Barriers to implementation of stroke rehabilitation evidence: findings from a multi-site pilot project

Purpose: To describe the barriers to implementation of evidence-based recommendations (EBRs) for stroke rehabilitation experienced by nurses, occupational therapists, physical therapists, physicians and hospital managers. Methods: The Stroke Canada Optimization of Rehabilitation by Evidence project developed EBRs for arm and leg rehabilitation after stroke. Five Canadian stroke inpatient rehabilitation centers participated in a pilot implementation study. At each site, a clinician was identified as the “local facilitator” to promote the 6-month implementation. A research coordinator observed the process. Focus groups done at completion were analyzed thematically for barriers by two raters. Results: A total of 79 rehabilitation professionals (23 occupational therapists, 17 physical therapists, 23 nurses and 16 directors/managers) participated in 21 focus groups of three to six participants each. The most commonly noted barrier to implementation was lack of time followed by staffing issues, training/education, therapy selection and prioritization, equipment availability and team functioning/communication. There was variation in perceptions of barriers across stakeholders. Nurses noted more training and staffing issues and managers perceived fewer barriers than frontline clinicians. Conclusions: Rehabilitation guideline developers should prioritize evidence for implementation and employ user-friendly language. Guideline implementation strategies must be extremely time efficient. Organizational approaches may be required to overcome the barriers.

Implications for Rehabiliation

• Despite increasingly strong evidence for stroke rehabilitation, there are delays in implementation into clinical practice.

• This study showed that lack of time, staffing issues, staff education, therapy selection or prioritization, lack of equipment and team functioning were the main barriers to implementation.

• Managers and stakeholders should consider these barriers and prioritize evidence when implementing.

     

Provider-perceived barriers and facilitators for ischaemic heart disease (IHD) guideline adherence

RATIONALE, AIMS AND OBJECTIVES: Clinical practice guidelines have become a standard way of implementing evidence-based practice, yet research has shown that clinicians do not always follow guidelines. METHOD: As part of a larger study to test the effects of an intervention on provider adherence to ischaemic heart disease (IHD) guidelines, we conducted five focus groups at three Veterans Administration Medical Centers with 32 primary care providers, cardiologists, and internists to identify key barriers and facilitators to adherence of the guidelines. Using content analysis, responses were grouped into categories. RESULTS: The main perceived advantages of using the IHD guidelines were improvements in quality and the cost of care. Perceived barriers were the lack of ability of guidelines to manage the care of any one individual patient, the difficulty of accessing guidelines, and high workloads with many complex patients. While providers agreed on the benefits of aspirin, beta-blockers and angiotensin converting enzyme inhibitors, barriers for use of these medications were lack of consensus about contraindications, difficulty in providing follow-up during medication titration, and lack of patient adherence. Sources of influence for guideline use were: professional cardiology organizations, colleagues, mainly cardiologists, and key cardiology journals. However, most providers acknowledged that following guidelines was a personal practice decision. CONCLUSIONS: While results validated the influences of using clinical practice guidelines, our results highlight the importance of ascertaining guideline-specific barriers for building effective interventions to improve provider adherence. An advisory panel reviewed results and, using a modified nominal group process, chose implementation strategies targeting key barriers.     

Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review

Solomons N.M. & Spross J.A. (2011) Journal of Nursing Management 19, 109–120
Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review Aims The purpose of the present study is to examine the barriers and facilitators to evidence-based practice (EBP) using Shortell’s framework for continuous quality improvement (CQI). Background EBP is typically undertaken to improve practice. Although there have been many studies focused on the barriers and facilitators to adopting EBP, these have not been tied explicitly to CQI frameworks. Methods CINAHL, Academic Search Premier, Medline, Psych Info, ABI/Inform and LISTA databases were searched using the keywords: nurses, information literacy, access to information, sources of knowledge, decision making, research utilization, information seeking behaviour and nursing practice, evidence-based practice. Shortell’s framework was used to organize the barriers and facilitators. Results Across the articles, the most common barriers were lack of time and lack of autonomy to change practice which falls within the strategic and cultural dimensions in Shortell’s framework. Conclusions Barriers and facilitators to EBP adoption occur at the individual and institutional levels. Solutions to the barriers need to be directed to the dimension where the barrier occurs, while recognizing that multidimensional approaches are essential to the success of overcoming these barriers. Implications for nursing management The findings of the present study can help nurses identify barriers and implement strategies to promote EBP as part of CQI.     

