How to Improve Knowledge Translation in Stroke Rehabilitation: A View from Occupational Therapy Practice

Abstract

Background/Aims

The study explores the experience and views of occupational therapists in stroke rehabilitation regarding knowledge translation. The apparent knowledge translation gap is described as the delay of use of research evidence into clinical practice.

Method

A qualitative, descriptive research design was used. The verbatim transcripts of the interviews with special section neurology practice (SSNP) occupational therapists were coded and analyzed using thematic analysis.

Findings

The themes identified included 1) how occupational therapists responded to change, 2) how knowledge translation barriers could be seen as learning needs and may lead to empowerment, 3) the use of knowledge translation strategies and professional body support.

Conclusion

Knowledge translation barriers need to be identified in each single environment in order to recommend solutions. To improve knowledge translation training is needed in time management, coping strategies, assistance through supervision and managerial involvement to prevent workplace burn out.  Personal initiatives must become natural, and networking similar to ‘communities of practice’ may keep healthcare professionals ahead of change. Learning needs appear to exist for clinicians and researchers., and improving knowledge translation in the future lies in personal initiative, innovation and involvement.

Introduction

Graham (2006) highlighted that new developments in health research are often a delayed and the process is uncoordinated, resulting in patients not receiving the optimum interventions due to the late transfer of new knowledge into practice. The definition of knowledge translation (KT) by the World Health Organization (WHO, 2005) is “the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health”. Knowledge translation in other words is the bridge between discovery and impact of evidence (Tetroe, 2008) and, as it has developed, it has been adopted by nursing, medicine and public health. The word knowledge used in the KT context means primarily scientific research (Graham, 2006).

Literature Review

Evidence- Based Practice       

“Evidence-based practice (EBP) is essentially a clinical decision making framework that encourages clinicians to integrate information from high quality quantitative and qualitative research with the clinician’s clinical expertise and the client’s background, preferences and values when making decisions” (Sackett et al. 1996, p. 71). Evidence-Based Practice (EBP) is seen as an essential part of the day to day work of occupational therapists (OT) and other health professionals.

 The results from a multidisciplinary team study by Humphries et al. (2000) suggested that occupational therapists want to base their practice on research outcomes but find the ever-growing amount of evidence difficult to manage. Additionally, they highlighted time restrictions, workload pressures and staff shortages as barriers to evidence-based practice. Over a decade later similar factors remain on the list of barriers (Menon et al., 2010; McCluskey et al., 2013). Therefore, for EBP to work the theory-practice gap has to be bridged by developing KT strategies (Graham, 2006).

 KT and EBP

KT has developed immensely over the last twenty years (Grimshaw et al., 2012) to translate evidence into practice.  Kielhofner (2005) explored the vast field of stakeholders involved in KT and suggested that more cooperation and teamwork between researchers and clinicians would facilitate more effective KT. Bayley et al. (2012) recommended that guideline developers set priorities in the way they transfer evidence into guidelines and employ easy to use language.

Jansen et al. (2012) performed a cross-sectional survey using focus groups and a two-round Delphi process to explore barriers to KT. The sample included 166 clinicians with varying academic degrees and professional backgrounds. Lack of time, access and the skills to use and appraise evidence-based literature were cited as barriers for clinicians not being up to date with the latest research. Although there was a low response rate of 38%, results highlighted that the allied health professionals (AHP) which included over 10 disciplines (occupational therapists, physiotherapists, dieticians, social workers and speech pathologists) used their colleagues and own experience as their most frequent evidence base, a finding supported by McKenna et al (2005) with occupational therapists. While physiotherapists had more positive results due to having adequate equipment, the occupational therapists reported missing relevance to practice in articles and lacking equipment at workplace to implement research into practice.

