Interventions for the uptake of evidence-based recommendations in acute stroke settings.

BACKGROUND: There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care. OBJECTIVES: To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date. SELECTION CRITERIA: We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations. MAIN RESULTS: We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes. AUTHORS' CONCLUSIONS: We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.

Stroke survivors' perceptions of the factors that influence engagement in activity outside dedicated therapy sessions in a rehabilitation unit: A qualitative study.

OBJECTIVE: To investigate stroke survivors' perceptions of factors influencing their engagement in activity outside of dedicated therapy sessions during inpatient rehabilitation. DESIGN: Qualitative study. SETTING: Four metropolitan rehabilitation units in Australia. PARTICIPANTS: People undertaking inpatient rehabilitation after stroke. METHODS: Semi-structured interviews conducted in person by a speech pathologist A stepped iterative process of inductive analysis was employed until data saturation was achieved with themes then applied against the three domains of the Theory of Planned Behaviour (perceived behavioural control, social norms and attitude). RESULTS: Interviews of 33 stroke survivors (60% female, median age of 73 years) revealed five themes (i) uncertainty about how to navigate and what was available for use in the rehabilitation unit restricts activity and (ii) post-stroke mobility, fatigue and pre- and post-stroke communication impairments restrict activity (perceived behavioural control); (iii) unit set up, rules (perceived and actual) and staff expectations influence activity and (iv) visiting family and friends are strong facilitators of activity (social norms), and (v) personal preferences and mood influence level of activity (attitude). CONCLUSION: At the individual level, stroke survivors perceived that their ability to be active outside of dedicated therapy sessions was influenced by their impairments, including mood, and their attitude towards and preference for activity. At the ward level, stroke survivors perceived that their ability to be active was influenced by ward set-up, rules and staff expectations. Visitors were perceived to be important facilitators of activity outside of therapy sessions.

Impairments, and physical design and culture of a rehabilitation unit influence stroke survivor activity: qualitative analysis of rehabilitation staff perceptions.

PURPOSE: This study aimed to investigate rehabilitation staff perceptions of factors influencing stroke survivor activity outside of dedicated therapy time for the purpose of supporting successful translation of activity promoting interventions in a rehabilitation unit. MATERIALS AND METHODS: Purposive sampling of multi-disciplinary teams from four rehabilitation units was performed, and semi-structured interviews were conducted by telephone, digitally audio-recorded and then transcribed verbatim. A stepped iterative process of thematic analysis was employed until data saturation was reached. RESULTS: All but one of the 22 participants were female, the majority were either physiotherapists or occupational therapists, with a median of 4 years (interquartile range, 2-10) working at their respective rehabilitation units. Analysis of the data revealed three themes: (i) stroke survivor characteristics influence their activity outside therapy, (ii) the rehabilitation environment influences physical, cognitive, and social activity, and (iii) institutional priorities, staff culture, and attitude can be barriers to activity. Rehabilitation units were perceived to be unstimulating, and visitors considered enablers of activity when resources were perceived to be scarce. CONCLUSIONS: Our results suggest careful consideration of the involvement of visitors, an individual's needs and preferences, and the institution's priorities and staff attitude may result in greater stroke survivor activity during rehabilitation.Implications for rehabilitationStaff should consider stroke survivor impairments and a rehabilitation unit's institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity.The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity.Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity.Discussion within the rehabilitation team concerning "ownership" of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same.

Consumer engagement in health care policy, research and services: A systematic review and meta-analysis of methods and effects.

