The patient, carer and service outcomes of this trial are published elsewhere [ 13 ]. ESD models of care share common features and components, including multidisciplinary team members, a workforce with specialist stroke care knowledge and the provision of services in the community [ 14 , 15 ]. However, ESD is has been implemented variably around the world, particularly in regards to recommended full time staff loadings and intensive treatment duration. In this study, ESD was offered as part of services provided by a community rehabilitation team supported by an ESD coordinator.
Patients were referred by the inpatient rehabilitation ward if they were medically stable post stroke, considered suitable for safe home discharge, able to be treated in the home environment and requiring intensive rehabilitation from at least two disciplines. ESD care was delivered by a multidisciplinary team including allied health clinicians, nurses, pharmacists, general practitioners and a rehabilitation consultant.
Care was provide for four weeks up to five days per week , with session frequency determined by individual patient needs. All patients with ongoing rehabilitation needs at the time of ESD discharge were referred on to community based rehabilitation services. Accessible and specific information about the ESD model and pathway of care was provided to all stroke survivors and carers, and the ESD team met on a weekly basis to coordinate care provision. Participants for this study were selected purposively [ 16 ], and there were two groups—staff who referred patients for ESD Referrers , and staff involved in the planning, implementation or delivery of ESD during the trial Delivering Staff.
All health service staff meeting these criteria was invited to participate at each time point, and could participate in all, some or none of the data collection. The CFIR describes constructs identified from previous research as influential on effective knowledge translation. The framework supports analysis of the relationships between constructs and implementation outcomes [ 18 ], and can be used prospectively or retrospectively. The CFIR has five domains intervention characteristics, outer setting, inner setting, characteristics of individuals and process , and 26 embedded constructs.
Detailed definitions for each domain and construct have been developed [ 19 , 20 ], and are described below in Fig 1 in specific reference to ESD. All the domains are interdependent, and constructs interact throughout implementation processes at the individual, service, organisational and community levels [ 17 ].
While complexity can be perceived as problematic to evaluation design, implementation is founded upon multiple influences, environments and interpersonal relationships [ 21 ]. All CFIR domains but not all constructs were addressed during the collection of both quantitative and qualitative data. Data related to trialability was not directly sought, as the trial as a whole tested ESD in this setting. Data about other personal attributes cannot be specifically collected given the lack of specific attributes in this construct, although relevant findings did emerge.
Planning for this trial of ESD was completed prior to this study, and it was anticipated this data would be present in responses provided in relation to other CFIR domains and constructs. Participants had the option of participating in interviews or focus groups to support choice, and reduce burden associated with either format. The surveys were undertaken with both Referrers and Delivering Staff at three time points T 0, T 1, T 2 , while focus groups and interviews were conducted with Delivering Staff only at the final time point T 2.
Informed consent for survey data was assumed if responses were returned, however specific written consent was obtained for all focus groups and interviews. A bespoke mixed methods survey was designed for each participant group based upon CFIR Interview Guide Tool [ 22 ], to support fidelity to the framework. Qualitative questions from this tool were converted to Likert items, and each survey also included space for open comments see S2 Appendix.
All data was collected anonymously with only workforce group identified to enable sample description , and the survey took around five minutes to complete. Anonymity was preserved due to ethical concerns around inadvertent identification given the case study method, and also accommodated regular workforce turnover at the organisation.
These data collection sessions took 45—60 minutes, with all data digitally recorded and transcribed verbatim. While identical questions were posed for many variables, slightly different wording was adopted to enhance relevance to each participant group. Quantitative data were analysed descriptively, with tests of normality indicating that non-parametric statistics should be employed.
Given the anonymous data, and that staff may not have participated at every time point, each group was considered independent for analysis. The Mann-Whitney U test was utilised the explore changes over time within each group, and also between the referring and delivering staff. Changes resulting from implementation occur over time, and implementation studies often only undertake data collection at baseline and post implementation to explore these changes [ 23 ].
For example; perceptions regarding intervention source may be most relevant as implementation commences, when stakeholders were receiving their initial information about ESD. These nuances in the development of perceptions would be obscured by the use of a repeat measure tests such as ANOVA , and hence the decision to analyse in two separate phases. Qualitative survey data, and from interviews and focus groups, was analysed using a priori thematic analysis, [ 24 ] with the CFIR constructs as codes.