Facilitating interprofessional evidence-based practice in paediatric rehabilitation: development,implementation and evaluation of an online toolkit for health professionals

Purpose: Lack of time, competencies, resources and supports are documented as barriers to evidence-based practice (EBP). This paper introduces a recently developed web-based toolkit designed to assist interprofessional clinicians in implementing EBP within a paediatric rehabilitation setting. Methods: EBP theory, models, frameworks and tools were applied or adapted in the development of the online resources, which formed the basis of a larger support strategy incorporating interactive workshops, knowledge broker facilitation and mentoring. Results: The highly accessed toolkit contains flowcharts with embedded information sheets, resources and templates to streamline, quantify and document outcomes throughout the EBP process. Case examples relevance to occupational therapy and physical therapy highlight the utility and application of the toolkit in a clinical paediatric setting. Workshops were highly rated by learners for clinical relevance, presentation level and effectiveness. Eight evidence syntheses have been created and 79 interventions have been evaluated since the strategy’s inception in January 2011. Conclusions: The toolkit resources streamlined and supported EBP processes, promoting consistency in quality and presentation of outputs. The online toolkit can be a useful tool to facilitate clinicians’ use of EBP in order to meet the needs of the clients and families whom they support.

• Implications for Rehabilitation

• A comprehensive online EBP toolkit for interprofessional clinicians is available to streamline the EBP process and to support learning needs regardless of competency level.

• Multi-method facilitation support, including interactive education, e-learning, clinical librarian services and knowledge brokering, is a valued but cost-restrictive supplement to the implementation of online EBP resources.

• EBP resources are not one-size-fits-all; targeted appraisal tools, models and frameworks may be integrated to improve their utility for specific sectors, which may limit them for others.

     

Instilling positive beliefs about disabilities: pilot testing a novel experiential learning activity for rehabilitation students

Purpose: To develop and test a novel impairment simulation activity to teach beginning rehabilitation students how people adapt to physical impairments.

Methods: Masters of Occupational Therapy students (n?=?14) and Doctor of Physical Therapy students (n?=?18) completed the study during the first month of their program. Students were randomized to the experimental or control learning activity. Experimental students learned to perform simple tasks while simulating paraplegia and hemiplegia. Control students viewed videos of others completing tasks with these impairments. Before and after the learning activities, all students estimated average self-perceived health, life satisfaction, and depression ratings among people with paraplegia and hemiplegia.

Results: Experimental students increased their estimates of self-perceived health, and decreased their estimates of depression rates, among people with paraplegia and hemiplegia after the learning activity. The control activity had no effect on these estimates.

Conclusions: Impairment simulation can be an effective way to teach rehabilitation students about the adaptations that people make to physical impairments. Positive impairment simulations should allow students to experience success in completing activities of daily living with impairments. Impairment simulation is complementary to other pedagogical methods, such as simulated clinical encounters using standardized patients.

• Implication of Rehabilitation

• It is important for rehabilitation students to learn how people live well with disabilities.

• Impairment simulations can improve students’ assessments of quality of life with disabilities.

• To be beneficial, impairment simulations must include guided exposure to effective methods for completing daily tasks with disabilities.

     

Closing the gap: collaborative learning as a strategy to embed evidence within occupational therapy practice

RATIONALE: The principles of clinical governance apply as guidelines for good practice to all practitioners. However, evidence-based practice (EBP) is proving a challenge for practitioners who lack the confidence to consume published research. For therapists not wishing to undertake formal study there is a risk of becoming disempowered within a culture of EBP. Opportunities to develop skills in consuming research have focused on the information dissemination model that has limited effect. Mutual reflective learning processes are recommended to empower practitioners to bridge the theory-practice gap. AIM: An action research approach investigated practice based collaborative learning as a catalyst to increase therapist's competence and confidence in consuming research and to explore the transition toward EB practitioner. METHOD AND RESULTS: A diagnostic survey reaffirmed therapist's lack of confidence in EBP. Formative interviews (n = 5) found an over reliance on professional craft and personal knowledge. Research knowledge was not included in participants' construct of a good practitioner and engagement in higher order critical reflection was limited. Collaborative learning groups (n = 6) embedded in practice integrated research, theory, practice and critical reflection. Supported by the collegial learning environment, a learning package developed participants' confidence and competence in consuming published research. Summative interviews (n = 5) evaluated the group and found that therapists were empowered to incorporate propositional knowledge into their clinical reasoning, engage in critical reflection and challenge their practice. They felt confident to incorporate EBP into their continuing professional development plans. Sustainability of these changes requires commitment from the therapists and the workplace.     

Motivational interviewing: a novel intervention for translating rehabilitation research into practice

Purpose: Despite recent advances in rehabilitation research, moving evidence into clinical practice remains a challenge. This article explores a novel approach to knowledge translation (KT) – motivational interviewing (MI). MI is a style of communication that is typically used to facilitate health related behavior change in patients. Here we explore its potential use as a KT intervention aimed at clinicians. Methods: Commentary. Relevant literature on MI and KT is summarized and discussed by considering how MI could be used in a KT strategy aimed at rehabilitation clinicians. Results: Clinician motivation and readiness to change are key issues influencing implementation of evidence-based practice. We provide an argument suggesting that clinicians’ readiness to change clinical practices can potentially be enhanced through MI. The MI conceptual framework, principles, and strategies, typically used in patients, are discussed here in a novel context – enhancing clinician change in practice. Conclusions: MI is an effective intervention when the goal is to motivate individuals to change a current behavior. We suggest that MI is an evidence-based intervention that has been proven to be effective with patients and warrants study as a promising KT intervention.