To assess the effects of consumer engagement in health care policy, research and services. We updated a review published in 2006 and 2009 and revised the previous search strategies for key databases (The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; PsycINFO; CINAHL; Web of Science) up to February 2020. Selection criteria included randomised controlled trials assessing consumer engagement in developing health care policy, research, or health services. The International Association for Public Participation, Spectrum of Public Participation was used to identify, describe, compare and analyse consumer engagement. Outcome measures were effects on people; effects on the policy/research/health care services; or process outcomes. We included 23 randomised controlled trials with a moderate or high risk of bias, involving 136,265 participants. Most consumer engagement strategies adopted a consultative approach during the development phase of interventions, targeted to health services. Based on four large cluster-randomised controlled trials, there is evidence that consumer engagement in the development and delivery of health services to enhance the care of pregnant women results in a reduction in neonatal, but not maternal, mortality. From other trials, there is evidence that involving consumers in developing patient information material results in material that is more relevant, readable and understandable for patients, and can improve knowledge. Mixed effects are reported of consumer-engagement on the development and/or implementation of health professional training. There is some evidence that using consumer interviewers instead of staff in satisfaction surveys can have a small influence on the results. There is some evidence that consumers may have a role in identifying a broader range of health care priorities that are complementary to those from professionals. There is some evidence that consumer engagement in monitoring and evaluating health services may impact perceptions of patient safety or quality of life. There is growing evidence from randomised controlled trials of the effects of consumer engagement on the relevance and positive outcomes of health policy, research and services. Health care consumers, providers, researchers and funders should continue to employ evidence-informed consumer engagement in their jurisdictions, with embedded evaluation. Systematic review registration: PROSPERO CRD42018102595.

Choosing and Managing Aged Care Services from Afar: What Matters to Australian Long-Distance Care Givers.

This research aims to identify the factors that influence caregivers' decisions about the aged care providers they select for their elder relatives when caring from a distance and what they value once they have engaged a service. Adult long-distance carers for older relatives living within Australia were purposively sampled and they participated in audio-recorded interviews. A thematic analysis was employed to investigate the data. A sample of 13 participants enabled data saturation with no new major themes identified in the final three interviews. Participants were 50 to 65 years (Mean = 59.8) and mostly (77%) female. Four themes emerged relating to selection of care providers: (1) availability of care, (2) financial arrangements, (3) proximity and location, and (4) reputation of care provider. Five themes detailed valued qualities of care: (1) vigilant monitoring and responsivity, (2) communication with family, (3) flexibility and proactiveness of care, (4) staffing, and (5) access to appropriate and holistic care to maintain wellbeing. Long-distance caregivers face barriers in selecting and managing aged care services from afar within a complex Australian aged care system. They strongly value regular, proactive communication about the wellbeing of their relatives and may be particular beneficiaries of communication and assistive monitoring technologies.

Changes in physiotherapists' perceptions of evidence-based practice after a year in the workforce: A mixed-methods study.

BACKGROUND: Few studies have explored evidence-based practice (EBP) knowledge, attitudes and behaviours of health professional graduates transitioning into the workforce. This study evaluated changes in these EBP domains in physiotherapists after one year of working. METHOD: A mixed methods design was used. Participants completed two psychometrically-tested EBP questionnaires at two timepoints. The Evidence-Based Practice Profile questionnaire collected self-report EBP data (Terminology, Relevance, Confidence, Practice, Sympathy) and the Knowledge of Research Evidence Competencies collected objective data (Actual Knowledge). Changes were calculated using descriptive statistics (paired t-tests, 95% CI, effect sizes). Qualitative interview data collected at one timepoint were analysed using a descriptive approach and thematic analysis, to examine the lived experience of participants in the context of their first employment. The aim of the mixed methods approach was a broader and deeper understanding of participants' first year of employment and using EBP. RESULTS: Data were analysed from 50 participants who completed both questionnaires at the two timepoints. After one year in the workforce, there was a significant decrease in participants' perceptions of Relevance (p<0.001) and Confidence with EBP (p<0.001) and non-significant decreases in the other domains. Effect sizes showed medium decreases for Relevance (0.69) and Confidence (0.57), small decreases in Terminology (0.28) and Practice (0.23), and very small decreases in Sympathy (0.08) and Actual Knowledge (0.11). Seven themes described participants experience of using EBP in their first working year. CONCLUSIONS: After a year in the workplace, confidence and perceptions of relevance of EBP were significantly reduced. A subtle interplay of features related to workplace culture, competing demands to develop clinical skills, internal and external motivators to use EBP and patient expectations, together with availability of resources and time, may impact early graduates' perceptions of EBP. Workplace role models who immersed themselves in evidence discussion and experience were inspiring to early graduates.