A codebook was developed from the definitions for each domain and construct [ 19 , 20 ] and including illustrative examples from the transcripts. Very few instances of divergence existed 3. A single researcher DH then assigned interpreted meanings to passages in all other transcripts. Two other researchers KL, SN independently reviewed these codes against the code book, and again low rates of divergence were found KL 2.
Key relationships between CFIR domains and constructs were also analysed at the conclusion of qualitative analysis. The code co-occurrence function of the Dedoose platform was used to describe relationships between these concepts, which assigns frequencies to codes assigned to overlapping excerpts [ 25 ].
All data sources for each CFIR domain and construct were then integrated in the final, mixed methods analysis. Within each construct, instances of consonance and dissonance between the data sources were described, and finally synthesised at the domain level.
A total of surveys were received, and 23 staff participated in focus groups or interviews. Table 1 confirms participants came from a range of workforce groups. As shown below in Table 2 , participants perceived their personal characteristics and attributes in relation to ESD fairly positively throughout the trial. Greater improvements in overall perceptions occur in both groups during Phase 1, however increases in overall knowledge occurred during different phases for each participant group.
Staff generally perceived ESD as closely aligned to their personal and professional beliefs about best practice and early intervention. Providing rehabilitation at home was also identified as a key aspect of ESD, which enabled meaningful goal setting and client centred practice. However, ESD implementation was both congruent with, and challenging to, their existing rehabilitation practice knowledge.
Referrers noted that Grade 1 staff required increased support in Phase 1 to develop self-efficacy, while staff noted ESD knowledge was not consistently developed for staff members joining the organisation mid-trial. An unintended consequence of these beliefs was an emphasis on the shortcomings of standard practices, which remained in place for most patients.
Diverse beliefs around the time commitment required by ESD were also evident, with consistent but not universal claims of increased workload made throughout this study. Staff reported generally positive organisational perceptions, which supported a sense of commitment, enthusiasm and pride specifically associated with the ESD trial. Participants also maintained generally positive perceptions about ESD itself, as shown below in Table 3. A mixed profile of changes was found, with some constructs experiencing only moderately fluctuations and others changing more markedly in specific phases.
Decreases in some constructs such as number of steps, degree of difference and cost represent positive responses, as these are constructs were less is better. Participants were generally well aware of the origin of ESD and its supporting evidence, which was perceived to provide support for good patient and service outcomes. ESD was unequivocally perceived to have more advantages than other stroke rehabilitation programs as indicated by the perceived disparity between ESD and standard practices.
Perceived adaptability of ESD was identified both within the intervention, and as a function of the deployment of available resources an Inner Setting construct. Perceptions of the duration and scope of ESD also became more positive, with duration influenced at times by staff attempting to meet their commitment to client centred practice.
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Four years since the When it comes to anything bike, Evo are the experts that live and breath cycling. There is never an investigation until there is a lawsuit. The board members aren't there for oversight - just for their own ego satisfaction. And perhaps to protect their own kids. Its too bad that Harvard is monitoring the situation and that it might affect our student's applications. I noticed ESD admissions to top schools have been dropping and I wonder if this is the cause.
The administration better get their act together soon. I am a current high school student at ESD, which I have been attending my whole life. I would just like to say how truly sad it is that all of these people are wasting their time trying to bring down an excellent school. I have had Dr. Hull as a teacher and known her as a head, and she is an incredible teacher and person.
She is so caring and has the best interest towards everyone. Cole might have had her scandals, but from the inside perspective which, in my opinion, is the most valid she did her job and was nice to all the students. ESD is such a wonderful, loving community that does not deserve this backlash.
If you search hard enough, you can find flaws in literally any sort of institution. ESD is still a young school and we have improved so much. We also believe that ESD has improved and the purpose of this website is to continue to encourage that improvement to avoid further harm to children. We know you are young, but one lesson you will learn is that a pleasant smile does not necessarily indicate a person is well-meaning.
In the case of Dr Hull, she is a coward who is more of a caretaker than a leader - just trying to protect her job. Did you know that she runs kids down behind their backs with others in the office? Did you know that she altered her own son's grades so he could get into the college of his choice? These are examples of why she is no longer Head of Upper School. We are gratified by the fact that ESD figured this out but she should have been fired rather than demoted. Texas is one of the very few states where the courts give child mistreatment protection in the name of religion.
