Abstract
Background and Purpose Current approaches to upper limb rehabilitation are not sufficient to drive neural reorganization and maximize recovery after stroke. To address this evidence-practice gap, a knowledge translation intervention using the Behaviour Change Wheel was developed. The intervention involves collaboratively working with stroke therapy teams to change their practice and increase therapy intensity by therapists prescribing supplementary self-directed arm exercise. The purposes of this case series are: (1) to provide an illustrative example of how a research-informed process changed clinical practice and (2) to report on staff members' and patients' perceptions of the utility of the developed intervention.
Case Descriptions A participatory action research approach was used in 3 stroke rehabilitation units in the United Kingdom. The intervention aimed to change 4 therapist-level behaviors: (1) screening patients for suitability for supplementary self-directed arm exercise, (2) provision of exercises, (3) involving family and caregivers in assisting with exercises, and (4) monitoring and progressing exercises. Data on changes in practice were collected by therapy teams using a bespoke audit tool. Utility of the intervention was explored in qualitative interviews with patients and staff.
Outcomes Components of the intervention were successfully embedded in 2 of the 3 stroke units. At these sites, almost all admitted patients were screened for suitability for supplementary self-directed exercise. Exercises were provided to 77%, 70%, and 88% of suitable patients across the 3 sites. Involving family and caregivers and monitoring and progressing exercises were not performed consistently.
Conclusions This case series is an example of how a rigorous research-informed knowledge translation process resulted in practice change. Research is needed to demonstrate that these changes can translate into increased intensity of upper limb exercise and affect patient outcomes.
It is widely accepted that a research-practice gap exists in physical therapy with regard to intensity of rehabilitation.1,2 One potential explanation for this gap may be the way in which the research evidence is produced in the first instance. That is, although high-intensity clinical trials have demonstrated the efficacy of stroke rehabilitation interventions, they have involved highly selective patients, extra resources, highly trained specialized research clinicians, and so forth. The effectiveness of these interventions in the usual care environment has been far less tested, but such studies are needed to ensure that the interventions still have the desired effects when delivered in today's health care settings involving existing personnel, procedures, and infrastructure.3 Knowledge translation (KT) studies have been proposed as a means of addressing this gap between evidence from interventions tested under “research conditions” and the effectiveness of delivery in everyday clinical life. Knowledge translation is the exchange, synthesis, and ethically sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate capture of the benefits of research.4 Knowledge translation embraces a constructivist approach to research utilization recognizing that knowledge is created by active and engaged users, often in a nonlinear and emergent fashion.5
Using a published framework, the Behaviour Change Wheel (BCW),6 we have developed an intervention to promote KT and address a research-practice gap in upper limb rehabilitation after stroke. Task-oriented training involving hundreds of repetitions is required to drive neural reorganization and maximize recovery after stroke.7 Observational studies, however, suggest that the dose of repetitions during current treatment for the upper limb falls significantly short. It has been reported that the average time spent in therapy sessions treating the upper limb is between 1 and 8 minutes,8 resulting in, on average, just 32 repetitions of task-oriented movements per session.9 Our intervention, called PRACTISE (Promoting Recovery of the Arm: Clinical Tools for Intensive Stroke Exercise), has been designed to support therapy teams to change their professional practice and increase therapy intensity by supporting them to provide supplementary self-directed arm exercise for patients with stroke during their inpatient rehabilitation. The evidence underpinning the PRACTISE intervention is directly derived from the literature on the effectiveness of intensive repetitive task-specific training in stroke rehabilitation.10–12 The content of the exercises is based on the Graded Repetitive Arm Supplementary Program (GRASP), which has been shown to be effective in a multicenter randomized controlled trial.12 The issue of how to successfully implement GRASP in clinical practice remains unclear, with existing implementation known to have limited fidelity to the original GRASP.13
In this case series, we describe the process of implementing PRACTISE to: (1) provide an illustrative example of how a research-informed improvement process changed clinical practice and (2) report on staff members' and patients' perceptions of its utility (ie, the usefulness and usability).
Case Descriptions
Target Settings
PRACTISE was implemented in 3 National Health Service stroke rehabilitation units in North West England. Stroke units were identified through existing contacts between the research team and local stroke therapy teams. The characteristics of these sites are shown in Table 1.
Characteristics of Participating Sitesa
Development of PRACTISE
A detailed report on the development of PRACTISE, which was guided by the BCW,6 has been published elsewhere14 and is summarized in Fig. 1. Target behaviors were identified and analyzed to determine how behavior change could be achieved using the COM-B (capability, opportunity, motivation, and behavior) model, the hub of the BCW.6 The COM-B is a simple model to understand behavior based on capability to enact the behavior, opportunity (the physical and social environment that enables the behavior), and motivation.
