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theses

Background: Standardized assessments are valid and reliable self-report and performance-based tools used to justify treatment, determine plan of care, and communicate progress with patients, providers and payers, yet physical therapists (PTs) do not routinely use them. Knowledge translation (KT) research evaluates the effectiveness of intervention strategies to improve the use of evidence in health care practice including the use of standardized assessments by PTs. Knowledge brokers (KBs) can be used to support KT, as KBs collaborate with PTs and organizations to develop strategies to implement research evidence while overcoming context specific barriers. The purpose of this dissertation was to determine if a theoretically informed multimodal KT intervention supported by an external KB would change the use of a selected outcome measure by PTs who work in inpatient rehabilitation.

Methods: Two studies, a single cohort and cluster randomized controlled trial, were conducted with PTs who worked in inpatient rehabilitation settings. Methods were replicated and scaled. Both studies used the Knowledge to Action Framework to guide the overall KT process and the Theoretical Domains Framework to guide the barrier assessment and develop the intervention. Physical therapists collaborated with the KB to determine barriers, select an outcome measure and develop the intervention. Barriers were determined by both qualitative and quantitative methods. Intervention strategies were multi-modal and included education, audit and feedback, engagement, and KB support. The PTs in the cohort had full implementation support by the KB and the cluster randomized trial compared full implementation support to partial implementation support. Documentation of standardized assessment use was evaluated quantitatively using chart audit data and the goal attainment scale and qualitatively through focus groups. Focus groups were coded using conventional content analysis. A realist-like evaluation was conducted on the cluster randomized controlled trial to map the relationship between chart audit data to positive and negative codes rated in the focus group on the intervention strategies (mechanisms) and contextual factors. A pilot study, interviewed four patients treated by PT’s in the fully supported group in the cluster trial to determine their experiences and perceptions of assessment practices while in physical therapy.

Results: The cohort included 11 PTs who worked in a sub-acute rehabilitation hospital that significantly improved the documented use of the 4 Meter Walk Test immediately following the intervention and sustained the use at 6 -month follow-up. For the cluster RCT, a total of 18 PTs, 9 in each group, participated. The fully supported site selected the Timed Up and Go test and the partially supported site selected the 10 Meter Walk Test. Both sites had short term improvement of the selected outcome measure that were not sustained at 6 month follow-up.
Both studies found the PTs reported barriers to using outcome measures including organizational challenges, policy changes, dissatisfaction with the outcome measure selected, impaired patient’s functional level and environmental issues. The four patients reported positive experiences in physical therapy and discussed observational assessments including distance walked rather than use of standardized outcome measures like the TUG.

Discussion/ Conclusion: In the cohort study, the KB in collaboration with the supervisor was able to implement a successful behavior change intervention. It is difficult, however, to determine if KB implementation support alone can improve the use of selected standardized assessment as multiple factors influenced outcome measures use in both studies. The realist-like evaluation in the cluster RCT highlighted the need for formal assessment of organizational factors and external policy changes when implementing a KT intervention and the need for organizational implementation support. Future KT projects should consider pragmatic designs rather than control and randomization as changes in context could not be controlled. In addition, training PTs on shared decision making using standardized outcome measures may be warranted in the future to determine patients’ value of standardized assessment.

ETD_9378

Ph.D.

Includes bibliographical references

by Wendy Romney

doi:10.7282/t3-aaeb-em70

ETD doctoral

The author owns the copyright to this work.