient contributed 24 observations to the data set, patients admitted to each setting. For each analysis, the
we thought that some of the observed differences individual observation was treated as the level-one
between settings might be explained by the activities variable and the patient was treated as the level-two
of one or two patients and/or differences in patient variable. Thus, within- and between-subject variation
characteristics in each of the settings. To explore this in each outcome could be explicitly incorporated into

Table 2. Patient location, position, activity and interaction (multi-level logistic regression)
Unadjusted Adjusteda
................................................... ............................................................

Setting OR 95% CI Pb OR 95% CI Pb

........................................................................................................................................................................................................................

Was patient in bay? Stroke unit 1 – – 1 – --

ECU 1.03 0.34–3.13 0.95 1.75 0.59–5.22 0.31
GMW 9.84 2.79–34.64 0.0004 6.74 1.73–26.18 0.006
Was patient in bed? Stroke unit 1 – – 1 – –
ECU 1.68 0.49–5.78 0.41 1.04 0.24–4.58 0.96
GMW 3.47 0.93–12.89 0.06 4.76 1.09–20.88 0.04
Was patient in chair? Stroke unit 1 – – 1 – –
ECU 1.12 0.42–2.93 0.82 0.78 0.15–4.16 0.77
GMW 0.61 0.20–1.89 0.39 0.30 0.04–1.97 0.21
Was patient elsewhere? Stroke unit 1 – – 1 – –
ECU 0.39 0.17–0.90 0.03 0.21 0.09–0.51 0.0007
GMW 0.29 0.09–0.89 0.03 0.12 0.05–0.28 < 0.0001
Was patient involved in activity? Stroke unit 1 – – 1 – –
ECU 0.99 0.47–2.08 0.98 0.69 0.34–1.43 0.32
GMW 0.91 0.40–2.06 0.81 0.64 0.32–1.27 0.20
Was patient alone? Stroke unit 1 – – 1 – –
ECU 1.31 0.62–2.78 0.48 1.31 0.62–2.76 0.48
GMW 1.29 0.54–3.11 0.57 1.31 0.61–2.81 0.48
Was patient involved in interaction? Stroke unit 1 – – 1 – –
ECU 0.95 0.50–1.83 0.88 0.95 0.49–1.82 0.87
GMW 0.88 0.41–1.91 0.76 0.87 0.44–1.71 0.68

ECU, elderly care unit; GMW, general medical ward; OR, odds ratio; CI, confidence interval.
a
Adjusted for the variables listed in Table 1 and the time of observation.
b
P-values (obtained by taking a normal approximation and dividing the estimate by its standard error) refer to the odds of the event occurring in
patients on the general medical ward or elderly care unit compared with the odds of it occurring in patients on the stroke unit.

435
P. Pound et al.

the model. The setting effect is presented both before in the patient characteristics on admission or at
and after adjustment for the patient characteristics observation (Table 1).
shown in Table 1 and the time of observation. Setting
effects were treated as random effects, in that the Inter-rater reliability
impact of the setting was allowed to vary between
individual observations. All other effects were treated Most items had good to moderate reliability (k values of
as fixed: in other words, each factor had the same 0.51–1.00) including 12 which had a k value of > 0.75.
effect on different observations. Only two items had fair reliability (k ¼ 0.21–0.4): ‘Was
Multi-level modelling methods were used in cases the patient given the chance to be independent?’ and
where observations applied to all patients. However, ‘Was patient given feedback (none/positive/negative)?’.
where observations only applied to some patients One item—‘Was patient given a choice about the
(for example, the quality of interaction among those activity?’—had poor reliability (k < 0.01).
engaged in interaction), the numbers were too small
for multi-level modelling techniques and frequencies Comparisons between settings
were used instead. Because the observations were not
independent we have not used conventional statistical
hypothesis testing in these cases. Inter-rater reliability Multi-level logistic regression
was calculated using weighted k. After adjusting for patient characteristics, general
medical ward patients were more likely to be in the
bay (P = 0.006) and in bed (P = 0.04) than patients on
Results the stroke unit (Table 2). There were no significant
differences between the stroke unit and elderly care
unit with these two variables. Patients on the general
Patients ward were less likely to be somewhere other than their
No significant differences were found between settings bed or chair (P < 0.0001) than patients on the stroke

Table 3. Location, position and activities (frequencies)

Stroke unit Elderly care unit General medical ward
(n = 288a) (n = 288) (n = 288)
........................................................................................................................................................................................................................