Development of Promoting Recovery of the Arm: Clinical Tools for Intensive Stroke Exercise (PRACTISE).
PRACTISE addresses 4 target behaviors for therapists: (1) identifying suitable patients for exercises by providing a screening tool; (2) provision of supplementary self-directed exercises by providing instruction material for a comprehensive range of exercises, from which the therapists select a few that are most suitable for the patient; (3) involving family and caregivers; and (4) monitoring and reviewing adherence to the exercises. PRACTISE consists of a paper-based tool kit and meetings between the research team and therapy team to ensure the tool kit is embedded into routine practice. By doing so, it aims to increase patients' physical opportunities to practice arm exercises, provide more efficient ways of therapists performing the behaviors needed to implement the exercises, and increase social opportunity by getting upper limb rehabilitation “higher up on the agenda” through managerial support and team engagement.14
A full intervention description based on the Template for Intervention Description and Replication (TIDieR) checklist,15 endorsed by Consolidated Standards of Reporting Trials (CONSORT), and examples of the PRACTISE tool kit materials are provided in eAppendix 1. It includes a screening tool/flowchart that therapists can use to categorize patients as “red,” “amber,” or “green” based on their initial assessments. Patients categorized as red either had no impairment or no active movement in their upper limb and, therefore, were not suitable for exercises. Patients categorized as amber had upper limb impairment and active movement but would require assistance or supervision with self-directed exercise due to cognition problems or limited safety awareness, for example. Patients categorized as green were those who had upper limb impairment and active movement and would be able to safely complete self-directed exercises independently. The exercises included in PRACTISE were based on the GRASP program12 (eAppendix 1). In the GRASP program, patients are provided with a comprehensive manual to complete during self-directed exercise. However, during the development work for PRACTISE, we learned that therapists often selected exercises from the GRASP manuals for patients.13 Thus, in PRACTISE, we recommended that patients be provided 5 exercises. Therapists had autonomy to select the exercises that they felt were most suited to the patient based on the patient's level of impairment and rehabilitation goals. PRACTISE also includes an audit tool to monitor the extent to which therapists performed the “target behaviors” of the PRACTISE intervention, which form the basis of discussion at the meetings between therapists and researchers. The audit tool is intended to be a method to facilitate implementation rather than a measure; therefore, the concepts of reliability and validity have not been tested.
Outcome Evaluation
The outcomes of interest were: (1) change in therapists' behaviors and (2) staff members' and patients' perceptions of the utility of the intervention. We collected outcome data using the audit tool, interviews with staff and patients, and field notes from site visits. The procedures for data collection and analysis are described below.
Audit tool.
Performance of the target behaviors by therapy teams was recorded using an audit tool. Therapy teams completed the audit tool in a way that fitted with their routine practice (eg, by nominating an individual to take responsibility for completing the tool or completing the tool during weekly multidisciplinary team meetings). Anonymized copies were collected each month by the research team. Data for each of the target behaviors for each month were organized into a spreadsheet for each site, and where possible, depending on the completeness of the data, totals and percentages were calculated (see eAppendix 1 for worked example).
Interviews.
Therapy team members' perceptions of the utility of PRACTISE were explored in semistructured interviews. Two authors (L.A.C. and N.E.M.) conducted the face-to-face interviews throughout the intervention at monthly onsite meetings at a convenient time for the interviewees. Where possible, interviews were conducted in private offices, but due to space limitations, it was sometimes necessary to carry out interviews in quiet corners of public spaces (eg, the hospital canteen). Team members provided written informed consent before participating and were interviewed only once over the course of the intervention.
An interview guide, underpinned by normalization process theory,16 was used. Normalization process theory is a sociological theory that can be used to understand the implementation, embedding, and integration of innovation in health care settings. This theory is made up of 4 constructs, each of which has 4 components:
Coherence describes the sense-making processes that people go through when introduced to a new innovation.
Cognitive participation describes the process of committing to implementing the innovation.
Collective action describes how the work to implement the intervention gets done.
Reflexive monitoring describes the evaluation work that takes place.
The emphasis of these components is on the dynamic and interactive processes that take place when attempting to embed a new innovation or practice.
Patients' perceptions of the utility of the arm exercises also were explored in semistructured interviews. Patients were eligible for inclusion if they had been provided supplementary self-directed exercises as part of the PRACTISE intervention during their time in the stroke rehabilitation unit. The interviewers conducted the interviews in the stroke rehabilitation unit at a time and location preferred by the patient (eg, bedside, private room). Patients who had been discharged after consenting to participate, but before it was possible to organize an appropriate time, were interviewed in their own home.
