Facilitation of research-based evidence within occupational therapy in stroke rehabilitation.
Abstract: Purpose: This study investigated the facilitation of evidence-based practice with the use of everyday life occupations and client-centred practice within occupational therapy in three settings of stroke rehabilitation.

Method: The study was based on a phenomenological hermeneutical research approach, and inspired by participatory action research methods. Participant observations, focus group discussions and individual interviews took place over a period of 20 months. Text interpretation, developed by Ricoeur, was used in data analysis.

Findings: The key role of the facilitator in the implementation of evidence-based practice as a change process was stressed. During the implementation, it was crucial that the therapists as a group had the opportunity to discuss local practice knowledge, and to appraise the knowledge use critically, in order to develop their practice knowledge and new skills adapted to local contexts. The implementation resulted in various new working routines. Learning processes became part of developing the occupational therapists' professional identities, expressed in more professional confidence. Collaboration in the organisation of the implementation process was significant.

Conclusion: The main findings indicated that the use of participatory action research methods and theory of situated learning interacting with the Promoting Action on Research Implementation in Health Services framework provided useful perspectives and structures for the investigation of the implementation of evidence-based occupational therapy.

Keywords:

Knowledge translation, clinical reasoning, occupational therapy.
Subject: Evidence-based medicine (Analysis)
Occupational therapists (Practice)
Occupational therapists (Services)
Occupational therapy (Usage)
Stroke (Disease) (Care and treatment)
Authors: Kristensen, Hanne Kaae
Borg, Tove
Hounsgaard, Lise
Pub Date: 10/01/2011
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Oct, 2011 Source Volume: 74 Source Issue: 10
Topic: Event Code: 200 Management dynamics; 360 Services information
Geographic: Geographic Scope: Denmark Geographic Code: 4EUDE Denmark
Accession Number: 271053262
Full Text: Introduction

In order to provide knowledge about evidence-based occupational therapy, the aim of this study was to investigate aspects that facilitate occupational therapists' reasoning when implementing evidence-based practice within stroke rehabilitation. The paper presents an implementation study, based on an action research approach in collaboration with three occupational therapy settings, which included 25 occupational therapists. Field observations, focus group interviews and case report-based interviews were used for data gathering. The findings concerning the facilitation of the implementation processes are presented and discussed. Finally, new knowledge of how occupational therapy cultures and evidence-based practice interact is deduced.

Literature review

Occupational therapy in stroke rehabilitation

Occupational therapy interventions improve the outcomes for stroke patients in everyday life occupations, including activities of daily living and social participation (Legg et al 2006). Occupational therapy is, therefore, a recommended part of early rehabilitation in stroke units, according to the National Clinical Guidelines for Stroke from Denmark, the United Kingdom, Australia, the United States, New Zealand and Sweden (Kristensen et al 2010).

Acute stroke is the one of the leading causes of morbidity and mortality worldwide. Stroke is the most important cause of morbidity and long-term disability in Europe, and imposes an enormous economic burden (European Stroke Organisation 2009). Stroke often affects the individual performance of everyday life activities and participation. Everyday life activities are a central concept in occupational therapy practice, and are considered to give meaning to and organisation in everyday life (Townsend et al 2002). In this framework, health and wellbeing are influenced by having choice, control and the ability to engage in everyday life activities. New patterns of everyday life activities are required when health is challenged.

Evidence-based practice

Evidence-based practice, initially developed in the area of medicine, has current interest for every health profession (Law 2002). Evidence-based medicine was defined as 'The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients' (Sackett et al 1996, p71), and has expanded into evidence-based practice in which the practitioner aims at creating a practice, integrating knowledge from patients' experiences and preferences, research-based evidence and clinical expertise while making clinical decisions in local contexts (Rycroft-Malone et al 2004). Due to increasing demands for documentation and evidence-based practice, many professionals in health services experience changes in organisation and working practice. These trends are seen as the result of social and economic changes, thus dictating demands for higher quality combined with efficient use of resources (Bennett and Bennett 2000). Nevertheless, a lack of the use of evidence from research to make informed decisions in health services is evident among all groups of decision makers (Straus et al 2009).

Implementation of evidence-based occupational therapy

The shift to evidence-based practice is critical to the continued development of occupational therapy (Finlayson et al 2005). In recent years, much emphasis has been placed on occupational therapists learning to read and evaluate research literature and then to integrate the new knowledge into clinical practices to support decision making and to enhance outcomes for their clients (Law 2002). However, when discussing the gap between research and practice, Kielhofner (2005) pointed to the fact that there is evidence that the growth theory and research produced by academics are not consistently translated into occupational therapy practice. Practitioners report that they find theory and research to be of limited relevance or difficult to implement in their everyday work (Kielhofner 2005).

The process of implementing evidence-based practice is essentially the same for occupational therapy as for other health professions. There is, however, limited evidence with regard to transferring research utilisation models within professional practices because the professions differ in philosophical approach, practice models and operational structures (Caldwell et al 2008). The framework Promoting Action on Research Implementation in Health Services (PARIHS) relates to the concept of evidence-based practice, and was developed within nursing research when trying to represent the complexity of the processes of change involved in implementing research-based practice. The framework has proved to be a useful practical and conceptual heuristic in framing research or knowledge translation, and has the potential to be used as a practical and pragmatic tool at the local level (Kitson et al 2008). The PARIHS framework presents successful research implementation as a function of the relationships between evidence, context and facilitation (Fig. 1). The framework considers these elements to have a dynamic, simultaneous relationship.

[FIGURE 1 OMITTED]

Each of the elements consists of sub-elements. Evidence is characterised by research, clinical experience, patient experience and local data/information; context by culture, leadership and evaluation; facilitation by purpose, role and skills and attitudes. Every element is on a continuum of low to high. The researchers who developed the PARIHS framework suggested that each sub-element has to be judged towards the high end of the continuum in order for an implementation to be successful (Harvey et al 2002, Rycroft-Malone et al 2004).

