Discussion
This study’s main finding is that providing a facilitator-mediated implementation package to occupational and physiotherapists was feasible and acceptable. Observed improvements in guideline adherence by therapists who received the facilitator-mediated package, inclusive of multiple implementation strategies, suggest that it may also lead to therapist behaviour change in provision of upper limb rehabilitation after stroke. No changes in therapist behaviour were found in either the self-directed implementation package or usual care groups, suggesting that providing a low-resource implementation package may be no more effective than usual care in terms of delivering guideline-based upper limb rehabilitation after stroke. While significant improvements in patient upper limb outcomes were found within groups, there were no between-group differences on any measure.
Our study was able to recruit well within each site, with around half of eligible therapists individually consenting to be active participants in the study (and 100% of eligible occupational therapists taking part at three of the six sites). This high recruitment rate may indicate therapists’ self-identified need to improve their knowledge and skills in upper limb therapy provision after stroke. The large representation of occupational therapists in our study is not surprising given that the role of upper limb rehabilitation is an occupational therapy domain of practice.29 30 We do, however, acknowledge that this may be contextually different in countries outside of Australia.
Findings also provide guidance for the development of other rehabilitation implementation interventions beyond upper limb therapy. Discussions and themes generated from the focus group held with participants of the facilitator-mediated group suggest that: (1) use of a facilitator; (2) interactive and regular education sessions; (3) targeted resources; (4) role modelling and (5) behaviour monitoring (fortnightly audit and feedback) were activities perceived by participants to contribute to their own changes in behaviour. While the self-directed group also received targeted resources and regular written education packs, the key differences were regular interactions with a facilitator and behaviour monitoring. This finding has important implications for future implementation efforts. Both intervention groups required financial and non-financial resources (eg, equipment and facilitator time); however, the facilitator-mediated group required significantly more investment than the self-directed group. Given that the self-directed implementation package was no more effective in achieving therapist behaviour change than our usual care group, investment in implementation activities without facilitation and audit feedback (as such received by the self-directed group) may not yield behaviour change. Results demonstrate that therapists are less prepared to implement knowledge gained through online approaches. One potential reason is that they spend comparatively less time in the virtual world than other professions (for example, academics or managerial staff) potentially contributing to the disconnect between screen learning and practice. More likely, however, is the physical and practical nature of the learning content. Most therapeutic interventions are complex, nuanced and require physical application (ie, therapists handing/positioning equipment or the physical position of the patient). 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). This perceived ‘time tradeoff’ is likely to also contribute to the positive acceptance of the study intervention, with therapists reporting personal and clinical benefits (increased skill and confidence, and clinical changes observed in their patients). Therapists in the self-directed group also reported their involvement to be time feasible (although they spent less time engaged in study interventions); however, they were not as satisfied with the time investment tradeoff for perceived increased skill and confidence.
Due to the small sample and lack of randomisation, no conclusion about patient upper limb outcomes between the three clusters can be made (no estimate of effect between-group differences was found). Patients in the facilitator-mediated inpatient group were on average 176 days post injury at the time of recruitment, compared with an average of 40 and 36 days in the self-directed and usual care groups, respectively. This may be a contributing factor to limited between-group differences of upper limb outcome measures. Few implementation studies measure patient outcomes, and future studies should incorporate this into their protocol design.
Previous allied health studies investigating the effectiveness of knowledge translation activities have reported little to no effect,31 which may be due in part to lack of explicit rationale for (1) intervention choice and (2) inappropriate methods to design translation activities.22 32 Our study interventions (ie, implementation packages) were informed by implementation theory,24 25 and underpinned by behaviour change implementation mapping.26 In this way, our knowledge translation activities were theoretically developed (explicitly) as opposed to pragmatically developed33 or conceptually based, and this may have contributed towards our successful study findings. As indicated by Davis et al,22 greater use of explicit theories in understanding barriers and designing interventions is required to advance the science of implementation. Additionally, promising knowledge translation activities reported in previous research or recommended for use in systematic reviews were incorporated into our intervention designs. For example, learnings from successful behaviour change trials such as Bekkering et al34 and Martin et al35 suggested the use of interactive education sessions, role modelling, rehearsal and performance feedback activities. Novel approaches were also employed such as the use of a facilitator (or ‘knowledge broker’ as described by Dobbins et al36) to establish a relationship between research producers and end users via interactive and face-to-face contact.
Two recent and notable behaviour change studies in stroke, the out and about trial37 and implementation of the Assessment for Rehabilitation Tool38 did not lead to behaviour change of therapists. In a cluster randomised control study, Lynch et al38 delivered active, multimodal knowledge translation activities (informed by conceptual theory) over 2 weeks, followed by phone call reminders in the month following intervention. While they conducted a barrier and enabler workshop and facilitated the development of ‘action plans’, they relied on site-based opinion leaders to implement and enact the action plans. In contrast, our study developed translation activities explicitly informed by theory, and supported implementation within the workplace context using a facilitator (knowledge broker). Additionally, we conducted fortnightly audit and feedback to therapists (12 rounds in total) about their compliance to guideline recommendations, whereas Lynch et al38 and McCluskey et al37 completed audit and feedback on one occasion, respectively. Strategies employed by both studies, while active and multimodal in approach, were not delivered with the same frequency (ie, interaction ‘dose’) and did not contain the same type of face-to-face activities (ie, modelling and rehearsal) as our study did (in the facilitator-mediated group). This is likely to be a contributing factor to the differences in behaviour change outcomes. Activities used in our self-directed implementation package group also contained active and multimodal approaches, yet were less interactive than activities used in Lynch et al38 and McCluskey et al37 trials. As concluded by Bird et al,21 the use of a facilitator appears to be a successful implementation intervention component within an implementation strategy. This finding is consistent with the findings of our study. The use of a facilitator (or knowledge broker) often removes championing tasks from busy therapists, and as identified in this study may lead to time saved in other work tasks.39 Frequency and dose of face-to-face interaction may be an important factor in successful behaviour change. While the use of opinion leaders is thought to promote EBP,40 asking therapists to champion change on top of their current workload is not ideal.
There are some limitations of this study. First, the sample size is small and caution needs to be taken when interpreting results. Grimshaw et al41 suggest that a randomised cluster controlled trial is the ideal design for implementation allowing head-to-head comparisons of activities; however, multiple arm groups are compromised by a loss of statistical power. Second, given the scope of this study (feasibility), we were unable to randomise the clusters, which would have greatly strengthened the design. Third, our method of recruitment (ongoing patient recruitment during the 3-month intervention period) meant that some patients were enrolled mid-way through the study, so given that the treating therapist was receiving study interventions, the baseline medical file audit for that patient may not be a true reflection of the therapist ‘preintervention’ behaviour. We attempted to control for this by removing baseline audits of patient participants enrolled after day 35 in the facilitator-mediated and self-directed implementation groups. Finally, the majority of therapist participants were occupational therapists, which may reduce generalisability of the results to physiotherapists.