Location Bay/single room 206 (71%) 209 (73%) 277 (96%)

Treatment location (therapy/investigations) 13 (5%) 11 (4%) 6 (2%)
Other (dayroom/bathroom/corridors/off ward etc.) 61 (21%) 68 (24%) 5 (2%)
Unobservable 8 (3%) 0 0
Position In bed 70 (24%) 101 (35%) 152 (53%)
In chair 142 (49%) 154 (53%) 111 (39%)
Other (bathing, dressing transferring, walking etc.) 76 (26%) 33 (11%) 25 (9%)
Activities Unconscious or drowsy patients sleeping 27 (9%) 40 (14%) 27 (9%)
Conscious patients sleeping or ‘disengaged’ 71 (25%) 51 (18%) 78 (27%)
Doing nothing, but alert 42 (15%) 59 (20%) 50 (17%)
Interacting (chatting/talking) 31 (11%) 35 (12%) 39 (14%)
Activities of daily living 44 (15%) 50 (17%) 37 (13%)
Recreation (TV/reading/trips etc.) 27 (9%) 16 (6%) 14 (5%)
Professional attention (all professionals) 17 (6%) 28 (10%) 29 (10%)
Other 3 (1%) 0 3 (1%)
Unobservable 26 (9%) 9 (3%) 11 (4%)
Total activity 122 (42%) 129 (45%) 122 (42%)
Total no activity 140 (49%) 150 (52%) 155 (53%)

a
Total units of observation.

436
 Observing the care of stroke patients

unit. Patients in both the general ward and the elderly Frequency of interactions
care unit were less likely to be involved in some form of
activity, although these effects were not statistically Patients were observed to be with therapists for similar
significant (P = 0.20 and 0.32 respectively). No sig- amounts of time in each setting (Table 4). Stroke unit
nificant differences were found between settings in patients, however, were with visitors more frequently
terms of whether patients were alone or accompanied, than elderly care unit or general ward patients. Patients
or engaged in interaction. The results from the on the elderly care unit were observed to be with
frequencies support these findings (Table 3). nurses more frequently than stroke unit and general
ward patients, while patients on the general ward were
observed to be with others (patients, domestics,
Frequency of different activities porters, doctors, psychologists, volunteers, pharma-
cists) more frequently than patients elsewhere. The
For about half of all observations in each setting
same pattern was found in terms of who interacted
patients were unoccupied, but those on the stroke unit
with patients. While the amounts of interaction were
were observed to be in recreational activity more often
similar in all settings, the types of interaction differed.
than those in the elderly care unit or general ward
Attempts to interact with drowsy, unconscious,
(Table 3). Conscious elderly care unit patients were
speech- or cognitively-impaired patients were observed
less frequently observed to be sleeping or ‘disengaged’
more frequently on the elderly care unit and stroke unit
(i.e. staring into space) than conscious stroke unit or
than on the general ward, while verbal interaction only
general ward patients.
was observed more frequently on the general ward
than elsewhere.

