Determining the barriers and facilitators to adopting best practices in the management of poststroke unilateral spatial neglect: results of a qualitative study.

BACKGROUND: A gap exists between best and actual management of poststroke unilateral spatial neglect (USN). Given the negative impact of USN on poststroke recovery, knowledge translation efforts are needed to optimize USN management. To date, no study has investigated the specific barriers and facilitators affecting USN management during the acute care process. OBJECTIVE: To identify the facilitators and barriers that affect evidence-based practice use by occupational therapists (the primary discipline managing USN) when treating individuals with acute poststroke USN. METHODS: Focus group methodology elicited information from 9 acute care occupational therapists. RESULTS: Key barriers identified included lack of basic evidence-based practice skills specific to USN treatment and personal motivation to change current practices and engrained habits. Key facilitators included the presence of a multidisciplinary stroke team, recent graduation, and an environment with access to learning time and resources. Synthesized Web-based learning was also seen as important to uptake of best practices. CONCLUSION: It is estimated that upwards of 40% of patients experience poststroke USN in the acute phase, and we have evidence of poor early management. This study identified several modifiable factors that prepare the ground for the creation and testing of a multimodal knowledge translation intervention aimed at improving clinicians' best practice management of poststroke USN.

Increasing knowledge of best practices for occupational therapists treating post-stroke unilateral spatial neglect: results of a knowledge-translation intervention study.

OBJECTIVE: The aim of this study was to investigate: (i) the feasibility of delivering a multi-modal knowledge translation intervention specific to the management of acute post-stroke unilateral spatial neglect; and (ii) the impact of the knowledge translation intervention on occupational therapists' knowledge of evidence-based unilateral spatial neglect problem identification, assessment and treatment, and self-efficacy related to evidence-based practice implementation. DESIGN: A 3-period (pre-post) repeated measures design. SUBJECTS: Acute care occupational therapists treating patients with post-stroke unilateral spatial neglect were recruited from two major Canadian cities. METHODS: Participants completed two pre-intervention assessments, took part in a day-long interactive multi-modal knowledge translation intervention and a subsequent 8-week follow-up, and completed a post-intervention assessment. Knowledge of evidence-based problem identification, assessment and treatment of unilateral spatial neglect, and self-efficacy to perform evidence-based practice activities were measured using standard scales. RESULTS: The intervention was tested on 20 occupational therapists. Results indicate a significant improvement in knowledge of best practice unilateral spatial neglect management (p < 0.000) and evidence-based practice self-efficacy in carrying out evidence-based practice activities (p < 0.045) post-intervention. CONCLUSION: Use of a multi-modal knowledge translation intervention is feasible and can significantly improve occupational therapists' knowledge of unilateral spatial neglect best practices and self-efficacy. The findings should help advance best practices specific to the management of post-stroke unilateral spatial neglect as well as informing knowledge translation studies in other areas of practice.

Driving poststroke: problem identification, assessment use, and interventions offered by canadian occupational therapists.

BACKGROUND AND PURPOSE: Driving is a key factor in maintaining autonomy and participation in life. Occupational therapists (OTs) are expected to assess individuals who want to resume driving post stroke and to provide retraining where appropriate. Research from the 1980s and 1990s indicated that patients were, for the most part, not being assessed and retrained. However, little is known about current practice management. Thus, this study examined clinicians' management of driving-related issues when treating clients with stroke. METHODS: We performed a Canadawide telephone survey of 480 OTs providing stroke rehabilitation in both inpatient rehabilitation and community-based settings. Clinicians reported on problems they noted and assessments and interventions they would provide for a "typical patient" described in a vignette that matched their work setting. RESULTS: 20% and 34% of clinicians responding to the inpatient rehabilitation and community-based vignettes, respectively, identified return to driving as a problem. Clinician and work environment variables significantly associated (P < .01) with identifying driving as a potential problem included being male, involvement in university teaching, research conducted in setting, and hosting student placements. The use of driving-specific assessments was under 12%. Less than 6% of clinicians offered driving retraining, and their desired use of retraining was low. CONCLUSION: Few clinicians identified driving as a problem post stoke, raising concern that patients attempt to drive on their own or never resume driving because of a lack of attention to driving during their rehabilitation. Poststroke driver assessment and retraining is a critical component of poststroke community reintegration that requires greater awareness by clinicians.

Using the knowledge to action process model to incite clinical change.

INTRODUCTION: Knowledge translation (KT) has only recently emerged in the field of rehabilitation with attention on creating effective KT interventions to increase clinicians' knowledge and use of evidence-based practice (EBP). The uptake of EBP is a complex process that can be facilitated by the use of the Knowledge to Action Process model. This model provides a sequence of phases for researchers and clinicians to follow in order to optimize KT across various fields of practice. METHODS: In this article we use an example from a series of national studies in stroke rehabilitation to demonstrate how the Knowledge to Action Process model is being used to increase the use of best practices in the management of a very prevalent poststroke impairment, unilateral spatial neglect. RESULTS: The series of research projects and actions described herein each address a specific phase of the model. The reader is introduced to a specific example with the goal of generalizing the process to his or her own domain of interest. Gaps in our research agenda are also highlighted and future initiatives to complete the process are described. DISCUSSION: It is important that KT is maximized in health care to improve patient outcomes. As demonstrated here, the Knowledge to Action Process model provides an excellent guide for clinicians, managers, and researchers who wish to incite change in patient care.

The risk of motor vehicle crashes and traffic citations post stroke: a structured review.

BACKGROUND: Stroke impacts the domains known to be important for driving and is a primary condition for driving evaluation referrals. Given the high prevalence of stroke, the objective was to summarize the evidence regarding risk of crashes and traffic citations post stroke. METHODS: A structured review of six databases was conducted to retrieve studies that included stroke as a separate exposure from other disorders and measured crashes or traffic citations as an outcome. RESULTS: Four cohort and three case-control studies met the inclusion criteria. Five of the seven studies found increased odds or risk ratios ranging from 1.9 to 7.7, while two found an association of 0.8. Only one result was statistically significant (RR=2.7). One study examined the outcome traffic citations and found no significant association. CONCLUSION: There is cause for concern regarding increased risk of crashes post stroke. Future studies that examine the impact of stroke severity and sequelae will help health professionals, families, and those with stroke make informed decisions regarding driving post stroke. This review indicates that drivers with stroke have an increased risk of crashing compared to their counterparts without stroke, as demonstrated by increased risk estimates in five out of the seven studies that have examined this issue. This review also points to an urgent need for rigorous studies investigating the risk of crashes according to specific stroke sequelae: an understanding of crash risk based on stroke severity, impairments, and function will assist clinicians in making informed decisions regarding the need for comprehensive driving evaluation and the potential for driver retraining for specific subgroups.