Assessment of Walking Speed and Distance Post-Stroke Increases After Providing a Theory-Based Toolkit.

BACKGROUND AND PURPOSE: While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs). METHODS: In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models. RESULTS: Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively). DISCUSSION AND CONCLUSIONS: Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390 ).

Experiences of Physical Therapists and Professional Leaders With Implementing a Toolkit to Advance Walking Assessment Poststroke: A Realist Evaluation.

OBJECTIVE: The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings. METHODS: A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice. RESULTS: Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m. CONCLUSION: Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings. IMPACT: This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

Interprofessional and multiprofessional approaches in quality improvement education.

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals' professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Perceptions of preparedness: How hospital-based orientation can enhance the transition from academic to clinical learning.

BACKGROUND: Clinical placements are essential for applied learning experiences in health professions education. Unfortunately, there is little consensus on how best to prepare learners for the transition between academic and clinical learning. We explored learners' perceptions of hospital-based orientation and resulting preparedness for clinical placement. METHODS: Sixty-three learners participated in a total of 18 semi-structured focus groups, during their clinical placements. Data were analyzed thematically. RESULTS: We organized learners' perceptions of hospital-based orientation that support their preparedness for placement into three themes: (1) adequate site orientation for learner acquisition of organization acumen and (2) clinical preceptor training to support unit/service and (3) individual components. CONCLUSION: Thoughtful attention to hospital-based orientation can support learners in transitioning from academic to clinical learning. Hospital organizations should attend to all three components during orientation to better support learners' preparedness for clinical learning.

CONTEXTE: Les stages cliniques sont essentiels aux expériences d'apprentissage appliquées dans l'enseignement médical. Malheureusement, il n'existe pas de consensus sur la meilleure manière de préparer les étudiants à la transition entre l'apprentissage académique et l'apprentissage clinique. Nous avons exploré la perception des étudiants de l'orientation en milieu hospitalier et de l'état de préparation qui en résulte pour les stages cliniques. MÉTHODES: Au total, 63 étudiants ont participé 'à travers 18 groupes de discussion semi-structurés lors de leurs stages cliniques. Les données ont été analysées de manière thématique. RÉSULTATS: Nous avons classé les perceptions des étudiants relativement à l'orientation en milieu hospitalier qui soutient leur état de préparation pour un stage en trois thèmes différents : (1) une orientation adéquate du site pour l'acquisition par l'étudiant de l'expertise de l'organisation et (2) la formation du précepteur clinique pour soutenir l'unité/le service et (3) les composantes individuelles. CONCLUSION: Une attention particulière centrée sur l'orientation en milieu hospitalier peut soutenir les étudiants dans leur transition de l'apprentissage académique à l'apprentissage clinique. Les organismes hospitaliers doivent inclure les trois composantes pendant l'orientation pour mieux soutenir l'état de préparation des étudiants pour leur apprentissage clinique.

Experiential Learning in Project-Based Quality Improvement Education: Questioning Assumptions and Identifying Future Directions.

PURPOSE: Project-based experiential learning is a defining element of quality improvement (QI) education despite ongoing challenges and uncertainties. The authors examined stakeholders' perceptions and experiences of QI project-based learning to increase understanding of factors that influence learning and project experiences. METHOD: The authors used a case study approach to examine QI project-based learning in 3 advanced longitudinal QI programs, 2 at the University of Toronto and 1 at an academic tertiary-care hospital. From March 2016 to June 2017, they undertook 135 hours of education program observation and 58 interviews with learners, program directors, project coaches, and institutional leaders and reviewed relevant documents. They analyzed data using a conventional and directed data analysis approach. RESULTS: The findings provide insight into 5 key factors that influenced participants' project-based learning experiences and outcomes: (1) variable emphasis on learning versus project objectives and resulting benefits, tensions, and consequences; (2) challenges integrating the QI project into the curriculum timeline; (3) project coaching factors (e.g., ability, capacity, role clarity); (4) participants' differing access to resources and ability to direct a QI project given their professional roles; and (5) workplace environment influence on project success. CONCLUSIONS: The findings contribute to an empirical basis toward more effective experiential learning in QI by identifying factors to target and optimize. Expanding conceptualizations of project-based learning for QI education beyond learner-initiated, time-bound projects, which are at the core of many QI educational initiatives, may be necessary to improve learning and project outcomes.

Collaborative Care Transitions Symposium: Insights from Participants.

BACKGROUND/PURPOSE: There are promising signs that interprofessional collaborative practice is associated with quality care transitions and improved access to patient-centred healthcare. A one-day symposium was held to increase awareness and capacity to deliver quality collaborative care transitions to interprofessional health disciplines and service users. METHOD: A mixed methods study was used that included a pre-post survey design and interviews to examine the impact of the symposium on knowledge, attitudes and practice change towards care transitions and collaborative practice with symposium participants. DISCUSSION: Our survey results revealed a statistically significant increase in only a few of the scores towards care transitions and collaborative practice among post-survey respondents. Three key themes emerged from the qualitative analysis, including: (1) engaging the patient at the heart of interprofessional collaboration and co-design of care transitions; (2) having time to reach out, share and learn from each other; and (3) reflecting, reinforcing and revising practice. CONCLUSION: Further efforts that engage inter-organizational learning by exchanging knowledge and evaluating these forums are warranted.

Factors associated with outcome after subtalar arthrodesis.

OBJECTIVES: To evaluate radiographic and functional outcomes after subtalar arthrodesis and to identify patient factors associated with poor outcome. DESIGN: Retrospective study. SETTING: Two academic hospitals. PATIENTS: Eighty-eight patients with primary or secondary osteoarthritis treated between 1995 and 2002. INTERVENTION: Primary subtalar arthrodesis. MAIN OUTCOME MEASUREMENTS: Radiographic outcome was assessed by determining union rates. Functional outcome was assessed through self-administered questionnaires (Short Form-36, Short Musculoskeletal Function Assessment, and the AAOS Foot and Ankle Instrument). RESULTS: After adjusting for age and sex smokers were 3.8 times more likely to go on to nonunion than nonsmokers (P < 0.05). As patients aged, there was a higher likelihood of nonunion if they also smoked (P < 0.05). Of patients undergoing subtalar bone block distraction arthrodesis 95% went on to union compared with 65% of patients treated with an in situ subtalar arthrodesis without bone graft (P < 0.05). There was a trend for higher rates of union if a bone graft was used among patients treated with an in situ subtalar arthrodesis. Diabetic patients were 18.7 times more likely to have a malunion (P < 0.05). As a group, patients who have undergone subtalar arthrodesis can expect significantly worse functional outcomes compared with the Canadian and American normative populations. The poorest functional outcomes were observed among patients with diabetes. A trend for poorer outcome in bodily pain and general health (Short Form-36) was seen in workers' compensation patients. CONCLUSIONS: Certain patient variables are associated with poorer outcomes after subtalar fusion. The results of this study will enable surgeons to provide better information to patients in preoperative discussions with respect to patient expectations, outcomes, and the success of surgery.