How can stroke care be improved for younger service users? A qualitative study on the unmet needs of younger adults in inpatient and outpatient stroke care in Australia.

Background: The incidence of young stroke is increasing worldwide. However, young adults are inadequately supported in their recovery by a system of stroke care in which the older patient is the majority consumer.Purpose: To examine the unmet needs of younger stroke survivors in inpatient and outpatient healthcare settings and identify opportunities for improved service delivery.Materials and Methods: In-depth semi-structured interviews were undertaken with 19 participants aged 18-55 at the time of their first-ever stroke and inductively analysed using a rigorous qualitative descriptive approach.Results: Many unmet care needs were identified within three emergent themes: inadequately addressed psycho-emotional and cognitive needs after young stroke; isolation from lack of information and structured support; and failure to deliver age-relevant patient-centred care. These themes were further divided into sub-themes and the sub-themes were named in a manner to signpost the way forward for young stroke care.Conclusions: This study provides new insights into the experience of inpatient and outpatient stroke care by younger stroke survivors and outlines possible improvements for clinical practice. Future research should evaluate the effect of targeted strategies to support younger adults after stroke.Implications for rehabilitationPost-stroke rehabilitation might be improved by providing more support for the non-physical effects of stroke (e.g., psycho-emotional support, cognitive rehabilitation).Younger stroke survivors may also benefit from a long-term community care plan and longer-term rehabilitation.Patient-centered rehabilitation and education about self-management interventions appear to be important areas for further development.Future research is required to evaluate the effect of targeted strategies to support younger stroke survivors, as well as identify the needs of younger adults with post-stroke communication impairment.

The evidence for services to avoid or delay residential aged care admission: a systematic review.

BACKGROUND: Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. METHOD: Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). RESULTS: Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001). CONCLUSIONS: Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes. TRIAL REGISTRATION: PROSPERO Registration CRD42016050086 .

Access to rehabilitation for patients with stroke in Australia.

OBJECTIVE: To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation, and receiving post-acute rehabilitation after having a stroke. DESIGN: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 - 28 February 2015. SETTING, PARTICIPANTS: 112 Australian hospitals that admit adults with acute stroke. MAIN OUTCOMES: Associations between patient-related and organisational factors and the provision of rehabilitation interventions. RESULTS: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75; 95% CI, 5.07-8.90) and receiving care in a stroke unit (OR, 2.08; 95% CI, 1.61-2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit (OR, 1.73; 95% CI, 1.34-2.22) and having an arm or speech deficit. Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33-0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30-0.61). CONCLUSIONS: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia, both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers.

The personal and social experiences of community-dwelling younger adults after stroke in Australia: a qualitative interview study.

OBJECTIVES: To examine the personal and social experiences of younger adults after stroke. DESIGN: Qualitative study design involving in-depth semi-structured interviews and rigorous qualitative descriptive analysis informed by social constructionism. PARTICIPANTS: Nineteen younger stroke survivors aged 18 to 55 years at the time of their first-ever stroke. SETTING: Participants were recruited from urban and rural settings across Australia. Interviews took place in a clinic room of the Florey Institute of Neuroscience and Mental Health (Melbourne, Australia), over an online conference platform or by telephone. RESULTS: Four main themes emerged from the discourses: (1) psycho-emotional experiences after young stroke; (2) losing pre-stroke life construct and relationships; (3) recovering and adapting after young stroke; and (4) invalidated by the old-age, physical concept of stroke. While these themes ran through the narratives of all participants, data analysis also drew out interesting variation between individual experiences. CONCLUSIONS: For many younger adults, stroke is an unexpected and devastating life event that profoundly diverts their biography and presents complex and continued challenges to fulfilling age-normative roles. While adaptation, resilience and post-traumatic growth are common, this study suggests that more bespoke support is needed for younger adults after stroke. Increasing public awareness of young stroke is also important, as is increased research attention to this problem.