Audio recordings of all interviews were transcribed, anonymized, and imported into NVivo 10 (QSR International Pty Ltd, Victoria, Australia) for content analysis. Transcripts were first read through several times for familiarization before developing an initial coding frame reflective of the intervention objectives. Patient interviews were free coded. The interviewers coded the transcripts separately and made iterative changes to the coding frame as analysis evolved. Discrepancies in coding were discussed until agreement could be reached.
Field notes.
Two of the authors (N.E.M. and L.A.C.) documented the following information in field notes after each site visit: observations, the content of monthly meetings, ad hoc discussions with therapists, details of the number and frequency of meetings between the therapy and research teams and issues arising, additional contacts (eg, email) between meetings and reasons for these contacts, and informal discussions on the progress of the intervention by therapists and managers. These data were summarized at the end of the data collection period to provide more detailed insight into the process of implementation, contextual factors influencing implementation, and therapy teams' perceptions of the utility of PRACTISE. The data were converted into implementation time lines and reviewed by the coders in conjunction with the interview transcripts to triangulate the data and validate emergent findings from the interviews.
Comments by therapists on the audit tool were synthesized with the interview data and field notes to ensure all views on the utility of PRACTISE were captured. Emergent themes were discussed with the patients to ensure that the data had been accurately interpreted and to provide opportunity for clarification of preliminary findings.
Implementing PRACTISE
We used a phased approach to implementing PRACTISE, guided by adoption of the target behaviors and the principles of a participatory action research approach as described by Riel17 (Fig. 2). At an initial project setup meeting between the research team (L.A.C. and N.E.M.) and therapy teams (ie, physical therapists, occupational therapists, therapy assistants, therapy managers) at each site, we collaboratively identified how all admitted patients could be screened for suitability of self-directed upper limb exercise based on the resources, skills, and processes in place at each site. Based on the outcomes of these meetings, the therapy teams reorganized their work to embed the screening process into their everyday activity change and document this change using the audit tool.
Intervention design.17
The research and therapy teams then met monthly for 6 months to reflect on the extent to which it would be possible to implement the change, identifying any issues that had arisen or modifications that needed to be made to intervention components. Once the screening tool had been embedded into routine practice, we progressed to the next target behavior (ie, provision of supplementary self-directed arm exercises in the form of PRACTISE packs), following the same reflexive cycle.
Significant differences emerged in the extent to which the therapy teams at each site were able to initiate and drive forward implementation at the outset. For example, at sites A and C, there was clear support from therapy leaders in engaging with the intervention and maximizing efforts to implement the intervention. It also was evident at both sites that more senior therapists took responsibility for reminding the team about intervention tasks (eg, completing the audit tool) until such a time as these activities were considered to be “embedded” in routine practice. However, at site B, a number of contextual factors emerged that negatively affected the team's capacity to implement change from the outset. The team was in the process of moving from a 5-day workweek on the acute and rehabilitation units to a 6-day service that also followed up patients in community. Additionally, the therapy team leader, who had been instrumental in getting the intervention up and running at this site, resigned from and left her post in the first month of the study. After this departure, it emerged that despite positive perceptions of the value of the intervention, the team did not feel they had the basic organizational structures in place to fully engage in an implementation. Despite these challenges, we were able to continue with the phased implementation with the input of a senior therapist. The process of implementation across the 3 sites is summarized in eAppendix 2.
Outcomes
Implementation commenced at sites A and B in October 2014. Site C acted as the development site for the intervention from December 2013 to June 2014. All members of the therapy teams participated in the improvement process across the 3 sites. A sample of 23 team members (8 physical therapists, 11 occupational therapists, and 4 therapy assistants) and 12 patients participated in interviews (Tab. 2). Patients were not recruited to participate in interviews at the development site (ie, site C). Data from the audit tool were available for 6 months at sites A and C and for 4 months at site B.
Interview Participants Across Sites
Adherence to the Intervention Protocol
Almost all patients admitted to the stroke rehabilitation unit of sites A and C were screened for suitability for self-directed upper limb exercise (98% and 97%, respectively). Due to an interruption in implementation at site B with staffing changes, there were gaps in the audit tool records; therefore, it was not possible to estimate the percentage of admissions screened, and implementation progressed only as far as prescribing exercises. There was marked variation in the proportion of patients categorized as red, amber, or green across sites. Of the patients screened, 71% were categorized as red in site A compared with 55% at sites B and C. Of the remaining patients categorized as amber or green, 77%, 70%, and 88%, respectively, were provided with additional self-directed exercises in the form of a PRACTISE pack. Reasons for not prescribing exercises included patients deteriorating or being discharged. At site C, both family involvement and reviewing of exercises were documented on the audit tool, which showed that these behaviors were performed for more than 80% of the patients. Family involvement was low at site A (13%) and can be explained, in part, due to restricted visiting times, and an emphasis placed on the role of therapy assistants in supporting patients with supplementary self-directed exercise. As a consequence of time spent working toward achieving family and caregiver involvement at site A, we did not progress to our final target behavior (ie, reviewing the exercises).
