A realist evaluation of mechanisms and contexts for facilitating the implementation of supported self-management in community stroke care (the IMPETUS study)

The past decade has seen a growing recognition of the role of supported self-management in the provision of long-term care and support for stroke survivors in primary and community care. However, its implementation and delivery across different contexts and models of community stroke care is inconsistent and patchy. This realist evaluation explored how and in which circumstances supported self-management is enacted and delivered within community stroke rehabilitation. Specifically, the study aimed to identify and explore contexts, mechanisms, and outcomes related to the delivery of collaborative supported self-management. It comprised a realist synthesis, Q-methodology study, and realist-informed interviews and focus groups with stroke survivors (n = 20), community-based stroke practitioners (n = 20), and community service delivery managers/clinical leads (n = 8) in stroke. The findings revealed that delivering supported self-management effectively and consistently in community stroke rehabilitation starts with embedding the ethos of collaborative supported self-management across staff, teams, and the organisation and involves collaborative relationships with stroke survivors that aim to build trust, confidence, and resilience. The findings identified specific mechanisms and facilitatory and inhibitory contexts that influence how well this is enacted and achieved in practice. A realist approach in this study is novel and has helped to generate new insights and perspectives how and when supported self-management approaches work in community stroke rehabilitation. The findings expand on and complement existing research on the efficacy of supported self-management in stroke and are of clinical importance for informing how collaborative, relational supported self-management approaches can be implemented, personalised, and tailored to people’s needs and evaluated within current healthcare systems.