Changes in physiotherapy students' knowledge and perceptions of EBP from first year to graduation: a mixed methods study.

BACKGROUND: Dedicated Evidence-Based Practice (EBP) courses are often included in health professional education programs. It is important to understand the effectiveness of this training. This study investigated EBP outcomes in entry-level physiotherapy students from baseline to completion of all EBP training (graduation). METHODS: Mixed methods with an explanatory sequential design. Physiotherapy students completed two psychometrically-tested health professional EBP instruments at baseline and graduation. The Evidence-Based Practice Profile questionnaire collected self-reported data (Terminology, Confidence, Practice, Relevance, Sympathy), and the Knowledge of Research Evidence Competencies instrument collected objective data (Actual Knowledge). Focus groups with students were conducted at graduation to gain a deeper understanding of the factors impacting changes in students' EBP knowledge, attitudes, behaviour and competency. Descriptive statistics, paired t-tests, 95% CI and effect sizes (ES) were used to examine changes in outcome scores from baseline to graduation. Transcribed focus group data were analysed following a qualitative descriptive approach with thematic analysis. A second stage of merged data analysis for mixed methods studies was undertaken using side-by-side comparisons to explore quantitatively assessed EBP measures with participants' personal perceptions. RESULTS: Data were analysed from 56 participants who completed both instruments at baseline and graduation, and from 21 focus group participants. Large ES were reported across most outcomes: Relevance (ES 2.29, p ≤ 0.001), Practice (1.8, p ≤ 0.001), Confidence (1.67, p ≤ 0.001), Terminology (3.13, p ≤ 0.001) and Actual Knowledge (4.3, p ≤ 0.001). A medium ES was found for Sympathy (0.49, p = 0.008). Qualitative and quantitative findings mostly aligned but for statistical terminology, participants' self-reported understanding was disparate with focus group reported experiences. Qualitative findings highlighted the importance of providing relevant context and positive role models for students during EBP training. CONCLUSIONS: Following EBP training across an entry-level physiotherapy program, there were qualitative and significant quantitative changes in participants' knowledge and perceptions of EBP. The qualitative and quantitative findings were mainly well-aligned with the exception of the Terminology domain, where the qualitative findings did not support the strength of the effect reported quantitatively. The findings of this study have implications for the timing and content of EBP curricula in entry-level health professional programs.

Boredom in patients with acquired brain injuries during inpatient rehabilitation: a scoping review.

PURPOSE: Boredom may impede engagement in inpatient rehabilitation following an acquired brain injury. This review aimed to: (1) describe the experience and (2) quantify the incidence of boredom; (3) identify measurement tools used to quantify boredom; (4) summarize factors contributing to boredom, and (5) outline evidence-based interventions shown to reduce boredom during inpatient rehabilitation. METHODS: Two researchers independently screened publications retrieved from electronic database searches. Publications presenting patient, carer or staff data relating to boredom in inpatients with acquired brain injuries were included. RESULTS: Two thousand four hundred and ninety-nine references were retrieved, 88 full texts were reviewed, with 24 studies included. The majority of studies reported qualitative data indicating boredom to be a common experience of patients with acquired brain injuries (n = 14 studies +1 review). The incidence of boredom post acquired brain injury is unknown. Personal and organizational factors and the physical environment may contribute to boredom (n = 11 studies +2 reviews). Qualitative work (n = 9 studies) indicates that use of the creative-arts or exposure to environmental enrichment may help alleviate boredom in patients with acquired brain injuries during inpatient rehabilitation. CONCLUSION: Further mixed-methods research is required to establish the incidence of and contributing factors to boredom in patients with acquired brain injuries undergoing rehabilitation. Understanding this will help inform future research aimed at improving patient engagement in inpatient rehabilitation. Implications for rehabilitation Boredom is commonly reported by hospitalised patients with ABI to negatively affect their rehabilitation yet the scope of the problem has not been measured. Boredom is a complex phenomenon, likely influenced by a number of personal and environmental factors that are not fully understood in this population. Through a better understanding of boredom, interventions may be developed to improve patient engagement in inpatient rehabilitation programs.

