Annie McCluskey

Providing education on evidence-based practice improved knowledge but did not change behaviour: a before and after study

BackgroundMany health professionals lack the skills to find and appraise published research. This lack of skills and associated knowledge needs to be addressed, and practice habits need to change, for evidence-based practice to occur. The aim of this before and after study was to evaluate the effect of a multifaceted intervention on the knowledge, skills, attitudes and behaviour of allied health professionals.Methods114 self-selected occupational therapists were recruited. The intervention included a 2-day workshop combined with outreach support for eight months. Support involved email and telephone contact and a workplace visit. Measures were collected at baseline, post-workshop, and eight months later. The primary outcome was knowledge, measured using the Adapted Fresno Test of Evidence-Based Practice (total score 0 to 156). Secondary outcomes were attitude to evidence-based practice (% reporting improved skills and confidence; % reporting barriers), and behaviour measured using an activity diary (% engaging/not engaging in search and appraisal activities), and assignment completion.ResultsPost-workshop, there were significant gains in knowledge which were maintained at follow-up. The mean difference in the Adapted Fresno Test total score was 20.6 points (95% CI, 15.6 to 25.5). The change from post-workshop to follow-up was small and non-significant (mean difference 1.2 points, 95% CI, -6.0 to 8.5). Fewer participants reported lack of searching and appraisal skills as barriers to evidence-based practice over time (searching = 61%, 53%, 24%; appraisal 60%, 65%, 41%). These differences were statistically significant (p = 0.0001 and 0.010 respectively). Behaviour changed little. Pre-workshop, 6% engaged in critical appraisal increasing to 18% post-workshop and 18% at follow-up. Nearly two thirds (60%) were not reading any research literature at follow-up. Twenty-three participants (20.2%) completed their assignment.ConclusionEvidence-based practice skills and knowledge improved markedly with a targetted education intervention and outreach support. However, changes in behaviour were small, based on the frequency of searching and appraisal activities. Allied health educators should focus more on post-workshop skill development, particularly appraisal, and help learners to establish new routines and priorities around evidence-based practice. Learners also need to know that behaviour change of this nature may take months, even years.

Effects of Splinting on Wrist Contracture After Stroke: A Randomized Controlled Trial

Background and Purpose— Splints are commonly applied to the wrist and hand to prevent and treat contracture after stroke. However, there have been few randomized trials of this intervention. We sought to determine whether wearing a hand splint, which positions the wrist in either a neutral or an extended position, reduces wrist contracture in adults with hemiplegia after stroke. Methods— Sixty-three adults who had experienced a stroke within the preceding 8 weeks participated. They were randomized to either a control group (routine therapy) or 1 of 2 intervention groups (routine therapy plus splint in either a neutral or an extended wrist position). Splints were worn overnight for, on average, between 9 and 12 hours, for 4 weeks. The primary outcome, measured by a blinded assessor, was extensibility of the wrist and long finger flexor muscles (angle of wrist extension at a standardized torque). Results— Neither splint appreciably increased extensibility of the wrist and long finger flexor muscles. After 4 weeks, the effect of neutral wrist splinting was to increase wrist extensibility by a mean of 1.4° (95% CI, −5.4° to 8.2°), and splinting the wrist in extension reduced wrist extensibility by a mean of 1.3° (95% CI, −4.9° to 2.4°) compared with the control condition. Conclusions— Splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. These findings suggest that the practice of routine wrist splinting soon after stroke should be discontinued.

A survey of adult power wheelchair and scooter users.

Purpose. Power wheelchairs and scooters have the potential to increase community participation for people with mobility limitations. However, there are also challenges associated with use. The aims of this study were to investigate the characteristics of adults who use power wheelchairs and scooters, explore the process of power-mobility provision and examine the benefits and challenges of use. Methods. A cross-sectional survey design was used to recruit power wheelchair or scooter users, aged over 18 years, or their carer, living in New South Wales, Australia. The survey was distributed by mail and e-mail. Results. Two hundred and two usable surveys were returned, 25% were power wheelchair users (median age: 57 years, IQR: 40–69) and 74% were scooter users (mean age: 81 years, IQR: 72–85). Only one-third of users (33%) consulted a health professional prior to purchasing their device. Benefits included increased independence and quality of life. Challenges included environmental barriers and accidents. A sizeable proportion of respondents (21%) reported accidents in the previous year, often resulting in personal injury and damage to their device. Conclusion. Power-mobility devices have many benefits for users, but can also have negative outcomes, like accidents resulting in injuries. Further high quality studies need to be conducted to determine whether the positive benefits outweigh the negative outcomes such as accidents and injuries.

