Objective The iWalk study showed significant increase in use of the 10-m walk test (10-mWT) and 6-Minute Walk Test (6-MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care, and inpatient and outpatient rehabilitation settings. Methods A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, we compared and synthesized site-specific context-mechanism-outcome (CMO) descriptions across sites to refine our initial theory of how the toolkit would influence practice. Results Analysis revealed 3 CMOs: No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and apply reference values for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10-mWT over the 6-MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m. Conclusion Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings. Impact This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

Purpose Project-based experiential learning is a defining element of quality improvement (QI) education despite ongoing challenges and uncertainties. The authors examined stakeholders’ perceptions and experiences of QI project-based learning to increase understanding of factors that influence learning and project experiences. Method The authors used a case study approach to examine QI project-based learning in 3 advanced longitudinal QI programs, 2 at the University of Toronto and 1 at an academic tertiary-care hospital. From March 2016 to June 2017, they undertook 135 hours of education program observation and 58 interviews with learners, program directors, project coaches, and institutional leaders and reviewed relevant documents. They analyzed data using a conventional and directed data analysis approach. Results The findings provide insight into 5 key factors that influenced participants’ project-based learning experiences and outcomes: (1) variable emphasis on learning versus project objectives and resulting benefits, tensions, and consequences; (2) challenges integrating the QI project into the curriculum timeline; (3) project coaching factors (e.g., ability, capacity, role clarity); (4) participants’ differing access to resources and ability to direct a QI project given their professional roles; and (5) workplace environment influence on project success. Conclusions The findings contribute to an empirical basis toward more effective experiential learning in QI by identifying factors to target and optimize. Expanding conceptualizations of project-based learning for QI education beyond learner-initiated, time-bound projects, which are at the core of many QI educational initiatives, may be necessary to improve learning and project outcomes.