Evidence needs to be appraised and evaluated, be strong, match local clinical experience and patient preferences and, furthermore, include relevant local data (high evidence). Local context is more receptive to change when there are sympathetic cultures, strong leadership and appropriate evaluative systems (high context). Moreover, the implementation needs to be supported by well qualified facilitation (high facilitation) (Harvey et al 2002, Rycroft-Malone 2004).

Implementation as a learning process

In an evidence-based practice, the practitioners need to be prepared to evaluate their practice, to critique the evidence on which they base their practice and to see themselves as agents of change who are confidently able to defend the quality of the work their profession offers (Higgs et al 2008). A complex interplay of personal characteristics, professional culture and context influences whether occupational therapists take up the challenge of thoroughly examining their clinical interventions (Bowman and Llewellyn 2002). The development of an evidence-based practice will involve high levels of personal change because it requires reflection, planning and action in a local context over long periods of time (Cusick and McCluskey 2000).

When investigating the practitioners' learning in the implementation processes of evidence-based practice, learning can be considered as an integral and inseparable aspect of social practice. In this perspective of situated learning, a professional knowledge base is contextually grounded and includes cognitive as well as cultural knowledge (Lave and Wenger 1991, Wenger 2004). As such, professional knowledge encompasses a certain body of cognitive knowledge along with shared values, beliefs, ways of reasoning and untold rules of thumb characterising the field (Higgs et al 2004).

Wenger (2004) emphasised meaning, practice, community and identity as essential components of social participation, and as interconnected and mutually defining in the process of learning and knowing.

Clinical reasoning

Research has been recognised for many decades as a key ingredient in developing the practice of occupational therapy (Finlayson et al 2005). The kind of knowledge that guides decision making in practice is, however, different from the traditional academic knowledge (Forsyth et al 2005). The possibilities of clarifying the professional dialogues concerning the development of an evidence-based practice are increased by including the knowledge and clinical experience created in practice (Kielhofner 2004). 'Clinical reasoning is recognised as the core of occupational therapy practice' (Chapparo and Ranka 2008, p269). So far, little empirical research examining occupational therapists' implementation of research in practice has been carried out (Trinder and Reynolds 2000, Rappolt 2003). Further research into clinical reasoning is required in order to assist the implementation of an evidence-based practice, which is in line with current conceptual frameworks in occupational therapy.

In this study, the aim was to investigate aspects that facilitate implementing evidence-based occupational therapy in the use of everyday life occupations and client-centred practice within stroke rehabilitation.

Method

As the study's main concern was to investigate occupational therapists' reasoning in an implementation process in order to gain a deeper understanding of the aspects involved, a phenomenological hermeneutic approach was chosen (Ohman 2005). In order to reduce the research-practice gap, this study was inspired by participatory action research methods (Finlayson et al 2005, Kemmis and McTaggart 2005). These were mainly carried out within an overarching action planning model, including workshops, planning meetings, discussions, audits and evaluations (Finlayson et al 2005, Taylor 2007, Stringer 2007). The idea of participation is central in action research and became the pivotal point of this study.

A group of occupational therapists specialising in stroke rehabilitation was consulted concerning the relevant clinical focus for literature reviews undertaken by the authors. The group identified client-centred practice and everyday life activities as key review topics because they represented core values in the conceptual frameworks of occupational therapy used in the settings. Findings from the literature reviews, corresponding with the conceptual frameworks, were incorporated into five clinical guidelines (Kristensen et al 2010), as evidence-based clinical guidelines have the potential to enhance the use of scientific knowledge in clinical practice (Bahtsevani et al 2004). Three guidelines concerning the use of standardised assessments and two guidelines defining occupational therapy interventions were developed by the occupational therapists and the first author. Evidence from the reviews was related to the consensus based on best practice within the group, and formed the basis for instructions concerning when, how and with whom the chosen assessment tools and interventions were to take place. Central elements in the five guidelines are presented in Table 1. The implementation was then investigated in the present study.

Participants

The sampling aimed at a differentiated and thorough description of the occupational therapists' clinical reasoning during an implementation process in stroke rehabilitation. Consequently data, generated in three settings, were purposefully sampled in order to cover the Danish health care services' general offers to adult stroke patients (Table 2).

The 25 occupational therapists participating in the study were all female and had an average age of 38 years (ranging from 27 to 57 years) and an average of 8 years of experience in stroke rehabilitation (ranging from 2 to 28 years) (Table 3).

Clinical experience affects clinical reasoning processes (Benner 1984). Therefore, the inclusion criterion was that the participants should have more than 2 years of experience in stroke rehabilitation. Benner (1984) suggested that as a practitioner passes through stages of proficiency, there are changes in three aspects of skilled performance. There is a shift in reliance from abstract principles to past experiences; a change in perception of the situation, that is, a shift from perceiving all parts of the picture equally to viewing the whole situation in which only parts are relevant; and a change from detached observer to involved performer.

Moreover, experts appear to possess a better knowledge base than novices. Experts also use less irrelevant information when making decisions and solve clinical problems faster than novices (Unsworth 2001).

Data generation

The data-generating process was carried out by the first author and took place over a period of 20 months (May 2006 to December 2008). The first author, being responsible for the implementation process, functioned as an external facilitator in all three settings. In settings A and B, local occupational therapists were appointed internal roles as being responsible for the development of the professional practice, and took part as internal facilitators. The internal facilitators and the first author worked closely together during the entire implementation process.

The data-generating process comprised participant observations, focus group discussions and individual interviews conducted in all three settings (Fig. 2 and Table 4).