Inequities in access to inpatient rehabilitation after stroke: an international scoping review.

Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.

Carers' Experiences, Needs, and Preferences During Inpatient Stroke Rehabilitation: A Systematic Review of Qualitative Studies.

OBJECTIVE: To report and synthesize the experiences, needs, and preferences of carers of stroke survivors undergoing inpatient rehabilitation. DATA SOURCES: MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science were searched to March 2016. Reference lists of relevant publications were searched. No language restrictions were applied. STUDY SELECTION: Eligible qualitative studies reported the experiences of carers of stroke survivors who underwent inpatient rehabilitation. The search yielded 3532 records; 93 full-text publications were assessed for eligibility, and 34 documents (33 studies) were included. Comprehensiveness of reporting was assessed using the Consolidated Criteria for Reporting Qualitative Health Research framework. DATA EXTRACTION: Data on the characteristics of included studies were independently extracted by 2 authors. Differences in data extraction between authors were resolved through discussion or by a third author. All text in studies' results and discussion sections were extracted for analysis. DATA SYNTHESIS: Extracted texts were analyzed inductively using thematic synthesis. Seven analytical themes were developed that related to the carers' experiences, needs, and preferences: (1) overwhelmed with emotions; (2) recognition as a stakeholder in recovery; (3) desire to be heard and informed; (4) persisting for action and outcomes; (5) being legitimate clients; (6) navigating an alien culture and environment; and (7) managing the transition home. CONCLUSIONS: This systematic review provides new insights into the experiences, needs, and preferences of carers of stroke survivors undergoing inpatient rehabilitation. Carers experienced distress as they navigated a foreign culture and environment without adequate communication and processes in place for their inclusion. We recommend deliberate efforts to provide a more inclusive environment that better supports and prepares carers for their new role.

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke.

OBJECTIVE: To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke. DESIGN: Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework. SETTING: Eight acute stroke units in two states of Australia. SUBJECTS: Health professionals working in acute stroke units. INTERVENTIONS: Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway. RESULTS: Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain 'social and professional role'); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation ('belief about consequences'); the influence of the unit's relationships with other groups including rehabilitation teams ('social influences' domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices ('knowledge' domain). CONCLUSION: This study has identified that health professionals' perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

Advancing Evidence-Based Practice in Physical Therapy Settings: Multinational Perspectives on Implementation Strategies and Interventions.

It is of critical importance that findings from the wealth of clinical physical therapist research are transferred into clinical practice without unnecessary delays. There is a lack of knowledge about strategies that can be used to effectively implement physical therapist research findings and evidence-based practice (EBP) into everyday clinical practice in different national settings and contexts. The purpose of this article is to contribute to knowledge about effective strategies for implementing EBP that have been studied in different national physical therapy settings. The specific aims of this article are to share experiences and provide a current multinational perspective on different approaches and strategies for implementing EBP and to highlight important considerations and implications for both research and practice. Six research studies from various settings in 3 countries are described and synthesized. Key characteristics of the studies and intervention components are tabulated and mapped to the Cochrane Effective Practice and Organisation of Care taxonomy. Commonalities and differences are presented. The implementation strategies described were: a theory-based guideline implementation tailored to identified barriers and facilitators; a multifaceted EBP training package; journal clubs; a multifaceted strategy comprising contextualized procedures, protocols, and standardized resources; barrier identification, education, audit, feedback, and reminders; and contextualized guidelines. Commonalities were the use of a multifaceted approach, educational measures, and clinical guidelines. Key outcomes across the studies were improved attitudes and increased awareness, knowledge, skills, and confidence in EBP; better access to clinical practice guidelines and other EBP resources; identification of barriers that could be targeted in future implementation activities; earlier referrals; and use of recommended outcome measures. The article can serve as a template for other physical therapist researchers in designing implementation studies, as well as to inform policies and practice for health care managers and decision makers who are looking for ways to implement research findings in their organizations.