Quality of activities and interactions

Table 4. Person with patient, person interacting with patient
and type of interaction (frequencies) Patients on the elderly care unit and stroke unit were
Stroke unit ECU GMW
observed to be given the chance to be independent (if
(n = 288a) (n = 288) (n = 288) appropriate) more frequently than those on the general
.......................................................................................................
ward. Patients on the elderly care unit were observed
Person with patient to be given help (if needed) more frequently than those
None 142 (49%) 172 (60%) 171 (59%) in the stroke unit and general ward (Table 5). Stroke
Visitor 66 (23%) 36 (12%) 45 (16%)
unit patients were given eye contact less frequently,
ignored more frequently, treated in a ‘dehumanizing’
Nurse 34 (12%) 52 (18%) 34 (12%) manner more frequently, and more frequently had an
Therapist 11 (4%) 11 (4%) 9 (3%) overall negative quality of interaction than those in the
b elderly care unit or general ward.
Other 12 (4%) 17 (6%) 29 (10%)
Unobservable 23 (8%) 0 0
Interactions Discussion
Allc
104 (36%) 108 (38%) 103 (36%) A randomized study design might be thought prefer-
d able to an observational comparison, but we felt that an
With visitors 53 (51%) 32 (30%) 36 (35%)
observational study would be more likely to reveal real
d
With nurses 28 (27%) 50 (46%) 32 (31%) differences in the processes of care between settings.
With therapists d
11 (11%) 11 (10%) 9 (9%) Furthermore, our use of multi-level modelling has
b,d
enabled us to make some allowance for patient
With others 12 (12%) 15 (14%) 26 (25%)
differences between the settings.
d
Interaction type The periods of observation within each hour were
Verbal 28 (27%)d 14 (13%) 47 (46%) not selected randomly, and this could have introduced
the possibility of systematic bias. However, the
Physical 9 (9%) 12 (11%) 9 (9%) researcher was usually present on the wards as an
Verbal and physical 16 (15%) 24 (22%) 14 (14%) observer throughout the whole of each 8 h shift, not
only during the 15 min periods of structured observa-
Attempted 51 (49%) 58 (54%) 33 (32%)
tion. As such, ward staff would not know exactly when
observations were being recorded and the researcher
ECU, elderly care unit; GMW, general medical ward. would have been aware of any systematic bias.
a
Total units of observation.
b Non-participant observation overcomes the discre-
Including other patients, doctors, psychologists, porters, domestics,
volunteers, pharmacists. pancies between what people say they do and what
c
Percentages are of total units of observation. they actually do. Nevertheless, the observer may affect
d
Percentages are of total units of observation. the situation under observation. With comparative

437
P. Pound et al.

studies, however, we can assume that if people alter
their behaviour under observation they will do so to
the same extent in each setting, so providing a stable
baseline for comparisons. Another possibility is that
two observers may report the same activity differently.
Most items on our schedule, however, showed good
inter-observer reliability, suggesting that the observa-
tions are reliable. Finally, observer bias (the influence
of the observer’s views about the appropriate setting
for stroke patients) seems minimal, since several of the
findings (for example, the poor quality of some
interactions on the stroke unit) were unanticipated.
In analysis of observational data, each observation
can be treated as an independent observation in the
analysis, with the patient characteristics repeated 24
times for each patient. However, because of the
correlations between observations on the same
patient, the variance of estimates from this approach
are often underestimated. An alternative approach is to
convert the 24 observations from each patient into a
single patient variable (e.g. was the patient in bed all
day) which then becomes the unit of observation for
the analysis. However, using this approach, the amount
of data is reduced to only 36 observations, and hence
the power to detect differences is reduced. Multi-level
modelling methods offer a convenient method for
analysing most of the data.
The better outcomes on stroke units may be
partially explained by patients in such units spending
more time out of bed and away from the bed area and
being given more opportunity for independence than
those in general medical wards. These findings suggest
that stroke unit patients are mobilizing more than
general ward patients and support earlier findings that
stroke unit patients spend less time lying down and
more time sitting and standing than those on conven-
tional wards [23]. Furthermore, stroke unit patients
spent more time with visitors, suggesting that informal
carers had more opportunity for involvement in
rehabilitation. Relatives were always welcome on the
stroke unit, but on the elderly care unit and general
ward they were restricted to visiting times (although
these were flexible). There were also more attempts on
the stroke unit to interact with patients who were
drowsy, or who had speech or cognitive impairments,
suggesting that these patients received more stimulation
than those on general wards.
With the exception of more contact with visitors,
however, these aspects of care were also observed on the
elderly care unit. The activities of the interdisciplinary

Table 5. Quality of interactions and activities (frequenciesa)

Interaction/activity Stroke unit Elderly care unit General medical ward
..................................................................................................................................................................

Request is answered 3 (75%) 6 (100%) 8 (73%)

Chance to be independent 24 (89%) 28 (100%) 6 (60%)
Given help if needed 23 (72%) 34 (97%) 21 (81%)
Shown patience 29 (88%) 34 (94%) 27 (84%)
Choice about activity 19 (66%) 4 (40%) 10 (62%)
Given explanation 18 (67%) 21 (62%) 33 (85%)
Listened to 38 (88%) 30 (97%) 66 (94%)
Concerns taken seriously 29 (85%) 17 (89%) 45 (96%)
Given eye contact 36 (51%) 52 (71%) 72 (76%)
On same level as patient 39 (48%) 40 (44%) 46 (47%)
Privacy is respected 67 (85%) 25 (89%) 12 (100%)
Patient is ignored 9 (11%) 5 (5%) 2 (1%)
Activity/interaction is dehumanizing 15 (18%) 5 (5%) 4 (4%)
Given negative feedback 2 (3%) 3 (5%) 1 (2%)
Given positive feedback 35 (57%) 44 (68%) 41 (72%)
Given no feedback 24 (39%) 18 (28%) 15 (26%)
Overall negative 18 (19%) 4 (4%) 5 (5%)
Overall positive 69 (72%) 53 (56%) 71 (72%)
Overall neutral 9 (9%) 37 (39%) 23 (23%)