Ethics

The study was presented to the management in all three settings and confirmations of participation, stating ethics, time use and collaboration, were signed. All occupational therapists were introduced to the study, and it was stressed that participation was voluntary. The occupational therapists who agreed to participate received a summary of the introduction in writing, which stressed the possibility of ending participation at any time. Every patient taking part in an observation was informed in advance of the study, and had consented to the presence of a researcher. Anonymity was promised. The study was approved by the Danish Data Protection Agency

[FIGURE 2 OMITTED]

Data analysis

The data analysis was conducted by the three authors. A phenomenological hermeneutic interpretation methodology, inspired by the philosophy of Ricoeur, was used (Ricoeur 1976). Ricoeur's textual interpretation of distanciation objectifies the text by releasing it from the research subjects' intentions and meanings, and gives it a life of its own (Ricoeur 1976, Lindseth and Norberg 2004). Ricoeur described the interpretation of a text as the hinge between language and lived experience. The focus in this process is on what the text is saying (its meaning) and what it talks about (its reference). In this interpretation method, dialectical movements between explanation and comprehension are crucial (Dreyer and Pedersen 2009). The method of interpretation used in this study moved between three levels: naive reading, structural analysis and comprehensive understanding.

The naive reading was a non-judgemental and open-minded reading in order to grasp meaning in the text as a whole, and was regarded as the first conjecture of the analysis to initiate the approach for structural analysis. All text in the transcriptions was read several times in order to grasp its meaning as a whole, which resulted in an initial impression of what the text was about. The impression was written down in short sentences, capturing the essentials. The analysis then moved from the naive reading to the structural analysis.

The structural analysis was conducted in order to explain the text and was continued with the aim of seeking to identify and formulate themes. This analysis took the form of a movement from units of meaning in the text to units of significance (Table 5). All transcriptions were re-read and analysed separately. In each transcription, the text was studied in order to interpret what the text said across data. The text was then divided into meaning units, presenting statements of importance for the investigation (Lindseth and Norberg 2004). The meaning units were read and reflected on using the naive reading, then condensed into everyday words as concisely as possible.

The condensed meaning units were then re-read and reflected upon regarding similarities and differences. They were sorted several times, taking into consideration their relationship to the aim of the study. The meaning units that seemed central to the aim were abstracted into subthemes and assembled into main themes, which again were considered, sorted and evaluated in relation to the aim in a dialectical process. At this point, the analyses of the transcriptions were also combined in order to analyse and interpret not only their relation to the integration process in the each setting but also to unify data from all three settings.

The authors' pre-understandings, theoretical frames and the aim of the investigation, together with the naive reading and findings from the structural analysis, formed the basis for the critical reflection and a comprehensive understanding. In the critical interpretation, the dialectical movement between explanation and comprehension in the interpretation continued. Moreover, literature that seemed appropriate in the process to revise, widen and deepen the understanding of the text was considered.

Findings

In this study, the findings concerning facilitation of the occupational therapists' reasoning when implementing evidence-based practice were investigated. The trustworthiness of the study was enhanced by combining research methods that had different approaches to generating knowledge of the implementation process. Using triangulation in this way offers depth and breadth, leading to a greater understanding of the aspects that influence the process as each research method contributes with a different piece of the puzzle. In the structural analysis, three main themes and six subthemes arose from the analysis. Table 5 presents the references to the therapists (Tp) who are quoted in the findings.

Theme 1. The facilitator

The main theme, 'The facilitator', was constructed from the three subthemes: facilitation of change, the facilitator in a key role and the facilitation tools.

In each setting, either an internal or an external facilitator in a dialogue with the participants was in charge of learning and of keeping the therapists up to the mark, changes of routines and evaluation in daily practice:

The facilitators' use of the therapists' records of daily documentation in the hospital settings was considered to facilitate the implementations: 'Now we have asked our facilitator to print [documentation] every month' (TpN). The feedback was discussed in audit sessions in the local groups and formed the basis for changes of the clinical routines:

The facilitators experienced the purpose and role of a facilitator as important for the change process:

Theme 2. Learning in practice development

The learning experiences were related to both the individual therapist's experiences and to the process in the group. The occupational therapists stressed the importance of being able to see the purpose of integrating research-based evidence in daily practice. They saw that becoming familiar with the research and theories in the clinical guidelines was a way of understanding the purpose and became more motivated to make use of them:

Another learning strategy was becoming familiar with the practice related to the clinical guidelines, and the use of reflections in groups 'Repetition ... repetition--and also talking with the colleagues like you are establishing groups related to the use of COPM where we can talk about our experiences' (TpIII) and experiencing the research-based evidence in clinical practice were useful:

Successes in clinical practice facilitated the implementation:

In one of the settings, the therapists worked relatively on their own, which made it more difficult to implement a standardised practice: 'It is just that when you are in your own little [world]--we do work a lot on our own--then we easily lose track ...' (TpIII). In all settings working in a group of therapists was considered a resource:

In order to compensate for the lack of specific courses in the use of standardised assessments (AMPS and A-ONE), setting A's occupational therapists developed new working routines:

A high level of professional competence was valued within the groups:

The learning process of an evidence-based practice supported the sense of professional competence:

'It seems as if they become more confident in their professional judgement' a facilitator said, continuing 'I do think it [the implementation process] pushes things at a qualitative course ... it is just a process that takes ages' (Tp7), even though the implementation was considered demanding 'to implement something new ... it is hard work' (TpI).

Theme 3. Participation

The main theme, 'Participation', was constructed from the one subtheme: cooperation.

The participatory action research design allowed all occupational therapists to participate in the study and, thereby, in the implementation process. The participants valued taking part in organising the integration process: 'It is more fun when you take part in a development' (TpII).

