Barriers and facilitators to the implementation of a structured visual assessment after stroke in municipal health care services

Abstract

Background Stroke is a leading cause of disability worldwide. Visual impairments (VIs) affect 60% of stroke survivors, and have negative consequences for rehabilitation and post-stroke life. VIs after stroke are often overlooked and undertreated due to lack of structured routines for visual care after stroke. This study aims to identify and assess barriers and facilitators to the implementation of structured visual assessment after stroke in municipal health care services. The study is part of a larger knowledge translation project. Methods Eleven leaders and municipal interdisciplinary health care professionals participated in qualitative interviews. During two workshops, results from the interviews were discussed with 26 participants from municipal health care services and user representatives. Data from interviews and workshops were collected before the intervention was implemented and analyzed using content analysis. Results The analysis identified individual and contextual barriers and facilitators. The individual barriers were related to the participants' experiences of having low competence of visual functions and vision assessment skills. They considered themselves as generalists, not stroke experts, and some were reluctant of change because of previous experiences of unsuccessful implementation projects. Individual facilitators were strong beliefs that including vision in stroke care would improve health care services. If experienced as useful and evidence based, the new vision routine would implement easier. Contextual barriers were experiences of unclear responsibility for vision care, lack of structured interdisciplinary collaboration and lack of formal stroke routines. Time constraints and practical difficulties with including the vision tool in current medical records were also expressed barriers. Contextual facilitators were leader support and acknowledgement, in addition to having a flexible work schedule. Conclusions This study shows that improving competence about VIs after stroke and skills in assessing visual functions are particularly important to consider when planning implementation of new vision routines in municipal health care services. Increased knowledge about the consequences of living with VIs after stroke, and the motivation to provide best possible care, were individual facilitators for changing clinical practice. Involving knowledge users, solutions for integrating new knowledge in existing routines, along with easily accessible supervision in own practise, are essential facilitators for promoting a successful implementation.

‘If we don’t assess the patient’s vision, we risk starting at the wrong end’: a qualitative evaluation of a stroke service knowledge translation project

“…Recently, we described the expected barriers and facilitators to the implementation of KROSS in municipal health care services, identifying the contextual differences between the municipal services. The participants experiences of having a flexible work schedule or not, degree of time constraints and competence especially affected their views on the likelihood of successful implementation [ 20 ]. When monitoring knowledge use during implementation, all services reported differences in their use of the KROSS tool and new vision routines in their practise.…”

“…With the VISA tool, health care personnel (HCP) in the stroke unit without formal competence in vision and eye care can identify VIs and appropriately refer patients to further vision assessments [ 19 ]. In Norway, a similar tool, the Competence, Rehabilitation of Sight after Stroke (KROSS) assessment tool, has been developed and tested in two stroke units and used by multidisciplinary HCP to assess vision poststroke and promote a follow-up for VIs [ 20 , 21 ]. The KROSS vision assessment tool consists of objective assessments of visual acuity, eye movements, visual field, visual attention and reading, questions for identifying subjective symptoms, and observations in activities of daily living (ADL).…”

“…The current study is an evaluation of the KROSS Knowledge Translation project (KROSS KT), a project to implement a structured vision assessment and follow-up of VIs poststroke among municipal health care services [ 10 , 20 , 22 ]. In collaboration with a Norwegian municipality and patient organisations, we adapted the KROSS tool and competence workshop to a municipal context [ 20 ] and implemented it in three municipal health services frequently used by stroke survivors [ 23 ]: the inpatient rehabilitation unit, home rehabilitation and home care. As the KROSS KT project progressed, other health care services wanted to be a part of the implementation, attend the workshop and use the KROSS tool.…”

“…We used the knowledge to action (KTA) model as the framework for the implementation [ 24 ]. The implementation strategies used in the KROSS KT project were chosen as a result of assessments of barriers and facilitators to implementing a structured vision assessment in municipal health care services, which have been described in an earlier study [ 20 ]. We used multicomponent initiatives that combined dissemination, education, collaboration with researchers and knowledge users, incentives and facilitation [ 25 ].…”

“…We used multicomponent initiatives that combined dissemination, education, collaboration with researchers and knowledge users, incentives and facilitation [ 25 ]. More details about the KROSS KT project are described in an earlier publication about the barriers and facilitators to the implementation of a structured vision assessment in the municipality [ 20 ].…”