Susan Rappolt

Practitioner and Organizational Barriers to Evidence-based Practice of Physical Therapists for People With Stroke

Background and Purpose: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists’ implementation of evidence-based practice (EBP) for people with stroke. Subjects: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada. Methods: A cross-sectional mail survey was conducted. Results: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature. Discussion and Conclusion: Lack of education, negative perceptions about research and physical therapists’ role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.

The contingencies of organizational learning in long-term care: factors that affect innovation adoption.

We apply the theoretical frameworks of knowledge transfer and organizational learning, and findings from studies of clinical practice guideline (CPG) implementation in health care, to develop a contingency model of innovation adoption in long-term care (LTC) facilities. Our focus is on a particular type of innovation, CPGs designed to improve the quality of LTC. Our interest in this area is founded on the premise that the ability of LTC organizations to adopt and sustain the use of innovations like CPGs is contingent on the initial capacity these institutions have to learn about them, and on the presence of factors that contribute to capacity building at each stage of innovation adoption. Based on our review of relevant theory, we develop a set of fifteen testable propositions that relate factors operating at the guideline, individual, organizational, and environmental levels in LTC institutions to stages of guideline adoption/transfer. Our model offers insights into the complexities of adopting and sustaining innovations in LTC facilities particularly, in health care organizations specifically, and in service organizations generally.

Spanning the know-do gap: Understanding knowledge application and capacity in long-term care homes

Using a multiple case study design, this article explores the translation process that emerges within Ontario long-term care (LTC) homes with the adoption and implementation of evidence-based clinical practice guidelines (CPGs). Within-organization knowledge translation is referred to as knowledge application. We conducted 28 semi-structured interviews with a range of administrative and care staff within 7 homes differentiated by size, profit status, chain membership, and rural/urban location. We further undertook 7 focus groups at 5 locations, involving a total of 35 senior clinical staff representing 15 homes not involved in earlier structured interviews. The knowledge application process that emerges across our participant organizations is highly complex, iterative, and reliant upon a facilitys knowledge application capacity, or absorptive capacity to effect change through learning. Knowledge application capacity underpins the emergence of the application process and the advancement of knowledge through it. We find that different elements of capacity are important to different stages of the knowledge application process. Capacity can pre-exist, or can be acquired. The majority of the capacity elements required for successful knowledge application in the LTC contexts we studied were organizational. It is essential for managers and practitioners therefore to conceptualize and orchestrate knowledge application initiatives at the organization level; organizational leaders (including clinical leaders) have a vital role to play in the success of knowledge application processes.

Qualitative Meta-Synthesis: Reflections on the Utility and Challenges in Occupational Therapy

Background. A qualitative meta-synthesis is an approach to synthesizing relevant findings from across qualitative studies on a particular topic using methods consistent with qualitative research. Purpose. Using examples of recently completed qualitative meta-synthesis projects, the purpose of this paper is to present the meta-synthesis approach; highlight the key steps, processes, and issues involved; and demonstrate its potential to advance knowledge about occupation and occupation-based practice. Key Issues. The qualitative meta-synthesis approach allows us to take stock of the current state of knowledge in a given area in order to ensure that we have explored the phenomenon from different perspectives and to begin to push the field forward by allowing us to develop deeper insights and understandings. Implications. Despite certain limitations and challenges associated with the approach, qualitative meta-syntheses can provide new knowledge through critical analysis and interpretation to inform client, practitioner, and policy audiences.

Occupational Justice: Future Directions

In this paper, we build on the findings from our scoping review (Durocher, Rappolt & Gibson, 2013) of occupational justice and its associated concepts, which revealed considerable conceptual confusion and barriers to the usability and understanding of occupational justice. In this paper we expand on those findings to provide a critique and way forward by drawing from four distinct perspectives. First, we take the stance of the sceptical occupational scientist to examine the interrelationships between occupation and health. We then consider occupational justice from a practice standpoint, and then from the view of the broad health care provider community. Finally, we discuss how the field of bioethics may contribute to occupational justice.

Physical Therapists’ Experiences Updating the Clinical Management of Walking Rehabilitation After Stroke: A Qualitative Study

Background: Little is known about physical therapists’ experiences using research evidence to improve the delivery of stroke rehabilitation. Objectives: The purpose of this study was to explore how physical therapists use research evidence to update the clinical management of walking rehabilitation after stroke. Specific objectives were to identify physical therapists’ clinical questions related to walking rehabilitation, sources of information sought to address these questions, and factors influencing the incorporation of research evidence into practice. Design and Methods: Two authors conducted in-depth telephone interviews with 23 physical therapists who treat people with stroke and who had participated in a previous survey on evidence-based practice. Data were analyzed with a constant comparative approach to identify emerging themes. Results: Therapists commonly raised questions about the selection of treatments or outcome measures. Therapists relied foremost on peers for information because of their availability, ease of access, and minimal cost. Participants sought information from research literature themselves or with the help of librarians or students. Research syntheses (eg, systematic reviews) enabled access to a body of research. Older therapists described insufficient computer and search skills. Most participants considered appraisal and application of research findings challenging and identified insufficient time and peer isolation as organizational barriers to the use of research. Conclusions: Physical therapists require efficient access to research syntheses primarily to inform the measurement and treatment of walking limitation after stroke. Continuing education is needed to enhance skills in appraising research findings and applying them to practice. Older therapists require additional training to develop computer and search skills. Peer networks and student internships may optimize the exchange of new knowledge for therapists working in isolation.

