Factors influencing allied health professionals’ implementation of upper limb sensory rehabilitation for stroke survivors: a qualitative study to inform knowledge translation

Abstract

ObjectivesSomatosensory loss is common after stroke with one-in-two individuals affected. Although clinical practice guidelines recommend providing somatosensory rehabilitation, this impairment often remains unassessed and untreated. To address the gap between guideline recommendations and clinical practice, this study sought to understand the factors influencing delivery of evidence-based upper limb sensory rehabilitation after stroke.DesignQualitative study involving focus groups and interviews. Data analysis used an inductive approach (thematic analysis) and deductive analysis using implementation theory (the Theoretical Domains Framework and Normalisation Process Theory).SettingEight healthcare organisations in metropolitan and regional areas of Victoria and New South Wales, Australia.ParticipantsEighty-seven rehabilitation therapists (79% occupational therapists and 21% physiotherapists) were purposively sampled and participated in a knowledge translation study with staggered recruitment from 2014 to 2018.ResultsThree types of factors influenced therapists’ delivery of upper limb somatosensory rehabilitation: individual (‘The uncertain, unskilled therapist’), patient (‘Patient understanding and priorities’) and organisational (‘System pressures and resources’). Deductive analysis using implementation theory identified key determinants of practice change, such as opportunities to consolidate new skills, the anticipated benefits of upskilling as a therapy team and the work anticipated by therapists to incorporate a new somatosensory rehabilitation approach.ConclusionsOccupational therapists and physiotherapists hold valuable insights towards practice change in somatosensory rehabilitation from the ‘frontline’. Therapists experience barriers to change including a lack of knowledge and skills, lack of resources and organisational pressures. Facilitators for change were identified, including social support and therapists’ perceived legitimacy in using new somatosensory rehabilitation approaches. Results will inform the design of a tailored implementation strategy to increase the use of evidence-based somatosensory rehabilitation in Australia.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12615000933550).

Healthcare professionals’ perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review

“…A lack of organisational processes acts as a negative influence on guideline implementation 50,51,55,[58][59][60][61]63,64,[68][69][70][71] by way of insufficient training/education, lack of protocols to influence [57][58][59]61,[63][64][65][66][68][69][70][71] Management and leadership were expressed as facilitators by actively supporting the organisational process mentioned above and protecting staff time for implementation creating a high level of organisational priority and commitment to guideline implementation resulting in a positive organisational culture. [53][54][55]59,67,68,69 Implementation interventions described in eight studies to increase the uptake of stroke guidelines included change management strategies, 52,56,57 training and education for that specific stroke rehabilitation guideline, 52,56-58,61,65,66 auditing, 52,58,65 facilitators/opinion leaders/champions 57,58,65-67 and reminders. 57,58,65 It is not the objective of this systematic review to determine which interventions are most effective, but due to the heterogeneity of the abovementioned studies, it would be challenging to stipulate which interve...…”

“…Nine studies targeted single professional disciplines only; physiotherapists, 60 , 62 , 70 speech and language therapists, 51 – 54 , 71 nursing staff 58 , 61 , 65 and other studies involved a combination of therapists. 55 , 63 , 66 , 67 , 68 Six studies included a mix of healthcare professionals working as part of multidisciplinary teams. 50 , 56 , 57 , 59 , 64 , 69 Participants recruited in included studies worked in a range of clinical settings along the post-stroke continuum of care – see Figure 2 .…”

“…Four studies investigated influential factors around national stroke guideline implementation in Ireland 59 , 60 and Australia. 51 , 53 The remaining studies investigated specific clinical practice guideline recommendation implementation, 50 , 52 , 54 – 58 , 61 – 71 focusing on the upper limb, lower limb, aphasia, balance, communication, swallow, neglect, urinary continence, falls, depression, pain and education. All but one study 52 examined both perceived barriers and facilitators of the guideline itself and the implementation process/interventions.…”

“…Unanimously, healthcare professionals' prioritisation of competing clinical and non-clinical tasks negatively interfered with guideline implementation. 50 – 52 , 54 , 55 , 58 , 63 , 64 , 68 , 69 , 71 This was not just in acute settings where time and the acute medical model is perceived to be a significant limitation but across the continuum of stroke rehabilitation.…”

“…6,39,40 There remains an over-reliance on identifying and targeting professional level barriers only especially with educational approaches. 63,68 Education in isolation is not an effective intervention for facilitating practice change. 64,72 Indeed, this systematic review reflects an emphasis on education as a trialled implementation intervention 52,[56][57][58]61,65 with a lack of facilitators addressing organisational barriers.…”