McCluskey and Middleton (2010) with community rehabilitation teams, Wilkinson (2012) with allied health staff, and Hughes et al. (2014) with healthcare professionals demonstrated that EBP had not been fully put into practice by the allied health professions. Solutions were identified as a need to change the behaviour of the allied health professions, more training in EBP and involvement in research, but also support from management. In summary, these studies have highlighted that similar barriers to KT still exist in contemporary practice. Suggestions to improve KT have included using peer support networks to promote EBP, and more equipment and training to improve access to research and in appraising information on the web.

The Health and Care Professionals Council (HCPC) requires health professions to maintain standards of proficiency and conduct which include the use of evidence-based practice in order “to be able to draw on appropriate knowledge and skills to inform practice” (HCPC, 2014, p. 12). Clinical guidelines are developed based on research evidence to advise health professionals in their practice. Some guidelines such as the National Clinical Guidelines for Stroke (NCGS) and the International Classifications of Functioning, Disability and Health (ICF) were developed to guide practice of healthcare professions working in neurorehabilitation settings. Hammond et al. (2005) utilized a retrospective audit to determine whether occupational therapists and physiotherapists showed complete compliance with the NCGS and found that there was surprisingly low adherence to them with more than 40% of admitted patients not seen within the recommended time frame, although the reasons for this lack of implementation were not explored. Wiseman-Hakes et al. (2012) highlighted the importance of considering context in EBP and KT and suggested a wider perspective in the definition of EBP.  In a suggested list of ‘key questions’ for EBP they asked for the reasons why recommended interventions worked in a study, under which conditions they worked, for which clients and at what point of their progress they were applicable? The answers to the key questions could provide better information to clinicians and thereby support correct and easier implementation. In summary, although health research evidence is part of policy and guidelines, health professionals still utilize other factors as part of the clinical reasoning process to discern the relevance of this evidence, for example, empirical knowledge and individual patient context, including their preferences, vulnerabilities and co morbidities  (Benner, Hughes & Sutphen, 2008).

Aim

This study will add to the existing body of research in knowledge translation. It explores the experiences and views of SSNP occupational therapists to answer the research question how to improve knowledge translation in stroke rehabilitation. The speed and dissemination of research into practice appears to be severely delayed (Hammond, 2005) and in order to allow stroke patients to profit from research as soon as possible, the delivery of new therapy interventions has to happen without delay (Graham, 2006).

Methods

This study used a qualitative, descriptive research design to allow the researcher to explore Specialist Section of Neurological Practice (SSNP) Occupational Therapists’ personal experiences and views regarding knowledge translation in stroke rehabilitation.  Semi-structured interviews were chosen to allow participants to explore views using open-ended questions and to ensure richness and depth of data (Oppenheim, 1992). Purposive sampling was used recruiting occupational therapists who were members of a specialist interest group for neurological practice. The participants were informed via an invitation email that identity would be kept anonymous, their participation was voluntary and they could terminate participation without giving a reason at any time.  The first 8 respondents that fulfilled the inclusion criteria were invited to take part in the study and informed written consent was gained before data collection. Telephone interviews were conducted to allow recruitment of participants from a wide geographical area.

Credibility was ensured by having one participant verifying verbatim notes of interview and developed themes; the detailed description of the interview procedure made transferability possible; the study was dependable as findings were confirmed with literature; bias was avoided by continual verbal and written reflections completed by the researcher. The evaluation points for qualitative research by Hammell et al. (2000) was used, alongsie a qualitative research checklist from the critical appraisal skills program (CASP, 2013).

Ethical approval was granted by the University of Brighton School Research Ethics and Governance Panel (SREGP)..

Participants

Inclusion criteria: Participants had to be members of the Specialist Section of Neurological Practice and have at least 2 years’ experience working in stroke rehabilitation. None of the respondents were personally known to the researcher ensuring that there was no coercion possible in the recruitment process, and a power dynamic was avoided (Braun & Clark, 2013).

Data analysis

The thematic analysis by Braun and Clarke (2013) was used including six phases of analysis: familiarization, coding, creating themes, reviewing, defining and naming themes, and finally report writing. The analysis was carried out independently by both the researcher and research supervisor and final themes and categories were agreed.

