Factors affecting the delivery of complex rehabilitation interventions in research with neurologically impaired adults: a systematic review

Abstract

Background Rehabilitation research does not always improve patient outcomes because of difficulties implementing complex health interventions. Identifying barriers and facilitators to implementation fidelity is critical. Not reporting implementation issues wastes research resources and risks erroneously attributing effectiveness when interventions are not implemented as planned, particularly progressing from single to multicentre trials. The Consolidated Framework for Implementation Research (CFIR) and Conceptual Framework for Implementation Fidelity (CFIF) facilitate identification of barriers and facilitators. This review sought to identify barriers and facilitators (determinants) affecting implementation in trials of complex rehabilitation interventions for adults with long-term neurological conditions (LTNC) and describe implementation issues. Methods Implementation, complex health interventions and LTNC search terms were developed. Studies of all designs were eligible. Searches involved 11 databases, trial registries and citations. After screening titles and abstracts, two reviewers independently shortlisted studies. A third resolved discrepancies. One reviewer extracted data in two stages; 1) descriptive study data, 2) units of text describing determinants. Data were synthesised by (1) mapping determinants to CFIF and CFIR and (2) thematic analysis. Results Forty-three studies, from 7434 records, reported implementation determinants; 41 reported both barriers and facilitators. Most implied determinants but five used implementation theory to inform recording. More barriers than facilitators were mapped onto CFIF and CFIR constructs. “Patient needs and resources”, “readiness for implementation”, “knowledge and beliefs about the intervention”, “facilitation strategies”, “participant responsiveness” were the most frequently mapped constructs. Constructs relating to the quality of intervention delivery, organisational/contextual aspects and trial-related issues were rarely tapped. Thematic analysis revealed the most frequently reported determinants related to adherence, intervention perceptions and attrition. Conclusions This review has described the barriers and facilitators identified in studies implementing complex interventions for people with LTNCs. Early adoption of implementation frameworks by trialists can simplify identification and reporting of factors affecting delivery of new complex rehabilitation interventions. It is vital to learn from previous experiences to prevent unnecessary repetitions of implementation failure at both trial and service provision levels. Reported facilitators can provide strategies for overcoming implementation issues. Reporting gaps may be due to the lack of standardised reporting methods, researcher ignorance and historical reporting requirements. Systemic review registration PROSPERO CRD42015020423

Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors

“…The premise is worthy, if staff can be trained to deliver trial interventions in real-life contexts, trial findings will be contextually relevant and may rapidly translate into practice. However, there are many obstacles which interfere with intervention delivery [4,5] that need addressing to maximise trial outcomes.…”

“…Multiple strategies may be needed to support staff because barriers to delivering complex interventions with fidelity exist at organisational and practitioner levels [1,[6][7][8], although evidence on the effectiveness of these strategies is limited [9]. In a systematic review, barriers to fidelity in delivery of rehabilitation to people with long-term neurological conditions included lack of availability of training and therapists' lack of confidence to deliver new interventions, especially where there was a gap between training and initiating intervention delivery [4]. Implementing new interventions in clinical practice or in a trial context may require changes to the staff member's knowledge, skills, confidence, and attitudes [10,11], and how they put new learning into practice is complex [9,[12][13][14].…”

Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors

“…The premise is worthy, if staff can be trained to deliver trial interventions in real-life contexts, trial ndings will be contextually relevant and may rapidly translate into practice. However, there are many obstacles which interfere with intervention delivery (4,5) that need addressing to maximise trial outcomes.…”

“…Multiple strategies may be needed to support staff because barriers to delivering complex interventions with delity exist at organisational and practitioner levels (1,(6)(7)(8), although evidence on the effectiveness of these strategies is limited (9). In a systematic review, barriers to delity in delivery of rehabilitation to people with long-term neurological conditions included lack of availability of training and therapists' lack of con dence to deliver new interventions, especially where there was a gap between training and initiating intervention delivery (4). Implementing new interventions in clinical practice or in a trial context may require changes to the staff member's knowledge, skills, con dence, and attitudes (10,11), and how they put new learning into practice is complex (9,(12)(13)(14).…”

“…Mentors also engaged in cognitive participation by facilitating independent problem-solving among OTs when issues arose, which is important because it encourages new thinking styles, behaviours, and independence among mentees(35). Both OTs and mentors saw value in mentoring being provided alongside future complex intervention delivery to ensure delity, providing further support for use of opinion leaders(4, 36,37); and these ndings may be replicated in future trials. RETAKE mentoring aligns with the UK government's vision for clinical health research (38), which includes empowering staff to contribute to NHS clinical research and innovative research designs incorporating virtual processes and technologies (e.g., RETAKE mentoring was delivered via teleconference or Microsoft Teams).…”