Utility of the Intervention
Staff views about the screening tool kit, providing exercises, and using the audit tool were generally positive. Not surprisingly, participants' views on the utility related to their adherence to the intervention. Patients had mixed opinions about the usefulness and usability of the exercises and whether family should be involved with their exercises. Their opinions are summarized with exemplar quotes in Table 3.
Summary of Utility Findings for the Intervention
Discussion
Although resource intensive, it was feasible to promote KT by embedding components of PRACTISE into routine practice using a phased and reflexive implementation approach. This approach was used at 3 hospital sites with different pathways and staffing levels. Therapists perceived that screening patients for supplementary self-directed exercise and providing exercises were useful activities, and these activities were performed consistently throughout the intervention. However, this took longer at site B due to staffing and service issues. Providing exercises was not done 100% of the time, although reasons for nonadherence were generally due to the realities of clinical environments and patients being discharged quickly. Contextual factors and patients' personal wishes influenced the extent to which families or visitors were involved in the exercise programs. Reviewing and progressing exercise programs prior to discharge was not always prioritized by therapists in this intervention due to the short length of stay in the hospital and competing demands on their time.
Although most suitable patients were prescribed supplementary self-directed exercises, this gives no indication of adherence, and it often was evident that regaining the ability to walk was their primary concern. This is an important finding, as survivors of stroke, caregivers, and health professionals have listed identifying effective treatments for the upper limb as a research priority.18 However, the survivors of stroke and caregivers involved in these priority-setting activities are typically at a later stage in their recovery when perhaps the limitations caused by their impaired upper limb are more pronounced. Future research should consider how, while respecting priorities of survivors of stroke in the acute setting, we can maximize engagement in upper limb rehabilitation, as the potential for neurological recovery is greatest at this time.
“Involving others” has been identified as an effective way of overcoming practical problems in patient-led therapy.19 For example, in this case series, it emerged that the ward environment often limited patients' opportunity to do their arm exercises because instructions and equipment were not always readily available. This issue might have been overcome by more active involvement of the wider multidisciplinary team. However, the optimum time to involve others in the improvement process is not clear. That is, do some components of the KT intervention need to be fully embedded before widening its scope? In this case series, we endeavored to involve family and caregivers in the self-directed exercise program, as this has been shown to improve outcomes for people after stroke.20,21 However, resistance to this idea from the therapy teams and patients emerged. Family dynamics, the logistics of communicating exercises family and caregivers, and the availability of therapy assistants who could fulfill this role were influencing factors.
Despite positive changes in therapy practice, it is unclear whether patients undertook the recommended dose of task practice, which is on the order of hundreds of repetitions per day.7 A recently published randomized controlled trial investigating different models of therapy provision (circuit class therapy and 7-day-per-week individual therapy) showed that although time in therapy increased, the time spent engaged in active task practice remained the same.22 To achieve increased intensity of practice, closer attention needs to be paid to measures such as patient active time23 to reliably establish therapy intensity.
Limitations
The absence of baseline data for the behaviors of interest limits the conclusions that can be drawn about the extent of the change that occurred at each site. Therapy teams were responsible for data collection, and there were some missing data at all sites. The research team (L.A.C. and N.E.M.) facilitated implementation at each site and conducted the interviews. Patients may have been inclined to provide favorable responses to the interviewers' questions and audit data (ie, a social desirability bias24), but it was stressed throughout the intervention that the purpose was to learn about the process of implementing the intervention to encourage patients to be candid in relaying their experiences.
It was possible to use a KT approach to change the routine practices of therapy teams. A screening process for suitability and provision of supplementary exercise were embedded in stroke rehabilitation units. Research is needed to demonstrate that these changes can translate into increased intensity of upper limb exercise in acute stroke rehabilitation settings and affect patient outcomes.
Footnotes
Dr Connell, Ms McMahon, and Dr Eng provided concept/idea/project design. All authors provided writing. Dr Connell and Ms McMahon provided data collection and analysis. Dr Connell, Ms McMahon, and Professor Tyson provided project management. Dr Connell and Professor Watkins provided fund procurement. Professor Tyson and Dr Eng provided consultation (including review of manuscript before submission).
This work was approved by the National Research Ethics Service (NRES), REC number 14/NW/1087, IRAS project ID: 157255.
Dr Connell is funded by a National Institute for Health Research (NIHR) Career Development Fellowship. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.
- Received December 24, 2015.
- Accepted May 30, 2016.
- © 2016 American Physical Therapy Association
References
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