Results/Findings

Nine SSNP members responded to the invitation and seven participated in the study. The participants had between three to ten years experience working with stroke survivors in rehabilitation, three of them had a Bachelor degree and four a Masters qualification.

Following the thematic analysis the main themes identified related to 1) how occupational therapists respond to change; 2) how knowledge translation barriers could be seen as learning needs and as such might lead to empowerment for clinicians and researchers; 3) how the step from knowledge to wisdom and applying KT strategies.

 

Theme One: Responses to Change

The clinicians’ responses to change such as new therapy interventions can either act as barriers or facilitators of KT. All participants highlighted responses to change as influencing KT in practice, including stress due to time pressure, uncertainty and geographical isolation. Interestingly participants reported both negative and positive responses to change in their practice.

• Stress due to Time Pressure

Several participants counted the reasons for stress such as increasing caseload, staff shortages and funding cuts which had direct impact on KT: “…with everybody being so busy trying to see patients that nobody steps back and changes anything…they are just trying to keep their head above water…” (P. 7:262).

• Reaction to New Evidence

Several quotes revealed the uncertainty clinicians have relating personal experience, empirical knowledge, clinical reasoning, and implementing new evidence in their practice: “…as far as I’m concerned the jury is still out on this splinting high tone thing…I have done it with people…who have really benefited…which is great for them…and…ehm…it becomes hard than not to do something…when you know it benefited someone” (P. 4:610).

Some participants mentioned a low motivation towards new interventions and the tendency to resist development as a response to prospective change. This highlights the difficulties some clinicians may experience when trying to link empirical knowledge with the current research evidence, and the complexity of clinical decision making, which KT does not take into account: “…and I think that people get set in their ways…and they are used to…you know…you almost have a little recipe when you have someone with a certain type of impairment and you do the same things all the time and they (clinicians) don’t have to change…ahmmm…so there is some…I guess resistance in a way to change…” (P. 7: 204).  

• Social and Geographical Isolation

The feeling of isolation was mentioned by three participants, two working in the community and one working in a hospital. For KT to happen the clinician has to be in the place where KT happens, however, this was difficult for some participants: “…yah, a lot of us would like to go on them (relating to cognitive rehabilitation training), but it’s just too far and they are usually two day courses, so you have to have an overnight stay and childcare and all sorts of things…” (P. 5:139).

• Accepting the Challenge

 Interestingly two participants expressed very positive reactions to new knowledge and research evidence. They showed their enthusiasm about new interventions they were introducing into their work with stroke patients: “…one […] excellent study day I went to was by Janice Eng and it is about the GRASP upper limb programme…so that’s another area of practice that we are trying to incorporate…” (P.7:126).

Theme Two: Learning Needs May Lead to Empowerment

All participants described initiatives used while adapting to change and participants highlighted that identifying and addressing learning needs can lead to empowerment. This is seemingly a new finding on this topic as the researcher could not find related literature which mentioned self-initiative and exploring alternative routes to KT goals. Strategies used by the participants included developing their own implementation guidelines, finding support, and networking. However, barriers to KT identified by the participants included lack of clarity in research evidence and issues related to translation of evidence for a laboratory research setting into the clinical setting.

• Developing Implementation Guidelines

One participant outlined how an implementation guideline for a new intervention which did not previously exist was created and was disseminated to other teams in the same Trust: “… there has been a lot of work on mirror box therapy specifically and have read lots of research articles and …and…ehm devised a sort of handy…quick user guide and they have made up a kit and we have all of that stored on our share work drive…so we can access it across the whole in-patient OT pathway” (P.2:58).

This is an excellent example in the field of KT as the participant showed initiative in synthesizing, disseminating and exchanging information with others.  No literature was found on the initiative of developing own guidelines however, it appears that self-learning can be an efficient tool when implementing new practices without guidelines.