A critical attitude to the clinical guidelines was considered necessary in order to adapt the guidelines to local contexts:

The clinical experience of the occupational therapists affected how the timing and content of the implementation process were perceived:

The experienced occupational therapists were able to work more flexibly, handling both interaction with the patients and intervention while implementing the research-based knowledge. They valued the common learning of the research-based evidence and were relatively more participative in the implementation, while the less experienced occupational therapists prioritised gaining more knowledge and skills from their present clinical practice.

Discussion

Discussion of findings

According to Ricoeur (1976), a comprehensive understanding of a text is a possible way to experience the world. In the critical interpretation, the main themes were discussed across the implementation process and across settings. Findings from current research and preconceptions were used to discuss and argue suitable interpretations of the facilitation of the implementation process.

The facilitator

Harvey et al (2002) stated that there is still little evidence to indicate the relative importance of the different skills and attributes needed for effective facilitation.

Many descriptions of facilitation aim to balance the achievement of goals with the development of individual and group processes. The purposes varied from the facilitator providing help and support in achieving specific goals to enabling the therapists to analyse, reflect and change their own attitudes and ways of working. Inspired by the participatory action research approach, the facilitators, in cooperation with the occupational therapists, aimed at implementing local changes towards an evidence-based practice, in line with the current conceptual framework in occupational therapy and in agreement with local policies and values.

The participants appreciated that the facilitators held key roles during the implementation processes. The therapists expressed the need for someone to have the assignment of facilitating the implementation process, and to keep the participants on track in busy environments where multifarious issues competed for the therapists' focus and time. They also expressed the need for someone to be in charge of providing new knowledge, creating opportunities for obtaining and building up experience in their daily work, and performing evaluations during the implementation process.

The facilitators were sensitive and flexible and possessed a range of task-focused and enabling skills, corresponding with the variation of experience and knowledge base within the local groups of participants, with the local context and the time range of the implementation process.

In accordance with other studies (Harvey et al 2002), the facilitators experienced that attempts to improve group processes and to change existing cultures required long periods of work to achieve their purpose.

The elements that are illustrated by the function of the facilitator matched the elements and sub-elements in the PARIHS framework. The PARIHS framework sees every sub-element as a point on a continuum of low to high, where each sub-element has to be judged towards high in order for an implementation to be successful (Harvey et al 2002). Evaluating the process in each setting on the continuum of facilitation, there is a tendency towards high in all three settings.

Situated learning in practice development

The occupational therapist's participation in this implementation process can be seen as situated learning processes, which are considered to be an integral and inseparable aspect of the social practice (Lave and Wenger 1991). The three settings formed communities of practice, within which the occupational therapists were given the opportunity to participate and learn by participation.

Learning and applying that knowledge in a community in practice is defined by apprenticeship, where the organisation of the community becomes a key factor for the learning process (Lave and Wenger 1991). At the starting point of the implementation process, the participants lacked the knowledge and skills to initiate and maintain a sustainable development of an evidence-based local knowledge base. Situated learning is not characterised by formal teaching sessions (Lave and Wenger 1991). Thus local workshops at routine group meetings acted as learning sessions, in which the theory on evidence-based practice and the research supplying evidence for the clinical guidelines were mixed with reflections and discussions within the groups of occupational therapists in cooperation with the facilitator. Later interactive group meetings, local audits combined with interviews, and the individual experiences gained in clinical situations constituted explorations and evaluations.

To accomplish common changes towards an evidence-based practice in the settings, the participants needed embodied experiences in combining new research-based knowledge, clinical reasoning and skills in their local context. The occupational therapists used learning strategies to become familiar with the practice related to the clinical guidelines, and to experience research-based evidence in clinical practice as being useful. Thus successful situations were created, which stressed the meaningfulness of the participation. The learning process was expressed by the therapists changing practice and changed their understanding of their own clinical practice.

In all three settings, implementation as a group process was stressed. During the implementation process, it became crucial that the therapists as a group had the opportunity to discuss local practice knowledge and to appraise the knowledge use critically in order to develop their practice knowledge and new skills. The purpose and process of the groups' practice development were negotiated within the group and together with the facilitators. A critical attitude to the clinical guidelines was considered necessary in order to adapt the guidelines to local contexts and thereby translate research-based evidence into local clinical practice. In all three settings, the conclusions resulted in the implementation of various new working routines based on the five clinical guidelines, and the learning processes became part of developing and thereby changing the occupational therapists' professional identities, as expressed by increased professional confidence (Kvale 1999).

Participation as bridging the gap

Finding a way of bridging the gap between researchers and practitioners is recommended from various research fields, including occupational therapists (Finlayson et al 2005, Kielhofner 2005) and researchers of knowledge translation

(McCormack et al 2002). Researchers have been recommended to involve stakeholders as true collaborators in shaping research, including what questions to address, data collection, and how to interpret and disseminate the findings (Kielhofner 2005). The therapists in this study also stressed the importance of being able to see the purpose of implementing research-based evidence in their daily practice. They considered the importance of getting familiar with the research and theories used in the guidelines as a way of understanding the purpose and as motivation to use them. The occupational therapists in these three settings expressed interest in becoming agents of change in their own clinical practice, while participating in the local implementation process. Participatory action research methods were adapted and carried out in the planning and collaboration with the facilitators and occupational therapists within workshops, group meetings and discussions, audits and evaluations. The data of the study showed productive paths for change processes.

