The aim of this study was to employ knowledge user perspectives to develop recommendations that facilitate implementation of a complex, shared decision‐making (SDM)‐based intervention in an interprofessional setting. This study was part of a larger knowledge translation (KT) study in which interprofessional teams from five freestanding, academically affiliated, rehabilitation hospitals were tasked with implementing a cognitive strategy‐based intervention approach that incorporates SDM known as Cognitive Orientation to daily Occupational Performance (CO‐OP) to treat survivors of stroke. At the end of the 4‐month CO‐OP KT implementation support period, 10 clinicians, two from each site, volunteered as CO‐OP site champions. A semi‐structured focus group was conducted with 10 site champions 3 months following the implementation support period. To meet the study objective, an exploratory qualitative research design was used. The focus group session was audio‐recorded, transcribed verbatim and analyzed through the lens of the integrated promoting action on research implementation in health services (iPARIHS) framework. The focus group participants (n = 8) consisted of occupational therapists, physical therapists, and speech language pathologists. Ten recommendations for CO‐OP implementation were extracted and co‐constructed from the focus group transcript. The recommendations reflected all four iPARHIS constructs: Facilitation, Context, Innovation, and Recipients. Implementation recommendations, from the knowledge user perspective, highlight that context‐specific facilitation is key to integrating a novel, complex intervention into interprofessional practice. Facilitators should lay out a framework for training, communication and implementation that is structured but still provides flexibility for iterative learning and active problem‐solving within the relevant practice context.
BackgroundThe Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians’ knowledge, self-efficacy, and practice related to implementing CO-OP.MethodsA single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.ResultsSixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).
Introduction The objective of this research study was to explore site and clinician specific experiences, successes and challenges in implementing a complex intervention (cognitive orientation to daily occupational performance approach) to enhance stroke team's ability to address cognitive impairments as part of comprehensive stroke rehabilitation. Methods A focus group was held with clinicians from five study sites, all rehabilitation stroke hospitals in a large urban setting, to discuss implementation experiences. Participants were clinicians (site champions) from each of the five participating stroke program study sites and included four occupational therapists, three physiotherapists and one speech‐language pathologist. Thematic analysis was used to identify themes that represented clinicians' perspectives. Results Implementing this complex team‐based intervention was influenced by three themes—organizational support, experiential evidence, and clinicians' perspectives. Continued implementation of the intervention following the withdrawal of study support was represented on a continuum that ranged from not using the approach at all to implementing it with all patients. Sites where managers encouraged and supported use of the intervention within teams (organization support), continued to use it after the study support period as did clinicians who were willing to try new interventions (clinicians' perspectives). Development of iterative conclusions through implementation or attempts to implement the intervention had both positive and negative effects on continued implementation (experiential evidence). Conclusions Strategies that reinforce development of positive experiential evidence and building organizational support for innovative practice were found to be useful adjuncts in facilitating implementation of complex interprofessional interventions.
The objective of this project was to examine the feasibility and preliminary outcomes of an evidence-based cognitive augmented mobility program (CAMP) for persons with stroke. Relevance• Current mobility treatment approaches for survivors of stroke are not usually associated with improved community participation, transfer of skills learned in therapy to new skills, nor skill maintenance 1,2 • A potential solution may be to combine the best practices for improving walking and mobility in persons with stroke with cognitive strategy training to improve problem solving, confidence, maintenance and transfer of skills to the community • Best evidence suggests therapists should incorporate task-specific training, aerobics, and strengthening to improve mobility in gait in persons with stroke • Related research suggests that incorporating cognitive problem-solving strategy training may lead to better skill maintenance and transfer 3,4 Methods Analysis: Due to the small sample size, non-parametric statistics were used. Medians and ranges were calculated, and to estimate efficacy, differences between assessment points were analyzed using Wilcoxon test and non-parametric effect size r was calculated and were are coded as small (.1), medium (.3) or large (.5) effects. 3 Additionally, for measures for which an estimate of a minimally important change was available, the proportion of participants who achieved that level was calculated and reported.Two groups of 4 participants post stroke, post usual care, with mobility goals, able to walk at least 3 metres, and able to follow directions. Analysis & Results Discussion & Conclusion• The positive results included a large effect on self-selected goal performance at one-month follow-up and transfer of learning to balance and mobility skills • Findings suggest CAMP is feasible, and, that there is a potential complementary effect in combining best evidence for mobility and fitness for persons with stroke with cognitive strategy training that warrants further investigation • These results may be a precursor to future discussions exploring methods to include active problem-solving & shared-decision making throughout care
Introduction Stroke rehabilitation teams’ skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians’ skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT. Methods CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post. Results The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%. Conclusions Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.
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