a
Percentages are of applicable observations.

438

teams in these settings were probably responsible for
the higher frequency of observations of patients away
from the bay and out of bed. In addition, however,
patients in elderly care units spent less time asleep or
‘disengaged’ and more time interacting with nurses,
and were given appropriate help more frequently
than patients on the stroke unit or general ward. These
last findings may be explained by the elderly care
unit philosophy of holistic care, which encourages
interaction with patients. Research has obscured the
particular contribution that elderly care units may
make to the care of elderly stroke patients and the
qualities they share with stroke units in delivering care
to this patient group.
Due to the small sample size, the power of this
study is low. Larger observational studies are therefore
needed. Also, further research is needed to determine
whether the poor quality of interactions found in this
stroke unit are also to be found in other stroke units.
Perhaps caring solely for patients with stroke is less
rewarding and affects the quality of the nursing. A
survey of health professionals in the same settings
found that more stroke unit nurses than elderly
care unit or general ward nurses reported that the
work was monotonous, while nurses in the elderly care
unit were the most positive about caring for stroke
patients [29].
Finally, there are other important aspects of the
process of care that we have not addressed here, such
as staff skills, technical aspects of rehabilitation (e.g.
goal setting) and organizational issues, as well as less
tangible factors, such as the quality of communication
between members of the interdisciplinary team. We
have studied some of these aspects using qualitative
methods and will report these data separately.
Key points
• Aspects of the process of care on a stroke unit and
elderly care unit are similar.
• Patients on both the stroke unit and the elderly care
unit spent more time out of bed and out of their
ward bay or room.
• Patients on the elderly care unit spent less time
asleep and more time interacting with nurses.
• Patients in all three settings spent half the time
doing nothing.
Acknowledgements
We are grateful to the staff and patients in the three
settings for granting access and for participating in the
study, to Min Yang of the Multilevel Modelling Project
for her advice on multi-level modelling and to the
Stroke Association for funding P.P. Ethical committee
approval was obtained from the two hospitals.
Observing the care of stroke patients
References
1. Langhorne P, Williams B, Gilchrist W, Howie K. Do stroke units
save lives? Lancet 1993; 342: 395–8.
2. Kalra L, Dale P, Crome P. Improving stroke rehabilitation. A
controlled study. Stroke 1993; 24: 1462–7.
3. Kalra L. The influence of stroke unit rehabilitation on functional
recovery from stroke. Stroke 1994; 25: 821–5.
4. Kalra L, Dale P, Crome P. Stroke rehabilitation units—do elderly
stroke patients benefit? Cerebrovasc Dis 1994; 4: 146–51.
5. Jorgensen HS, Nakayama J, Raaschou HO, Larsen K, Hubbe P, Olsen
TS. The effect of a stroke unit: reductions in mortality, discharge rate
to nursing home, length of hospital stay, and cost. A community
based study. Stroke 1995; 26: 1178–82.
6. Bath PMW, Soo J, Butterworth RJ, Kerr JE. Do acute stroke units
improve care? Cerebrovasc Dis 1996; 6: 346–9.
7. Ronning OM, Guldvog B. Stroke units versus general medical
wards. 1: Twelve- and eighteen-month survival. Stroke 1998; 29: 58–
62.
8. Juby LC, Lincoln NB, Berman P. The effect of stroke unit
rehabilitation on functional and psychological outcome: a randomised
controlled trial. Cerebrovasc Dis 1996; 6: 106–10.
9. Drummond A, Lincoln N, Juby L. Effects of a stroke unit on
knowledge of stroke and experiences in hospital. Health Trends
1996; 28: 26–30.
10. Stroke Unit Trialists’ Collaboration. Collaborative systematic
review of the randomised trials of organised inpatient (stroke unit)
care after stroke. Br Med J 1997; 314: 1151–9.
11. Langhorne P, Dennis M. Stroke units: their role in acute stroke
management. Vasc Med Rev 1995; 6: 33–44.
12. Stroke Unit Trialists’ Collaboration. How do stroke units improve
patient outcomes? Stroke 1997; 28: 2139–44.
13. Gompertz P, Dennis M, Hopkins A, Ebrahim S. Development and
reliability of the Royal College of Physicians Stroke Audit form. Age
Ageing 1994; 23: 378–83.
14. Ellul J, Watkins C, Ferguson N, Barer D. Increasing patient
engagement in rehabilitation activities. Clin Rehab 1993; 7: 297–302.
15. Newton T, Butler NM, Dawson J. Engagement levels on a unit for
people with a physical disability. Clin Rehab 1993; 3: 299–304.
16. Davies ADM, Snaith PA. The social behaviour of geriatric patients
at mealtimes: an observational and an intervention study. Age Ageing
1980; 9: 93–9.
17. Clarke P, Bowling A. Quality of life in long stay institutions for the
elderly. An observational study of long stay hospital and nursing
home care. Soc Sci Med 1990; 30: 1201–10.
18. Kitwood T, Bredin K. A new approach to the evaluation of
dementia care. J Adv Health Nursing Care 1992; 1 (5): 41–60.
19. Keith RA. Activity patterns of a stroke rehabilitation unit. Soc Sci
Med 1980; 14A: 575–80.
20. Keith RA, Cowell KS. Time use of stroke patients in three
rehabilitation hospitals. Soc Sci Med 1987; 24: 529–33.
21. Tinson DJ. How stroke patients spend their days. Int Disabil Stud
1989; 11: 45–9.
22. Lincoln NB, Gamlen R, Thomason H. Behavioural mapping of
patients on a stroke unit. Int Disabil Stud 1989; 11: 149–54.
23. Lincoln NB, Willis D, Philips SA, Juby LC, Berman P. Comparison
439
P. Pound et al.