The extent of clinical experience within the occupational therapist groups affected how the timing and content of the implementation process were perceived. In communities of practice, the newcomer gradually acquires essential skills, knowledge and values of the craft by moving from a peripheral participation to becoming a full participant in a social-cultural practice. The standards and values of the craft are embodied through the participation of the communities' practice forms (Lave and Wenger 1991). In this study, challenges in the implementation, and thereby learning processes, were seen as related to the level of the practitioner's clinical experience. The experienced occupational therapists valued the participation in the implementation processes relatively more and were more open for personal changes related to the process, while the less experienced occupational therapists prioritised gaining more practice knowledge and skills as this was considered to be the next phase of their personal development. The facilitators evaluated that the composition of the groups of practitioners was a key factor in the organisation of the implementation process.

Discussion of methods

The scientific trustworthiness of the study was evaluated using the concepts of credibility, dependability, confirmability and applicability (Ohman 2005, Rolfe 2006, Carter and Little 2007). The transparency in writing down the study's process and results allows the reader to follow the process. The prolonged data-gathering period, the method triangulation used to enrich the investigation, and focus group discussions of the results contributed to the credibility of the study.

A community of practice is a rich entity for researchers who study practice-related questions and an opportunity for practitioners for dialogue and collaboration (Corcoran 2006). The action research approach called on flexibility. Throughout the research process, the continuous generating and analysing of data affected the extent, focus and use of methods in the generating process.

The inclusion of participants in the study was voluntary and continuous during the entire implementation process. The disparity in numbers and difference in length in collaboration did not weaken the process or the findings in the settings because the implementation process took place over a long period and had the group level as the focus and not the participants' individual change processes.

Relating to the study's dependability, reflective field notes and thorough transcriptions were used to document the data-gathering process. Furthermore, the thorough and systematic analysis using Ricoeur's (1976) textual interpretation of distanciation and the detailed description of the analysis increased the confirmability of the study.

Conclusion

Factors that facilitate the implementation of an evidence-based knowledge in occupational therapy practice can be evaluated by means of the PARIHS framework in order to evaluate the success of the implementation process. The results showed that the facilitators were in charge of key roles in collaboration with the therapists in order to translate the evidence of the guidelines into clinical practice.

The occupational therapists' participation in this implementation process can be seen as situated learning processes. To attain common changes towards an evidence-based practice in the settings, the participants needed embodied experiences in combining new research-based knowledge, clinical reasoning and skills in their local context. The learning process was expressed by the therapists changing practice and changing their understanding of their own clinical practice.

During the implementation process it became crucial that the therapists, as a group, had the opportunity to discuss local practice knowledge and to appraise the knowledge use critically in order to develop their practice knowledge and new skills. The facilitators evaluated that the variation of experience and knowledge base within the groups of practitioners was a key factor in the organisation of the implementation process.

The study reinforced the current knowledge of implementation processes requiring long periods of work to achieve their purpose.

Key findings

* Appointed facilitators had key roles in the implementation.

* Situated learning was an important part of the implementation.

* Collaboration in implementation was stressed by the occupational therapists.

What the study has added

The use of participatory action research methods and theory of situated learning interacting with the PARIHS framework provided useful perspectives and structures for the investigation and implementation of evidence-based occupational therapy.

Acknowledgements

The authors would like to thank the Danish Association of Occupational Therapists for the grant donation. We are also grateful to Mette Boll for contributing to the development of the figures and Professor Jo Rycroft-Malone, MSc, PhD, RGN, University of Wales, UK, for kindly commenting on the article draft. Conflict of interest: None declared.

References

Bahtsevani C, Uden G, Willman A (2004) Outcomes of evidence-based clinical practice guidelines. A systematic review. International Journal of Technology Assessment in Health Care, 20(4), 427-33.

Benner P (1984) From novice to expert: excellence and power in clinical nursing practice. Meno Park, CA: Addison-Wesley.

Bennett S, Bennett J (2000) The process of evidence-based practice in occupational therapy: informing clinical decisions. Australian Occupational Therapy Journal, 47(4), 171-80.

Bowman J, Llewellyn G (2002) Clinical outcomes research from the occupational therapist's perspective. Occupational Therapy International, 9(2), 145-66.

Caldwell E, Whitehead M, Fleming J, Moes L (2008) Evidence-based practice in everyday clinical practice: strategies for change in a tertiary occupational therapy department. Australian Occupational Therapy Journal, 55(2), 79-84.

Carter SM, Little M (2007) Justifying knowledge, justifying method, taking action: epistemologies, methodologies, and methods in qualitative research. Qualitative Health Research, 17(10), 1316-28.

Chapparo C, Ranka J (2008) Clinical reasoning in occupational therapy. In: J Higgs, MA Jones, S Loftus, N Christensen, eds. Clinical reasoning in the health professions. 3rd ed. Oxford: Butterworth Heinemann Elsevier.

Corcoran M (2006) Dissemination or knowledge translation? American Journal of Occupational Therapy, 60(5), 487-88.

Cusick A, McCluskey A (2000) Becoming an evidence-based practitioner through professional development. Australian Occupational Therapy Journal, 47(4), 159-70.

Dreyer PS, Pedersen BD (2009) Distanciation in Ricoeur's theory of interpretation: narrations in a study of life experiences of living with chronic illness and home mechanical ventilation. Nursing Inquiry, 16(1), 64-73.

Emerson RM, Fretz RI, Shaw LL (1995) Writing ethnographic fieldnotes. Chicago: The University of Chicago Press.

European Stroke Organisation (2009) Available at: www.eso-stroke.org Accessed 25.09.09.

Finlayson M, Shevil E, Mathiowetz V, Matuska K (2005) Reflections of occupational therapists working as members of a research team. Australian Occupational Therapy Journal, 52(2), 101-08.

Forsyth K, Summerfield-Mann L, Kielhofner G (2005) A scholarship of practice: making occupation-focused, theory-driven, evidence-based practice a reality. British Journal of Occupational Therapy, 68(6), 261-68.

Halkier B (2005) Focus groups. Roskilde: Samfundslitteratur Roskilde Universitetsforlag.

Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B, Seers K (2002) Getting evidence into practice: the role and function of facilitation. Journal of Advanced Nursing, 37(6), 577-88.

Higgs J, Richardsson B, Dahlgren MA (2004) Developing practice knowledge for health professinals. Oxford: Butterworth Heinemann.

Higgs J, Jones MA, Loftus S, Christensen N (2008) Clinical reasoning in the health professions. 3rd ed. Oxford: Butterworth Heinemann Elsevier.

Hovmand B, Lund H, Albert H, Winkel A (2001) Writing and evaluating case reports. Nyt om forskning nr. 1, 10-17.

Kemmis S, McTaggart R (2005) Participatory action research, communicative action and the public sphere. ln: NK Denzin, YS Lincoln, eds. The Sage Handbook of Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage, 559-603.

Kielhofner G (2004) Conceptual foundations of occupational therapy. 3rd ed. Philadelphia: FA Davis.

Kielhofner G (2005) Research concepts in clinical scholarship--scholarship and practice: bridging the divide. American Journal of Occupational Therapy, 59(2), 231-39.

Kitson A, Harvey G, McCormack B (1998) Enabling the implementation of evidence-based practice: a conceptual framework. Quality and Safety in Health Care, 7(3), 149-58.

Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A (2008) Evaluating the successful implementation of evidence into practice using the PARlHS framework: theoretical and practical challenges. Implementation Science, 3(1).

Kitzinger J (1994) The methodology of focus groups: the importance of interaction between research participants. Sociology of Health and Illness, 16(1), 103-21.

Kristensen HK, Persson D, Nygren C, Boll M, Matzen P (2010) Evaluation of evidence within occupational therapy in stroke rehabilitation. Scandinavian Journal of Occupational Therapy, Early Online, 1-15.

Kvale S (1999) Mesterlaere som aktuel laeringsform. ln: K Nielsen, S Kvale, eds. Apprenticeship as social practice. Copenhagen: Hans Reitzels Forlag A/S, 11-32.

Kvale S, Brinkmann S (2009) InterViews. Learning the craft of qualitative research interviewing. 2nd ed. Thousand Oaks, CA: Sage.

Lave J, Wenger E (1991) Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press.

Law M (2002) Evidence-based rehabilitation: a guide to practice. Thorofare, NJ: Slack.

Legg LA, Drummond AE, Langhorne P (2006) Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003585. DOI: 10.1002/14651858.CD003585.pub2.

Lindseth A, Norberg A (2004) A phenomenological hermeneutical method for researching lived experience. Scandinavian Journal of Caring Sciences, 18(2), 145-53.

McCormack B, Kitson A, Harvey G, Rycroft-Malone J, Titchen A, Seers K (2002) Getting evidence into practice: the meaning of 'context'. Journal of Advanced Nursing, 38(1), 94-104.

Ohman A (2005) Qualitative methodology for rehabilitation research. Journal of Rehabilitation Medicine, 37(5), 273-80.

Rappolt S (2003) The role of professional expertise in evidence-based occupational therapy. American Journal of Occupational Therapy, 57(5), 589-93.

Ricoeur P (1976) Interpretation theory: discourse and the surplus of meaning. Fort Worth, TX: Texas Christian University Press.

Rolfe G (2006) Validity, trustworthiness and rigour: quality and the idea of qualitative research. Journal of Advanced Nursing, 53(3), 304-10.

Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B (2004) What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47(11), 81-90.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn't. British Medical Journal, 312(7023), 71-72.

Silverman D (2006) Qualitative reseach: theory, method and practice. Thousand Oaks, CA: Sage.

Spradley J (1980) Participant observation. New York: Wadsworth, Thomson Learning Academic Resource Center.

Straus SE, Tetroe JM, Graham ID (2009) Knowledge translation is the use knowledge in health care decision making. Journal of Clinical Epidemiology, 62(6) 617-23.

Stringer ET (2007) Action research. 3rd ed. Thousand Oaks, CA: Sage.

Taylor MC (2007) Evidence-based practice for occupational therapists. 2nd ed. Oxford: Blackwell Publishing.

Townsend E, Stanton S, Law M, Polatajko H, Baptiste S, Thompson-Franson T, Kramer C, Swedlove F, Brintnell S, Campanile L (2002) Enabling occupation: an occupational therapy perspective. Revised edition. Ottawa, ON: CAOT Publications ACE.

Trinder L, Reynolds S (2000) Evidence-based practice: a critical appraisal. Oxford: Blackwell Publishing.

Unsworth C (2001) The clinical reasoning of novice and expert occupational therapists. Scandinavian Journal of Occupational Therapy, 8(4), 163-73.

Wenger E (2004) Communities of practice, learning, meaning, and identity. Copenhagen: Hans Reitzels Forlag.

Hanne Kaae Kristensen, (1) Tove Borg (2) and Lise Hounsgaard (3)

(1) Head Research Therapist, Rehabilitation Unit, Odense University Hospital, Odense, Denmark.

(2) Senior Scientist and Occupational Therapist, Research Unit for Neurorehabilitation, Hammel, Denmark.

(3) Associate Professor, Research Unit of Nursing, University of Southern Denmark, Institute of Clinical Research, Odense, Denmark.

Corresponding author:

Dr Hanne Kaae Kristensen, Head Research Therapist, Rehabilitation Unit, Odense University Hospital, Sdr Boulevard 29, Odense C 5000, Denmark.

Email: hanne.kaae@ouh.regionsyddanmark.dk

Reference: Kristensen HK, Borg T, Hounsgaard L (2011) Facilitation of research-based evidence within occupational therapy in stroke rehabilitation. British Journal of Occupational Therapy, 74(10), 473-483.