• Finding Support

 One of the participants initiated fund-raising and recounted several projects being started: “So for example we are looking to develop a […] project, so we’re looking to be firstly […] with an expert charity in that field” (P. 3:243).

 Several participants took similar initiative with how they justified the attendance of courses and in-services in occupational therapy departments: “…I think we as practitioners we have kind of…stood by saying: Well, look it’s time well spent, if we spend an hour a month (for in-services)…it’s going to be directly invested in improvement of practice…and better results for our patients…” (P. 5:216).

The researcher agrees that justifying training on the background of professional standards (COT, HCPC, RCP), including the goals of best practice and lifelong learning will support KT by making courses, workshops, and training available to staff.

• Networking

 Many participants highlighted the importance of networking and how this improved knowledge exchange, opportunities for additional training, discovering new interventions and projects, sharing skills, finding support groups, covering supervision needs and linking to academic support: “…we’re also part of the…ehm…district wide…OT Stroke Forum which meets quarterly…all grades and again people share back from training, share evidence-based practice, each time we meet we have a new focus” (P. 2:68).

• Application to clinical practice

 Some participants stated that articles were too academic and they would prefer more easily understood and less complicated descriptions from researchers: “…so it’s sometimes the evidence is there, but the clarity of the evidence is hard…” (P. 6:559). “…and articles tend to be very academic, and they don’t actually talk about the practical applications…” (P.5:96)

Several participants described situations where the implementation did not work for their patients and that the research lacked information they needed, they did not consider the psycho social needs of the individuals or the resource limitations of the clinical setting. All of these issues were cited as key barriers for KT.

Theme Three: From Knowledge to Wisdom

This theme appeared to the author with the realization that knowledge applied in practice is wisdom. This principle was postulated by Ackoff (1989) within the field of systems thinking. It implies the evaluated thinking and according to Ackoff (1989) leads to understanding. Some participants after evaluating and understanding the advantages suggested possible strategies to facilitate KT in practice.

• KT Brokers

One participant was very knowledgeable in the area of KT strategies and had information about using a KT facilitator or broker to improve KT. However, most participants were not aware of this as a possible strategy: “…but it’s a massive study […]…which just use guidelines and those who have a knowledge broker plus the guideline…looking at outcomes, ‘cause that’s the only way…you know they have to be a big study which says: Oh, look this unit gets people out quicker cause their interventions are better…” (P. 7:647).

• Collaborative Research

This topic relates to the combined effort between academic, researcher and clinician. Several participants mentioned that the research outcomes did not always assist in changing practice and one participant recommended collaborative research: “…they (undergraduates) do a research proposal…with an extensive review…and the university is always saying to us: Tell us what you want…you know …tell us where the gaps are…’ (P. 4:870).

• Role of College of Occupational Therapy (COT)

 Several participants suggested a role for COT in creating a central website, making articles more easily available and highlighting importance. Five participants supported the idea that the COT could highlight and summarize articles including their relevance and news worthiness but also including any suggested changes to practice: “…but annually some really strong articles saying why we should do one thing and not another…or at least qualify why we are not doing one thing and not another could be generated…that would be helpful…” (P1:56).

Although all participants were aware of the BAOT/COT website and some also knew the Australian (OT-seeker) or Canadian (Stroke-Engine) website they felt the development of a central website as KT pool could result in easier and faster uptake of new interventions when accessing databases.

Discussion

Responses to Change

The NHS is ever-changing and participants all identified responses to change which influenced knowledge translation in practice. Graham et al. (2006) stated that it is an enormous commitment for clinicians to keep up to date with KT despite it being essential to AHPs as it presents part of their professional and regulatory body standards. Stress due to time pressure was identified as a key barrier to KT and Poulsen et al. (2014) made the recommendations that “Educators, clinicians, administrators, and policy makers need to take proactive steps to assist practitioners at risk of burn-out” (p. 163). Gupta et al. (2012) found that there was a direct relationship between ‘unmanageable workload and exhaustion’ (p. 93). The authors recommended coping strategies and workshops to lighten the load of work related stress, including approaching the issue as a team and sharing responsibilities. These findings suggest that time appears to be one of the most significant barriers to knowledge translation and all recommendations to improve KT require time.