It makes Texas sound like a backwater and it makes ESD sound like a medieval orphanage. Whether this is true or not the reputation damage has been done. And it is clear to all that few ESD students will be accepted to Ivy League and other top colleges until the reputation is repaired. Its not right that children and parents lose their rights when they enroll in a religious school. I want my kids to have a religious education, but I want the school to be held accountable if they abuse or mistreat my child - or any child.
Is there anything I can do to help? I would like to know what constitutes a religious school. Is ESD owned by a church? ESD was founded by an Episcopal priest and began using the name for that reason.
The school sprinkles the curriculum with enough light religious curriculum that it can appear to be affiliated for the marketing benefits that brings, while still being able to attract families of all faith and no faith. The Episcopal church claims the school is an "auxillary" which has no legal meaning and insulates the church from legal liability.
So to answer your question crisply, what makes a school or day care center or assisted living facility, etc "religious" in the State of Texas this varies by state and has not yet been tested at the US Supreme Court is the fact that the entity merely represents itself to be "religious".
Abuse and mistreatment can happen anywhere including at religious institutions. The problem with ESD is that the insular central command has no oversight. The top people investigate themselves.
If the Head of School causes the problem, which has happened every time at ESD, the only recourse for the victim is a lawsuit. That is why ESD has been sued so often. There has to be a better way. ESD is not the only religious school that abuses and mistreats children. Dallas Lutheran School had a teacher who sexually abused a 17 year old boy.
When busted the teacher left the school but was given a good enough recommendation to get a teaching job in a different state. Instead of addressing the matter and apologizing, these schools just circle the wagons and deny. Here again the court system is of very little value. Like ESD, the case went to court and was successful at the Dallas district court level where the facts were presented , but the Court of Appeals and the Texas Supreme Court stand in the way of a resolution for the student and parents.
Threatened with religious immunity, the parents are being forced by the school to sign a document stating that the school was not responsible in any way - which they clearly were. Thank you for this website.
My son is graduating this year. By raising the visibility of the problem, you helped us get through without suffering the irrational behavior of the past.
Discipline seems better thought out now. Please keep it up. As soon as the heat is off, the school will probably revert to its old ways. But we are finished with the school at last. To the parents of Lovett boys: I was one of Cole's victims. If you have boys who are athletic, popular and fun-loving meaning they l joke around at school with other boys, never disrespectfully , then you need to leave Lovett now.
Cole has a personality defect that causes irrational behavior toward this group. The more popular they are the more hostile she becomes. It may have something to do with the girls school she worked at for 26 years like maybe the girls were also complaining about boys who did them wrong.
Or maybe it has to do with her own childhood and she has unresolved issues. But she needs professional help - seriously. She covers it well but that is because she is afraid of being exposed. Maybe it won't rear its ugly head because she is afraid of losing her job again - but I can absolutely tell you that this is in her heart.
Don Carty is the chairman of the board who fired Cole. Good for him. But what has he done to stop the abuse and mistreatment? The board is still the same. Carty only cares about his own kid. I just found out about the D Mag article and this is ridiculous. My kids certainly aren't going here.
Imagine expelling child with an unblemished record in the middle of his important junior year who was grieving his mother's death for simply being in the car with a child who smoked pot. The kid should have gotten an award for standing up to peer pressure because he didn't smoke and had a drug test to prove it. And to top it off the kid who actually smoked was the son of the head of school who got no punishment. So the board fired the head of school OK, but where was the board supervision?
This school seems to have a pattern of damaging vulnerable kids. It hasn't changed much if at all. The Board is still full of numb nuts who don't do anything but sit around and congratulate themselves on their self-importance and the money they have made. Baad is better than Cole but nothing else has changed. The executive committee and board don't care about the kids - except for their own.
So glad Cole is gone. Mr Baad is so much better. He had experience before he came which Cole did not. ESD has had a lasting impact on me. Fairhill gave me confidence and even cockiness. It was the 's. I think Fairhill was one of the first places it was okay to feel good about yourself. At holy cross, it was mostly snickering and giggling. ESD knocked any confidence right out of me. My main takeaways from ESD are body dysmorphic disorder and later in my twenties: flashbacks.
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