DOI: 10.4276/030802211X13182481841949

Submitted: 31 January 2010.

Accepted: 15 April 2011.
I think you need help with some of the working procedures.
   How you basically ... some detailed guiding until you have
   developed new daily routines (TpB).


We have also started to keep our therapy records and put a
   minus or a plus. And if there is a minus you have to write an
   explanation. That is really good because then you have to
   reason 'why didn't I do it?' (TpB).


It is not done by developing a clinical guideline and just
   putting it there. It takes much. well the group dynamic.
   in order to integrate it positively and say 'but it is helping us
   and we are doing a good job' (Tp7).


You like to see sense in what you are doing (TpI).


... it is the repetition ... When you have seen it many times,
   then you get a picture of how things work (TpI).


We think that it is exciting to rehabilitate using everyday life
   activities in natural environments. The results are quickly
   noticeable which sharpens the motivation both for the client
   and the therapist (TpI, TpII and TpIII).


But I also have the possibility of getting help from my colleagues
   (Tp3). I think we use each other a lot and it is fully legitimate,
   and at our team meetings we regularly make room for clinical
   questions (TpD).


We are not so good at swopping ... patients. We have become
   better now ... because we jolly well have to (TpD).

   It worked to bring it up at our team meetings where we talked
   about how to improve our practice (TpB).


Just look at us. Now we have therapists appointed to be
   responsible for developing the clinical practice. It's because
   they [the leaders] want to raise the standards and also
   because we in our group like to do a good job, isn't it? (TpP).


I use it [evidence] to buck myself up ... I have probably also
   become more conscious (TpC).


You could not just take the one [guideline] developed in the
   acute setting. It did not fit our culture. We could not just take
   over something others have developed. You have to consider
   the implications (Tp7).


... and some of the feedback we got has been that the
   teaching we have given has been too theoretical ... they say
   ... they want something more practice-related. I think it has
   to do with the constellation of the group. there are new
   therapists who are in need of elementary instructions (Tp7).


Table 1. Central elements in the five evidence-based clinical
guidelines

Clinical           Activity-based                Client-centred
guideline           intervention                    practice

Aim          To use activities that        To use client-centred
             the patient considers         occupational therapy
             meaningful, both as           practice in order to
             means and goals, in           improve satisfaction with
             occupational therapy          occupational therapy
             practice. The purpose is      intervention, increase
             to use activities and         adherence to therapy
             environments actively in      recommendations, and
             order to assist the patient   improve outcome in
             in enabling meaningful        everyday life occupations.
             occupational performance
             in everyday life.

Standard     At least 80% of the           At least 60%/30% of
             intervention given to         the admitted patients
             the patients is activity      collaborate with the
             based.                        occupational therapist
                                           in common goal-setting
                                           within 8/14 days of
                                           admission.
                                           At least 80% of the
                                           outpatients collaborate
                                           with the occupational
                                           therapist in common
                                           goal-setting using COPM.

Clinical           Assessment of             Arnadottir OTADL
guideline        Motor and Process            Neurobehavioral
                   Skills (AMPS)            Evaluation (A-ONE)

Aim          To use AMPS as part of      To use A-ONE as part of
             the assessment process      the assessment process
             and basis for common        and basis for common
             goal-setting, in order to   goal-setting, in order to
             use standardised and        use standardised and
             valid assessment tools      valid assessment tools
             in the assessment           in the assessment
             process of the patients'    process of the patients'
             occupational performance    occupational performance.
             and prognosis.

Standard     At least 40% of the         At least 40% of the
             admitted patients are       admitted patients are
             tested by the use of        tested by the use of
             the AMPS within 8 days      A-ONE within 8 days
             of admission.               of admission.

Clinical         Canadian Occupational
guideline         Performance Measure
                         (COPM)

Aim          To use COPM as a
             standardised assessment
             in occupational therapy
             practice, in order to clarify
             the patients' subjective
             experience of problems
             in their occupational
             performance in everyday
             life and to create a
             basis for client-centred
             and goal-directed
             rehabilitation.

Standard     At least 30% of the
             admitted patients
             collaborate with the
             occupational therapist
             in common goal-setting
             using COPM within
             14 days of admission.
             At least 80% of the
             outpatients collaborate
             with the occupational
             therapist in common
             goal-setting using COPM.

Table 2. Settings

Setting            Location               Occupational therapists

Setting A   At an acute hospital     The 15 occupational therapists
                                     taking part in the study were
                                     all working within neurology.

Setting B   At a rehabilitation      The seven occupational
            hospital exclusively     therapists participating in the
            for patients with        study were all working within
            neurological diseases    neurorehabilitation.

Setting C   In the municipality      The three occupational
                                     therapists taking part in the
                                     study were working as
                                     generalists.

Setting         Phase in the patients' rehabilitation

Setting A   In this setting, the patients were mainly in
            the acute phase of their rehabilitation.

Setting B   This setting represented solely subacute
            rehabilitation.

Setting C   This setting represented subacute and
            home rehabilitation.

