Background
Implementation investigates the gap between evidence and clinical practice, which can be influenced by individuals' knowledge, the nature of evidence, organisational context, and facilitation processes. Increasing knowledge about implementation, including which implementation strategies work best in which circumstances, is necessary. This is pai1icularly the case for physiotherapy, where implementation research has generally focused on individual clinician factors mediating the use of evidence. This thesis will address this challenge by investigating implementation around the management of the post-stroke shoulder. Post-stroke shoulder (PSS) problems are common after stroke, and rehabilitation in this area is complicated by their multifactorial nature, which exists across anatomical, functional and social levels. As such, evidence for practice is widely distributed across the literature and national clinical guidelines.
Aims
Drawing on the knowledge to action (KTA) framework (Graham et al., 2006), this
study aims to understand the process of implementation of evidence relating to
management of the PSS, and the experiences of physiotherapists around
implementation more broadly. A series of interlinked studies aim to investigate:
• Current knowledge of implementation in physiotherapy.
• The implementation context of physiotherapy.
• Physiotherapy practice around the PSS.
• The use of national clinical guidelines for stroke in relation to PSS management
into physiotherapy practice.
Methods
The thesis presents a series of scoping reviews and mixed methods investigations to investigate the nature of evidence use in physiotherapy using the post-stroke shoulder as an exemplar. The KT A framework is used as linking heuristic to synthesise findings which build on an initial literature review of knowledge at the interface of physiotherapy and implementation. The implementation context of physiotherapy in three national health services (NHS) organisations is investigated in a questionnaire survey (n=250) and interview study with specialist physiotherapists (n= 15) in stroke services. To identify the domains of physiotherapy around the post-stroke shoulder, a concept review of the literature was completed, augmented with exploratory interviews of physiotherapists (n=15). These domains guided a consensus study,
incorporating a modified nominal group technique with therapists (n=l2), which
investigated the tailoring of recommendations from national stroke guidelines into a clinical tool for management of the PSS. Analysis of the consensus work was used to illuminate the process of tailoring by physiotherapists.
Results
Implementation challenges were identified across individual, organisational, patient and epistemological domains. Findings re-affirm the importance of team working and a supportive organisational culture, including a culture of continuing education and knowledge sharing in supporting therapists' use of evidence. This research has generated a conceptual framework which maps the role of the physiotherapy in the care of the PSS, with five key aspects of the role: conceptualisation, prevention, assessment, management, and delivery, which was used to guide an investigation of tailoring. The interface of this framework and the work of implementation by physiotherapists was explored in consensus work around the implementation of national guidance on the care of the PSS. Five key elements which characterised tailoring activities were identified: the nature of organisational context, the engagement of the end-user in the implementation process, the nature of practice and complexity of the evidence around clinical tasks, and the balance between feasibility and fidelity. These provide new insights into the nature of tailoring activity when utilising the KTA framework in implementing evidence for the management of the PSS.
Discussion
The thesis presents the first empirically derived framework that establishes the
physiotherapy contribution to PSS management. The findings allude to a complex role, with clinical decisions and work operating at different levels of patient impact, specific to both the patient's recovery path and the clinical setting. Whilst informing clinical practice and research, the framework guided development of practical guidance for therapists which drew on a complex and distributed evidence-base for PSS. The novel aspects of this thesis also include the use of different evidence synthesis methods to illuminate aspects of implementation in stroke rehabilitation physiotherapy, and the investigation of cognitive tailoring processes in a nominal group context.
Conclusion
Synthesis across the studies presented in this thesis provide comprehensive, rigorous and systematic approaches to illuminate ambiguities in the KTA framework, specifically around tailoring. Tailoring is a dynamic and iterative process that includes synthesis, exchange and ethically sound application of knowledge to local practice in order to improve the implementation process as well as provide more effective health services.