Implications for Rehabilitation

• Despite recent advances in rehabilitation research, moving evidence into practice remains a challenge.

• Clinician motivation is one key issue influencing the implementation of evidence-based practice.

• Clinician motivation to implement evidence-based practice can potentially be enhanced through an approach called motivational interviewing (MI).

• Motivational interviewing is an evidence-based intervention that has proven to be effective in promoting behavioral change in patients, and warrants study in terms of its potential as a KT intervention.

     

Research-based evidence in stroke rehabilitation: an investigation of its implementation by physiotherapists and occupational therapists

Purpose: Stroke rehabilitation is a multidimensional process that is designed to facilitate restoration of and/or adaptation to loss of functioning. The use of research-based evidence in informed decision-making is insufficient. Occupational therapy and physiotherapy constitute important contributions to rehabilitation. The study aim was to investigate characteristics of the implementation of research-based evidence in stroke rehabilitation by occupational therapists and physiotherapists, using the International Classification of Functioning, Disability and Health as a conceptual framework.

Method: A prospective cohort study, including all service levels within stroke rehabilitation. Consecutive patients with stroke admitted to a university hospital between May and December 2012 were enrolled by 13 therapists. Documentation of daily practice was collected from medical records. Analysis compared the therapists’ documentation with the national clinical guidelines for physiotherapy and occupational therapy in the rehabilitation of adults with brain injury.

Results: The study included 131 patients. The therapists’ praxis was seen to be in agreement with the majority of the national clinical guidelines. However, joint goal-setting and evaluation using standardized measures were seldom documented.

Conclusions: Although the therapists recognize evidence-based practice as a framework for achieving quality in rehabilitation, findings suggest that they do not employ research-based evidence to the fullest extent.

• Implications for Rehabilitation

• In order to individualize the rehabilitation offered, more attention and focus on involving and giving words to patients’ expectations, perceptions, experiences, and perspectives is needed.

• With the intention of enabling meaningful participation the health professionals need to pay more attention to the importance of environmental factors.

• Both guidelines and clinical practice should consider all components of the International Classification of Functioning, Disability and Health when formulating, and implementing, recommendations in rehabilitation praxis in order to aim for rehabilitation that is based both on evidence and a holistic approach.

     

Registered nurse management of urinary catheters in a rehabilitation and long-term care hospital

Nurses are the primary managers of all the routine care and problem solving associated with patients who have indwelling urinary catheters. Despite the key role nurses have, there is a lack of uniformity in the nature of documentation provided to guide practice. This paper discusses the findings from a research project that identified knowledge levels and management practices in a rehabilitation and long-term care hospital. A convenience sample of 39 registered nurses completed a questionnaire examining knowledge levels and identifying current practices. The results revealed knowledge deficits in catheter-related knowledge, and variation in client education and documentation. The results also demonstrated the continued use of traditional knowledge as well as unclear application of fundamental nursing principles. There is a clear need for increased use of evidence-based practice and development of suitable post-registration education.     

Provider-identified barriers and facilitators to implementing a supported employment program in spinal cord injury

Purpose: In a 5-year study, individual placement and support (IPS) significantly increased employment rate of United States Veterans with spinal cord injury (SCI), a historically underemployed population. In a follow-up study, data on barriers and facilitators to IPS implementation were identified.

Methods: Over 24?months of implementation, 82?key medical and vocational staff underwent semi-structured interviews (n?=?130). Interviews were digitally recorded and qualitatively analyzed (ATLAS.ti v0.7) using a constant comparative method to generate themes.

Results: Some barriers to implementation occurred throughout the study, such as Veterans’ lack of motivation and providers’ difficulty integrating vocational and medical rehabilitation. Other barriers emerged at specific stages, for example, early barriers included a large geographic service area and a large patient caseload, and late barriers included need for staff education. Facilitators were mostly constant throughout implementation and included leadership support and successful integration of vocational staff into the medical care team.

Conclusions: Implementation strategies need to be adjusted as implementation progresses and matures. The strategies that succeeded in this setting, which were situated in a real-world context of providing IPS as a part of SCI medical care, may inform implementation of IPS for other populations with physical disabilities.

• Implications for Rehabilitation

• Key facilitators to IPS in SCI implementation are integrating vocational staff with expertise in IPS and SCI on clinical rehabilitation teams and providing leadership support.