of rehabilitation practice on hospital wards for stroke patients. Stroke
1996; 27: 18–23.
24. Mackey F, Ada L, Heard R, Adams R. Stroke rehabilitation: are
highly structured units more conducive to physical activity than less
structured units? Arch Phys Med Rehabil 1996; 77: 1066–70.
25. Newall JT, Wood VA, Langton Hewer R, Tinson DJ. Development
of a neurological rehabilitation environment: an observational study.
Clin Rehabil 1997; 11: 146–55.
26. Goldstein H. Multilevel Models in Educational and Social
Research. London: Charles Griffin & Co., 1987.
27. Rice N, Leyland A. Multilevel models: applications to health data.
J Health Serv Res Policy 1996; 1: 154–64.
28. Woodhouse G ed. Multilevel Modelling Applications. A guide for
users of MLn. London: Institute of Education, 1996.
29. Pound P, Ebrahim S. Redefining ‘doing something’: health
professionals’ views on their role in the care of stroke patients.
Physiother Res Int 1997; 2 (2): 12–28.
Received 27 August 1997; accepted in revised form 1 October
1998

Appendix. Sample page from observation schedule

Centre ID: 3 Observation
..................................................................................................

Patient ID: 12 0–5 min 5–10 min 10–15 min

.......................................................................................................................................................................

Location Bay Bay Bay

Bed/chair/other Chair Chair Chair
Activity Having blood Eating lunch Eating lunch
pressure taken
Alone/accompanied (by whom) Nurse Visitor Visitor
a
Interaction Verbal and physical Verbal Verbal
Chance for independence N/A Yes Yes
Request (none/answered) None None None
Given help if needed N/A Yes Yes
b
Feedback Positive Positive Positive
Treated with patience Yes Yes Yes
Given choice about activity Yes Yes Yes
Given explanation Yes Yes N/A
Listened to N/A N/A N/A
Concerns taken seriously N/A N/A N/A
Eye contact No Yes Yes
Same level No Yes Yes
Privacy respected Yes N/A N/A
Ignored No No No
Dehumanizing No No No
b
Overall quality of activity/interaction Positive Positive Positive

a
None/verbal/physical/verbal and physical/attempted.
b
None/positive/negative.
N/A, not applicable.

440