An Integrated Review of the Processes and Factors Relevant to Vocational Evaluation Following Traumatic Brain Injury

Introduction: In order to develop the evidence base for a clinical practice guideline (CPG) for vocational evaluation following traumatic brain injury (TBI), we undertook a review to identify the key processes evaluators should follow and the key factors they should consider when completing a vocational evaluation. Methods: Processes outlined in the Cochrane Handbook of Systematic Review guided our processes and included: development of review questions, search strategies and selection criteria; quality appraisal; extraction, analysis and data synthesis; drawing conclusions. Four data bases (i.e. Medline; PsychInfo; Embase; The Cochrane Library of Systematic Reviews) were searched for descriptive articles, quantitative and qualitative studies, and nine websites were searched for CPGs (e.g. Scottish Intercollegiate Guideline Network; US National Guideline Clearinghouse; New Zealand Guideline Group). Two reviewers independently appraised methodological quality. Data were extracted into evidence tables which included: study purpose; location; participants; design/method; themes; findings; relevant processes and factors. Directed content analysis was utilized to analyze and synthesize the descriptive process evidence. A constant comparative method was employed to compare study findings in relation to factors associated with successful employment. Results: Results from process and factors syntheses are integrated into the Evidence-based Framework for Vocational Evaluation Following TBI. This framework identifies seven key processes in a vocational evaluation, including: (1) identification of the evaluation purpose and rationale; (2) intake process; (3) assessment of the person; (4) assessment of the environment; (5) assessment of the occupation/job requirements; (6) analysis and synthesis of assessment results; (7) development of evaluation recommendations. Relevant factors are integrated into each key process. Conclusions: This framework outlines the key information evaluators should gather, the domains of the person, environment and occupation they should assess, and elements of rigour they should consider when completing a vocational evaluation and making recommendations for work re-entry following a TBI.

Towards developing a guideline for vocational evaluation following traumatic brain injury: the qualitative synthesis of clients’ perspectives

Purpose: This paper is a qualitative synthesis of clients’ perspectives of the elements significant to return to work following traumatic brain injury (TBI). This is part of a larger review, completed to provide the evidence base for a vocational evaluation guideline. Methods: Processes outlined in the Cochrane Handbook of Systematic Review guided the full review including: developing review questions, search strategies and selection criteria; quality appraisal; data extraction, analysis and synthesis; drawing conclusions. Four data bases (i.e. Medline, Embase, PsychInfo, Cochrane) were searched for relevant qualitative studies. Evidence tables were used to extract data from studies and thematic analysis employed to analyze the qualitative data. Results: Analysis of clients’ perspectives on return to work resulted in four key themes including the following: 1) meaning of work; 2) process of return to work and reconciling new identities; 3) opportunities to try versus risks of failure; 4) significance of supports. Themes are discussed in relation to vocational evaluation and findings from other syntheses. Conclusions: Vocation evaluation should include the assessment of: the meaning clients ascribe to work following a TBI and their post-injury goals; clients’ self-perceptions of work competency, work readiness and anticipated challenges with return to work; and the available supports. Implications for Rehabilitation Incorporating clients’ perspectives within vocational evaluation facilitates their partnership in the process. Vocational evaluators should assess clients’ post-injury work goals, interests and motivations, as the meaning of work can change following traumatic brain injury (TBI). Vocational evaluators should assess the opportunities for experimentation with work activities, to facilitate clients’ development of self-awareness and new self-identities. Vocational evaluators should identify instrumental and emotional supports available to clients, to mediate challenges that may arise during return to work.

Enhancing Research Use through Online Action Research

Background. Many health professionals, including occupational therapists, have difficulty utilizing research findings in daily practice. Purpose. To determine if an online action research project could enhance research use among occupational therapists working in similar practice areas. Methods. Four groups of 12–14 occupational therapists met online for approximately one year. They discussed barriers and facilitators to research utilization, defined practice questions, and attempted to search for, synthesize and apply relevant research findings. Online communications and post-group interviews were thematically analyzed. Results. Only half of the participants who began the project were still online with the research project at completion. These participants believed that their involvement in the group led to increased personal awareness, motivation and confidence regarding the use of research evidence in practice and knowledge to be used in practice. Time to review, critique and synthesize research evidence continued to be a major barrier to enhanced research utilization. Practice Implications. Online meetings designed to enhance research use among occupational therapists appear to hold some promise, but refinements are needed to ensure their ultimate success.

Inter-Professional Clinical Practice Guideline for Vocational Evaluation Following Traumatic Brain Injury: A Systematic and Evidence-Based Approach

Introduction This paper introduces an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. This guideline aims to explicate the processes and factors relevant to vocational evaluation to assist evaluators (i.e. health care teams, individuals and employers) in collaboratively determining if clients are able to work and to make recommendations for work entry, re-entry or vocational planning. Methods Methods in the Canadian Medical Association’s (CMA) Handbook on Clinical Practice Guideline and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were utilized to ensure rigour. Steps in the CMA handbook were followed and included: (1) identifying the guideline’s objective and questions; (2) systematic literature review; (3) study selection and quality appraisal; (4) development of clear recommendations by key stakeholders; (5) guideline pilot testing and endorsement. Results The resulting guideline includes 17 key recommendations within the seven domains: (1) evaluation purpose and rationale; (2) initial intake process; (3) assessment of the personal domain; (4) assessment of the environment; (5) assessment of occupational/job requirements; (6) analysis and synthesis; (7) evaluation recommendations. Conclusions The guideline may be useful to individually practicing clinicians, health care teams, employers and individuals with TBI. Future research will formally examine the success of the guideline’s implementation.