The Adapted Fresno Test of competence in evidence‐based practice

Introduction: Health educators who teach professionals about evidence‐based practice (EBP) need instruments to measure change in skills and knowledge. This study aimed to develop and evaluate the interrater reliability, internal consistency, and responsiveness of the Adapted Fresno Test (AFT) of competence in EBP. Methods: Reliability testing involved 2 raters. The AFT was completed by 114 occupational therapists before, and 106 therapists after a 2‐day workshop on EBP. A random sample of 20 completed tests (10 pre‐ and 10 postworkshop = Versions 1 and 2) were scored by 2 raters. Interrater reliability was calculated with the use of intraclass correlation coefficients (ICC, 1,2) for 7 summed subtest scores and the total AFT score. Internal consistency was calculated with the use of Cronbachs &agr;. Responsiveness was calculated by comparing mean pre–post change scores, change in low scorers with high scorers. Results: Interrater reliability ranged from good to excellent for individual AFT subtests (Version 1: ICC, 0.80–0.96; Version 2: 0.68–0.94), and excellent for total AFT scores (Version 1: ICC, 0.96; Version 2: ICC, 0.91). Internal consistency was acceptable (Cronbachs &agr;, 0.74). Overall mean change on the 156‐point test was 20.6 points (95% confidence interval [CI], 15.6–25.5), 26.8 points (95% CI, 21.6–1.9) for low scorers and −1.8 points (95% CI, −6.4 to 10.1) for high scorers. Discussion: The AFT has acceptable psychometric properties, and measures change in knowledge and skills of rehabilitation professionals following EBP training. The test is most useful for evaluating change in novice learners.

Feasibility and results of a randomised pilot-study of pre-discharge occupational therapy home visits

BackgroundPre-discharge home visits aim to maximise independence in the community. These visits involve assessment of a person in their own home prior to discharge from hospital, typically by an occupational therapist. The therapist may provide equipment, adapt the home environment and/or provide education. The aims of this study were to investigate the feasibility of a randomised controlled trial in a clinical setting and the effect of pre-discharge home visits on functional performance in older people undergoing rehabilitation.MethodsTen patients participating in an inpatient rehabilitation program were randomly assigned to receive either a pre-discharge home visit (intervention), or standard practice in-hospital assessment and education (control), both conducted by an occupational therapist. The pre-discharge home visit involved assessment of the older persons function and environment, and education, and took an average of 1.5 hours. The hospital-based interview took an average of 40 minutes. Outcome data were collected by a blinded assessor at 0, 2, 4, 8 and 12 weeks. Outcomes included performance of activities of daily living, reintegration to community living, quality of life, readmission and fall rates.ResultsRecruitment of 10 participants was slow and took three months. Observed performance of functional abilities did not differ between groups due to the small sample size. Difference in activities of daily living participation, as recorded by the Nottingham Extended Activities of Daily Living scale, was statistically significant but wide confidence intervals and low statistical power limit interpretation of results.ConclusionEvaluation of pre-discharge home visits by occupational therapists in a rehabilitation setting is feasible, but a more effective recruitment strategy for a main study is favored by application of a multi-centre setting.

Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study

BackgroundTranslating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit.MethodsA qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005).ResultsSix group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler).ConclusionsFindings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.

What people say about travelling outdoors after their stroke: A qualitative study

BACKGROUND/AIM Reduced walking ability and loss of confidence are common after stroke. Many people cannot drive or use public transport, which can restrict participation. This qualitative study aimed to explore the experiences and attitudes of people following stroke to travelling outdoors early after hospital discharge. METHODS Two semi-structured interviews were conducted with 19 people post-stroke, all of whom were receiving rehabilitation to increase outdoor travel. Mean age was 68.6 years (SD 11.7years). Eight significant others also participated. Interviews were conducted at home (median 21 days post-discharge), with a second interview three months later. Questions focussed on common destinations, modes of travel including driving when relevant and factors that influenced outdoor travel. Qualitative data were analysed using constant comparative (grounded theory) methods, resulting in themes and categories. RESULTS People with stroke were categorised as either a hesitant or confident explorer, in relation to walking, catching public transport and driving. Factors influencing outdoor travel included their emotional disposition, having meaningful destinations, expectations of recovery and the sphere of influence, including family and therapists. These factors could have an enabling or restricting effect. A pre-stroke walking habit also positively contributed to outdoor travel. Gate-keeping by therapists, general practitioners and family members seemed to adversely affect travel. CONCLUSIONS   This emerging theory offers insights into the experiences and attitudes to outdoor travel of people who were ambulant and participating in community rehabilitation following a stroke. Future research could explore the experiences of people with more severe mobility, cognitive and communication problems.