• Ongoing barriers to IPS in SCI include patient specific and program administration factors such as caseload size and staffing patterns.

• Varying implementation strategies are needed to address barriers as they arise and facilitate successful implementation.

     

Hospital rehabilitation for patients with obesity: a scoping review

Purpose: To explore the evidence on rehabilitation for hospitalized patients with obesity.

Methods: Medline, Embase, CENTRAL, CINAHL, and PubMed were searched from 1994 to May 2016. Grey literature was hand-searched. Two reviewers independently selected studies examining patients with obesity receiving hospital-based therapy for a physical impairment. One reviewer extracted the data and a second reviewer verified a random sample.

Results: Thirty-nine studies (two trials, 37 observational) were included. Patients underwent rehabilitation following orthopaedic surgery (n?=?25), neurological conditions (n?=?7), acute medical illnesses (n?=?3), or various procedures (n?=?4). Three studies investigated the effectiveness of a specific rehabilitation program in patients with obesity; however, two lacked a control group, precluding inferences of causal associations. Most studies compared functional outcomes across patients in different BMI categories (n?=?33). There was much variability in the rehabilitation components, intensity, and providers used across the studies. The most frequent components were gait training and mobility (n?=?17) and training in assistive devices (n?=?12). Across the 50 outcomes measured, length of hospital stay (n?=?24) and Functional Independence Measure (n?=?15) were assessed most frequently.

Conclusions: Evidence to guide rehabilitation for patients with obesity is sparse and weak. Rigorous comparative studies with clearly defined interventions and consensus outcome measures are needed.

• Implications for Rehabilitation

• Obesity rates have dramatically increased among patients requiring rehabilitation following joint arthroplasty, stroke, injury, or an acute medical event.

• There are currently no guidelines by which to define best practice for rehabilitating patients with obesity and comparative studies on rehabilitation programs are needed.

• Professional development focused on patient-centered rehabilitation and sensitivity training is known to promote quality care, reduce weight bias, and improve patient satisfaction.

• Access to and knowledge about equipment is necessary to promote patient and health care provider safety.

     

Standing activity intervention and motor function in a young child with cerebral palsy: A case report

Purpose: There is limited evidence to fully justify the use of standing interventions for children with cerebral palsy (CP). This case report describes the impact of an 8-week standing program on motor function in a child with severe CP living in western Africa. Methods: The subject was diagnosed with ischemic – hypoxic encephalopathy shortly after birth and with CP at 12 months of age. Gross Motor Function Classification of CP was level IV. Early attempts at physical therapy were interrupted by limited access to medical services. At 18 months, a standing program using a locally constructed standing frame was initiated. The standing intervention was completed at home 5 times a week for 8 weeks. Motor skills were assessed at baseline and post-intervention using the Gross Motor Function Measure (GMFM-66). Results: Scores on the GMFM-66 increased from 28 at baseline to 37.4 in 8 weeks. Improvements in motor function included improved head control, improved upper extremity function, and increased sitting ability. Conclusions: Implementation of a home-based standing program may have contributed to improved motor skills for this child. Further research is needed to determine the effect of standing interventions on functional motor development for children with severe CP.     

Implementing a client-centred approach in rehabilitation: an autoethnography

Purpose: Client-centred practice is widely considered a key element of rehabilitation. However, there is limited discussion of how it should be implemented. This study explored how client-centred practice was operationalized during a clinical trial of innovative goal-setting techniques. Method: This study drew on principles of co-autoethnography. The personal experiences of three clinical researchers were explored to identify insights into client-centred practice, and seek understanding of this within the broader socio-cultural context. Data were collected through group discussions and written reflections. Thematic analysis and coding were used to identify the dominant themes from the data. Results: The primary way that client-centred practice was operationalized was through listening in order to get to know, to uncover and to understand what was meaningful. Four strategies were identified: utilizing mindful listening, allowing time, supporting clients to prioritize what is meaningful and viewing the therapists’ role differently. Conclusion: While technical competence in rehabilitation is important, our study suggested a starting point of ‘being with’ rather than ‘doing to’ may be beneficial for engaging people in their rehabilitation. We have highlighted a number of practical strategies that can be used to facilitate more client-centred practice. These approaches are consistent with what clients report they want and need from rehabilitation services.

Implications for Rehabilitation

• At face value, clinical practice may appear to be client-centred. However, critical reflection of existing practice suggests that in reality, it is not well operationalized.

• Prioritizing getting to know the client, their story and what is meaningful to them appears fundamental to client-centred practice. A number of strategies may facilitate this process, including mindful listening on the part of the clinician and allowing time.

• Structures and processes need to be instituted to support implementation of client-centred practice.

• Autoethnography is an approach that may support clinicians’ to reflect on their practice.