Table 3. Occupational therapists--age, professional experience and
participation

Occupational    Year of       Age       Experience        Field
therapist      graduation   (years)   within stroke    observation
                                      rehabilitation
                                         (years)

Setting A

TpA               1987        44            5               X
TpB               2002        31            5               X
TpC               2002        30            5               X
TpD               1987        48                            X
TpE               2005        46            2               X
TpF               2000        41            6
TpG               2006        27            2
TpH               1979        57            28
TpI               2001        32          5 1/2             X
TpJ               1988        49            19
TpK               2004        29            2
TpL               2002        31            5
TpM               2005        29          3 1/2
TpO               2000        34            3
TpP               2000        32          6 1/2

Setting B

Tp1               2002        32          6 1/2             X
TP2               1997        36            2
Tp3               1996        36            11              X
Tp4               2006        28            2               X
Tp5               1999        38            8               X
Tp6               2003        30            2
Tp7               1987        45            16

Setting C

TpI               1982        48            8               X
TpII              1985        48            22              X
TpIII             2002        30            4               X

Summary                       38            8              13

Occupational   Individual     Focus
therapist      interview      group
                            interview

Setting A

TpA
TpB                X            X
TpC
TpD                X            X
TpE
TpF                             X
TpG                             X
TpH                             X
TpI                X            X
TpJ                             X
TpK                             X
TpL                             X
TpM                             X
TpO                X
TpP                X            X

Setting B

Tp1                X
TP2                X
Tp3                X            X
Tp4                             X
Tp5                X            X
Tp6                X
Tp7                             X

Setting C

TpI                X            X
TpII               X            X
TpIII              X            X

Summary            13          18

Table 4. A summary of the data-generating methods, purpose and sample
size

Data-generating methods                           Purpose

Participatory observations In the    The structure of the
observations, the occupational       participatory observations was
therapists' and the patients'        focusing on the space, the
actions and conversations were       actors, the activity, the
noted.                               feelings expressed and the time
                                     in order to generate detailed and
                                     differentiated data in the
                                     contexts in which the sessions
                                     took place (Spradley 1980).

In the continuation of the           At first the researcher aimed at
observations, short informal         being open in choosing the
interviews with the occupational     sessions that were recorded.
therapists took place.               Later, observations were
                                     strategically weighted in order
                                     to ensure variation and aim at
                                     saturation.

Field notes of complementary         Reflections, preliminary analysis
observations from the settings       and interpretations on the
and researcher's reflections were    implementation process were noted
produced.                            and included in the background
                                     for interview guides as the next
                                     step of generating data (Emerson
                                     et al 1995).

Individual interviews                The individual interviews were
In the continuation of the           held in order to generate data
observations, semi-structured        concerning the occupational
individual interviews (Kvale and     therapists' clinical reasoning
Brinkmann 2009) across settings      related to the individual
were performed.                      patient's rehabilitation process.
                                     In order to provide a thorough
                                     and systematic description of
                                     clinical reasoning in daily
                                     practice, the structure of the
                                     interview guide was based on a
                                     descriptive case (Hovmand et al
                                     2001) as case reports are
                                     sensitive in picking up novelty
                                     in a qualitative way and,
                                     furthermore, are suitable for
                                     investigation of clinical
                                     reasoning.

Focus group interviews               In accordance with Kitzinger
Preliminary results from the         (1994) and Halkier (2005), these
observations, the researcher's       discussions were related to the
reflections and literature           participants' experiences and
studies were used to design the      reflections on daily practice,
interview guide. The combination     their reflections on contextual
of group interaction and the         issues, own attitudes and
researcher deciding the themes       personal values.
for discussion is the strength of
the focus group interview
(Halkier 2005, Silverman 2006).

Data-generating methods                         Sample size

Participatory observations In the    Participatory observations in all
observations, the occupational       three settings were generated
therapists' and the patients'        over a period of 10 months and
actions and conversations were       amounted to 41 recorded
noted.                               observations, which lasted 30-90
                                     minutes.

In the continuation of the           Data from the informal interviews
observations, short informal         were also noted.
interviews with the occupational
therapists took place.

Field notes of complementary
observations from the settings
and researcher's reflections were
produced.

Individual interviews                Thirteen semi-structured
In the continuation of the           individual interviews were
observations, semi-structured        carried out across the settings.
individual interviews (Kvale and     Each interview lasted
Brinkmann 2009) across settings      approximately 45 minutes, was
were performed.                      audio-recorded and transcribed.

Focus group interviews               Four focus group interviews with
Preliminary results from the         17 occupational therapists were
observations, the researcher's       carried out. Due to local work
reflections and literature           schedules and the number of
studies were used to design the      participants, two focus group
interview guide. The combination     interviews were held in setting A
of group interaction and the         and only one each in setting B
researcher deciding the themes       and setting C. These four focus
for discussion is the strength of    group interviews were kept
the focus group interview            separate within the settings in
(Halkier 2005, Silverman 2006).      order to be able to analyse data
                                     related to local context. Each
                                     focus group interview lasted 1
                                     1/2-2 hours, and was
                                     audio-recorded and transcribed.

Table 5. Findings in the structural analysis

Quotations                          Condensation       Theme:
                                                       Facilitator

I think you need help with       Help to change        Facilitation
some of the working              daily routines        of change
procedures. How you basically
... some detailed guiding
until you have developed new
daily routines (TpB).

The facilitator is important     The facilitator       The facilitator
for keeping people up to the     keeps track           in a key role
mark and reminding them of
why it is important (TpM).

[It is important for the         Registration          Facilitation
implementation.] That there      promotes              tools
is focus on it                   implementation
[implementation] and that it
is recorded. It's a good
thing. It promotes the
process (TpL).

                                                       Theme: Learning
                                                       in practice
                                                       development

But it is just very important    Knowledge of          New knowledge
to be able to see the purpose    the purpose is
of them [the standardised        important
assessment tools]--andbe
familiar with the theories
behind them. Andunderstand
the purpose of these things
in order to be motivated to
make use of them (TpII).

[It is important for the         The clinical          New clinical
integration] that it is          guidelines need       experiences
something that is useful. And    to be useful in
that you have some               clinical practice
goodexperiences using it.
This makes you go on using
it. And not just that it is a
clinical guideline (Tp3).

                                                       Theme:
                                                       Participation

Yes andI think that the          Clinical experience   Cooperation
clinical experience within       and participation
the therapist group andhow       matters
active the group has taken
part in the process [affects
the integration process]
(Tp7).
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