From what we know to what we do: translating stroke rehabilitation research into practice

Despite the recent advances in stroke rehabilitation research, the translation of research evidence into practice remains a challenge. The purpose of this article is to communicate practical experience and describe research methodologies used to promote change and implementation of stroke rehabilitation research in three international settings. In England, the development of an evidence-based consensus document, combined with qualitative and quantitative methods, was used to promote practice change in community-based stroke services. The Canadian research program involved synthesis of evidence, creation of user friendly information, and development of multimodal knowledge transfer strategies to promote change at an individual clinician level. Australian researchers followed a multistep process, involving audit and feedback, identification of barriers, and tailored education to improve implementation of one clinical guideline recommendation. Reducing the evidence–practice gap requires the development of active management strategies. This article highlights the importance of close collaboration between stakeholders – both in terms of the transfer of evidence into clinical practice and for optimizing future Phase IV implementation research endeavours.

A review of factors that influence adult handwriting performance.

BACKGROUND Handwriting is an important activity for people of all ages. Handwriting is frequently affected after stroke and other neurological conditions. However, research on the handwriting of healthy adults is difficult to find. This review aims to advance the development of evidence-informed handwriting assessment and retraining. AIM The aim of this paper was to review factors that influence the handwriting performance of unimpaired adults, some of which are amenable to intervention. METHODS Searches were conducted of eight electronic databases up to April 2009 and again in November 2010. Reference lists were also used to identify potential studies of interest. No limits were placed on study design. FINDINGS  Age: Younger adults write more legibly and faster than older adults. Gender: Women write faster and more legibly than men. Pengrip: Grips other than the traditional dynamic tripod are functional, producing legible text in an acceptable time. Pen pressure: Pressure varies with different letters, words, text size, speed and across a page of text. Error corrections and a mixed writing style occur in healthy adult handwriting. Research was inconclusive about the association between speed, pressure and upper limb movements on handwriting performance. Other factors able to predict adult handwriting legibility have been largely unexplored. DISCUSSION A number of knowledge and research gaps about adult handwriting were identified, including the need for more contemporary normative data.

Effect of affordable technology on physical activity levels and mobility outcomes in rehabilitation: a protocol for the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial

Introduction People with mobility limitations can benefit from rehabilitation programmes that provide a high dose of exercise. However, since providing a high dose of exercise is logistically challenging and resource-intensive, people in rehabilitation spend most of the day inactive. This trial aims to evaluate the effect of the addition of affordable technology to usual care on physical activity and mobility in people with mobility limitations admitted to inpatient aged and neurological rehabilitation units compared to usual care alone. Methods and analysis A pragmatic, assessor blinded, parallel-group randomised trial recruiting 300 consenting rehabilitation patients with reduced mobility will be conducted. Participants will be individually randomised to intervention or control groups. The intervention group will receive technology-based exercise to target mobility and physical activity problems for 6 months. The technology will include the use of video and computer games/exercises and tablet applications as well as activity monitors. The control group will not receive any additional intervention and both groups will receive usual inpatient and outpatient rehabilitation care over the 6-month study period. The coprimary outcomes will be objectively assessed physical activity (proportion of the day spent upright) and mobility (Short Physical Performance Battery) at 6 months after randomisation. Secondary outcomes will include: self-reported and objectively assessed physical activity, mobility, cognition, activity performance and participation, utility-based quality of life, balance confidence, technology self-efficacy, falls and service utilisation. Linear models will assess the effect of group allocation for each continuously scored outcome measure with baseline scores entered as a covariate. Fall rates between groups will be compared using negative binomial regression. Primary analyses will be preplanned, conducted while masked to group allocation and use an intention-to-treat approach. Ethics and dissemination The protocol has been approved by the relevant Human Research Ethics Committees and the results will be disseminated widely through peer-reviewed publication and conference presentations. Trial registration number ACTRN12614000936628. Pre-results.