Increasing the uptake of stroke upper limb guideline recommendations with occupational therapists and physiotherapists. A qualitative study using the Theoretical Domains Framework

Abstract

Introduction Despite the availability of stroke clinical practice guidelines and acceptance by therapists that guidelines contain ‘best practice’ recommendations, compliance remains low. While previous studies have explored barriers associated with implementing rehabilitation guidelines in general, it remains unknown if these barriers are applicable to upper limb rehabilitation specifically. To plan effective implementation activities, key motivators and barriers to use should be identified. Method To investigate occupational and physiotherapists’ perceptions of motivators and barriers to using upper limb clinical practice guideline recommendations in stroke rehabilitation, a mixed‐method study was conducted. Using an online survey and semi‐structured focus groups, physiotherapists and occupational therapists working in one of six stroke rehabilitation teams in Melbourne, Australia were invited to participate. Survey data were analysed using descriptive statistics, and thematic coding of free‐text responses. Focus groups were transcribed, thematically coded and mapped against the Theoretical Domains Framework. Results Forty‐six participants completed the survey and 29 participated in the focus groups. Key motivators to use guideline recommendations included past experience with specific interventions, availability of required resources and an enabling workplace culture. Barriers included: limited training/skills in specific interventions, the complexity of intervention protocols, and beliefs about intervention effectiveness. Lack of accountability was highlighted and therapists perceived they are rarely checked for quality assurance purposes regarding guideline adherence. Conclusion Therapists identified that both motivators and barriers to implementing best‐practice upper limb rehabilitation occur largely at the levels of the individual and the environment. As such, intervention efforts should focus at both these levels to facilitate change.

What is the feasibility and observed effect of two implementation packages for stroke rehabilitation therapists implementing upper limb guidelines? A cluster controlled feasibility study

“…Given this, such therapies need to be physically practised or role modelled to ensure comprehensive learning for accurate replication (or application) with patients. It is therefore unsurprising that therapists have a preference for learning in small group environments and/or through demonstrations with patients, 19 further supported by the acceptability feedback we received from both groups of this study. More time commitment was also required by therapists in the facilitator-mediated group, yet despite this, therapists reported interventions to be time feasible and perceived it to save them time in other ways (eg, establishing patient programmes).…”

“…Using data collected from prior focus groups completed with therapists from participating organisations on the barriers and enablers for implementing the best practice arm and hand interventions, 19 behaviour change intervention mapping was undertaken using the Theoretical Domains Framework, 24 Behaviour Change Wheel 25 and method outlined by French et al 26 Online supplementary 1 outlines the planned knowledge translation activities that contributed towards the 'implementation package' for each of the intervention groups. Strategies in the self-directed group were designed to be low cost, and implementable with distance (ie, no direct intermediary contact by the research team).…”

“…In stroke rehabilitation, there is now a good understanding of the issues faced by health professionals who seek to implement upper limb guideline recommendations. [17][18][19] However, much work is still needed to develop and test the effectiveness of behaviour change interventions. Organisations seeking to implement clinical guidelines do not yet know what activities to fund and how they should be delivered, so as to improve therapist adherence.…”

“…22 To improve adherence to upper limb rehabilitation guidelines, 1 we developed implementation strategies to specifically target the knowledge, belief in consequences and skill barriers identified in Australian stroke rehabilitation therapists. 19 The aim of this study was to test the feasibility and potential efficacy of two tailored implementation packages for improving adherence to upper limb stroke rehabilitation guidelines, and to understand the acceptance from the therapists' perspective. The following research questions were therefore addressed: 1.…”

Why allied health professionals use evidence-based clinical guidelines in stroke rehabilitation: A systematic review and meta-synthesis of qualitative studies

“…The study characteristics for the 22 included studies are presented in Table 1. The studies originated from seven different countries: nine from Australia, 21–27 seven from Canada, 28–34 two from the United Kingdom, 35,36 one from Norway 37 one from Ireland, 38 one from New Zealand 39 and one from the Netherlands. 40 There was a total of 850 included participants comprised of 371 speech language pathologists, 356 physiotherapists, 100 occupational therapists, four dieticians, five rehabilitation assistants/therapy assistants, two social workers and one psychologist.…”