Some participants showed uncertainty between knowing about the evidence (Lannin et al, 2007) which recommended not to splint stroke patients with high upper limb tone in general and the participant’s own positive experience of splinting. As a result the new evidence was not implemented into practice. Kilbride et al. (2013) clarified that guidelines for splinting required further research  in order to improve KT for splinting in future. Subsequently new splinting guidelines in the UK were published in 2015 (Kilbride et al., 2015).

According to McCluskey et al. (2013), resistance was a more hidden barrier in KT; they pinpointed several requirements for behavioural changes in therapists, which are: beliefs about AHP’s capability and consequences of therapy assessment and intervention, remembering steps and reasoning for interventions, becoming knowledgeable about new interventions and prioritizing new interventions. Appleby and Tempest (2006) highlighted common factors responsible for resistance to change “seeking to protect the status quo, misunderstanding and lack of trust, contradictory assessments and low tolerance for change” (p.477). They reported good results with dissemination and adherence to guidelines following the eight step process of Creating Major Change by Kotter (1996); the steps included 1. Evidence and establishing a sense of urgency, 2. Creating the guiding coalition, 3. Context and developing a vision and strategy, 4. Communicating the vision and strategy, 5. Facilitation and empowering broad-based action, 6. Generating short-term wins, 7. Consolidating gains and producing more change, 8. Anchoring new approaches in the culture.  His application of change strategies and developing rehabilitation intervention protocols were important factors for a successful KT strategy in 2006.

Literature exists on occupational therapists working in rural jobs in countries such as Australia, Canada and USA but no literature was found for the UK. Campbell et al. (2012) highlighted poor job satisfaction when having decreased access to professional development and working in professional isolation. The extrinsic factors for job satisfaction were, for example, salary and security, while intrinsic factors were “challenge, autonomy and perceived significance of work” (p. 2). The authors identified in their study that intrinsic factors were rated higher by the AHPs. The solutions recommended by the authors were a combination of extrinsic and intrinsic factors which would increase job satisfaction and decrease job turnover (Campbell, 2012). Poor access to professional development is a barrier to KT and would need to be addressed to support the clinicians.

Accepting the challenge is a facilitator for KT in implementing best practice. Menon et al. (2010) stated that new interventions can be challenging. They explored challenges in the use of rehabilitation guidelines and found that time was the main work place barrier, while confidence in skills was the barrier for clinicians. They identified the rewards as improved knowledge for therapists, improved practice behaviours as well as better outcomes for patients (Menon et al., 2010).

Learning Needs May Lead to Empowerment

The learning need of finding support can be changed into the empowerment of using support. In an NHS organization for example the League of Friends or the Goodwood Trust are mostly applied to for funding to support courses or projects or other organizations depending on the area. No literature was found which compared NHS and private funding for occupational therapy projects. The initiative mentioned by participant 7 had a fast and direct impact on KT by funding a group project.

Though no articles were found on the topic of networking in stroke rehabilitation, contacts with networks can be realized on the COT (2014) website. Kielhofner in 2005 suggested the idea of  ‘Communities of Practice’. He reasoned that clinicians who use knowledge together must also generate knowledge together and by doing so progress knowledge into practice (Kielhofner, 2005). Several participants highlighted that combined effort between clinical practice and education could enhance KT. However, achieving the goal of collaborative research to improve KT is rather complicated in the United Kingdom due to separate accountabilities in patient care, research and education (Ovseiko et al., 2014).

