Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study

Abstract

Objective Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting. Methods A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR) informed content analysis for clinician and manager perspectives, respectively. Results Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources. Conclusion Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills; the provision of clinical decision-making tools; access to expert consultation; the roles and social influence of the interprofessional team and formal and informal leaders; and supportive processes adapted to the local context. Impact Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.

Healthcare professionals’ perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review

“…A lack of organisational processes acts as a negative influence on guideline implementation 50,51,55,[58][59][60][61]63,64,[68][69][70][71] by way of insufficient training/education, lack of protocols to influence [57][58][59]61,[63][64][65][66][68][69][70][71] Management and leadership were expressed as facilitators by actively supporting the organisational process mentioned above and protecting staff time for implementation creating a high level of organisational priority and commitment to guideline implementation resulting in a positive organisational culture. [53][54][55]59,67,68,69 Implementation interventions described in eight studies to increase the uptake of stroke guidelines included change management strategies, 52,56,57 training and education for that specific stroke rehabilitation guideline, 52,56-58,61,65,66 auditing, 52,58,65 facilitators/opinion leaders/champions 57,58,65-67 and reminders. 57,58,65 It is not the objective of this systematic review to determine which interventions are most effective, but due to the heterogeneity of the abovementioned studies, it would be challenging to stipulate which interve...…”

“… 55 , 63 , 66 , 67 , 68 Six studies included a mix of healthcare professionals working as part of multidisciplinary teams. 50 , 56 , 57 , 59 , 64 , 69 Participants recruited in included studies worked in a range of clinical settings along the post-stroke continuum of care – see Figure 2 .…”

“…Four studies investigated influential factors around national stroke guideline implementation in Ireland 59 , 60 and Australia. 51 , 53 The remaining studies investigated specific clinical practice guideline recommendation implementation, 50 , 52 , 54 – 58 , 61 – 71 focusing on the upper limb, lower limb, aphasia, balance, communication, swallow, neglect, urinary continence, falls, depression, pain and education. All but one study 52 examined both perceived barriers and facilitators of the guideline itself and the implementation process/interventions.…”

“…Unanimously, healthcare professionals' prioritisation of competing clinical and non-clinical tasks negatively interfered with guideline implementation. 50 – 52 , 54 , 55 , 58 , 63 , 64 , 68 , 69 , 71 This was not just in acute settings where time and the acute medical model is perceived to be a significant limitation but across the continuum of stroke rehabilitation.…”

Prenatal oral health guidelines: a theory- and practice-informed approach to survey development using a modified-Delphi technique and cognitive interviews

“…This process used three rounds of a modified-Delphi technique, followed by cognitive interviews, and deliberations among the research team, SAB, and PAB members to identify, operationalize, and pre-test CFIR survey items. Many studies using the CFIR to implement and evaluate clinical practices rely largely on qualitative methods to identify salient constructs [34][35][36][37][38][39]. Our approach is unique in employing an interactive process that begins with examining all CFIR constructs to prospectively and quantitatively examine implementation barriers and facilitators [15,17].…”