Bosch et al. (2014) indicated that the clarity of evidence was an important factor to researchers and made suggestions for improving clarity which are: specifying intervention definition, clear description of intensity, frequency and duration as well as similar outcome measures for (in this research) upper limb stroke studies. The impact on improving KT is evident as clarity of evidence supports appropriate transfer of knowledge into practice.

Stroke survivors exhibit heterogeneity in practice which impacts on how the clinician can apply new techniques. Kloda et al. (2009) in a literature review investigated the clinical information behaviours of AHPs working in rehabilitation and compared them to physicians. They concluded that AHP’s information behaviour was not much studied and their requirements were poorly known; therefore they suggested further research in the area of AHPs information requirements to be able to apply new interventions in their practice. The improved awareness of clinicians’ requirements may support KT in future.

From Knowledge to Wisdom

The topic from knowledge to wisdom became evident in Ackoff (1989), a systems theorist who explained the development from data to wisdom hierarchy, in which he defines wisdom as applied knowledge.  One participant introduced research which used clinical guidelines and a knowledge broker. Knowledge brokering is assisting clinicians to make EBP decisions and include knowledge application (Frazer Health, 2009). Bayley et al. (2012) in a study across five stroke rehabilitation centers recruited 79 multidisciplinary team members who were trained in a six month workshop and additionally had a facilitator (broker) to support KT. The results consisted of enhanced clinician implementation skills and improved outcomes for patients which are a perfect example for improved KT.

Di Rezze et al. (2013) used a KT strategy called Summary of Findings (SoFs) in which they gave detailed information of articles regarding risks of a study (comparing intervention group to control group), including details such as the relative effect of the intervention, the sample size, the quality of evidence and a comment section. The results suggested easier application of evidence when using Summary of Findings for clinicians which in turn can improve KT.

Conclusion

This study highlighted that KT is not routinely happening in clinical practice and KT the clinical guidelines are not always followed. KT barriers such as time and resources, attitude and behaviour of clinicians, uncertainty towards research and resistance towards change were identified. These barriers need to be identified in a case by case approach due to variable organizational barriers in each single environment in order to recommend solutions. Training is needed to improve time management skills, coping strategies, assistance through supervision and managerial involvement to prevent workplace burn out.  The multiple personal initiatives reported by participants in this study needs to become natural to all occupational therapists  and thereby create new areas of occupational therapy innovation. Networking was one initiative which has similarities with communities of practice; this is a means of keeping up to date and ahead of change. Learning needs appear to exist for clinicians as well as for researchers; they require recognition of their learning needs and these are seen as an opportunity for empowerment. Further improvements need to happen giving a wider perspective on EBP and KT. The answers to the key questions would provide better information to clinicians and thereby support correct and easier implementation ,an area that could be influenced by policymakers and publishers of new evidencee. There is a vast field of stakeholders involved in KT and occupational therapists have only a small area they can influence in the KT process, which makes initiative, innovation and involvement even more important.

Limitations

The data for this study was collected via telephone interviews, this was chosen as the participants lived very far apart and in quite a distance from the researcher, which would have caused high travel expenses. The use of telephone interviews might be of disadvantage and instead opting for Skype interviews would improve the reception of visual cues, gain more contextual information, improve rapport with participants and ensure the possibility of reading body language.

Further areas of work

Further topics for future studies were suggested by the author leading into additional investigation of the topic of KT and EBP, into collaborative research amongst separate accountabilities, into improvement of clarity regarding evidence and better application in practice, and into AHP information behaviour.

Key points

• KT barriers need to be identified in each single environment.
• Training and managerial involvement is required to prevent burn out.
• Initiative, innovation, involvement and I are answers to KT improvement.
• KT barriers can be seen as learning needs and thereby can develop into steps of empowerment.

Acknowledgments

We gratefully acknowledge the supportive advice provided by Jon Wright (course lead) of the University of Brighton, MSc Health through Occupation.

Uta Schoch, Lecturer, Ludwig Fresenius Schulen, Marberg, Germany; and Patricia Fordham, Principal Lecturer, University of Brighton.

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