Education-only versus a multifaceted intervention for improving assessment of rehabilitation needs after stroke; a cluster randomised trial.

BACKGROUND: In 2011, more than half of the patients with stroke in Australian hospitals were not assessed for the need for rehabilitation. Further, there were no recommended criteria to guide rehabilitation assessment decisions. Subsequently, a decision-making tool called the Assessment for Rehabilitation Tool (ART) was developed. The ART was designed to assist Australian hospital clinicians to identify the rehabilitation needs of patients with stroke using evidence-based criteria. The ART was released and made freely available for use in 2012. This study evaluated the effectiveness of an education-only intervention (1 onsite education session and distribution of the ART) and a multifaceted intervention (2 or more onsite education sessions, distribution of the ART, audit and feedback, barrier identification, site-specific strategy development, promotion of interdisciplinary teamwork, opinion leaders and reminders) for improving assessments of rehabilitation needs after stroke. METHODS: Ten hospitals in 2 states of Australia were randomly assigned to an education-only or a multifaceted intervention. Medical records were audited by assessors blinded to group allocation before and after the implementation period. Difference in the proportion of patients assessed for rehabilitation before and after the intervention was analysed using mixed-effects logistic regression analysis, with time period as the dependent variable, an interaction between intervention type and time included to test for differences between the interventions, and hospital included as the random effect to account for patient clustering. RESULTS: Data from 586 patients (284 pre-intervention; 302 post-intervention; age 76 years, 59 % male) showed that the multifaceted intervention was not more effective than education-only in improving the proportion of patients whose rehabilitation needs were assessed (reference category education-only; odds ratio 1.29, 95 % confidence interval 0.63-2.67, p = 0.483). Post-intervention, the odds of a patient's rehabilitation needs being assessed was 3.69 times greater than pre-intervention (95 % confidence interval 2.57-5.30, p < 0.001). Evidence-based criteria were not consistently used when patients were deemed to have no rehabilitation needs. CONCLUSIONS: A multifaceted intervention was not more effective than education-only in improving the assessment of rehabilitation needs of patients with stroke. Further interventions are required to ensure that all patients are assessed for the need for rehabilitation using evidence-based criteria. TRIAL REGISTRATION: ANZCTR (Australian New Zealand Clinical Trials Registry), ACTRN12616000340437.

Self management programmes for quality of life in people with stroke.

BACKGROUND: Stroke results from an acute lack of blood supply to the brain and becomes a chronic health condition for millions of survivors around the world. Self management can offer stroke survivors a pathway to promote their recovery. Self management programmes for people with stroke can include specific education about the stroke and likely effects but essentially, also focusses on skills training to encourage people to take an active part in their management. Such skills training can include problem-solving, goal-setting, decision-making, and coping skills. OBJECTIVES: To assess the effects of self management interventions on the quality of life of adults with stroke who are living in the community, compared with inactive or active (usual care) control interventions. SEARCH METHODS: We searched the following databases from inception to April 2016: the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, OTSeeker, OT Search, PEDro, REHABDATA, and DARE. We also searched the following trial registries: ClinicalTrials.gov, Stroke Trials Registry, Current Controlled Trials, World Health Organization, and Australian New Zealand Clinical Trials Registry. SELECTION CRITERIA: We included randomised controlled trials of adults with stroke living in the community who received self management interventions. These interventions included more than one component of self management or targeted more than a single domain of change, or both. Interventions were compared with either an inactive control (waiting list or usual care) or active control (alternate intervention such as education only). Measured outcomes included changes in quality of life, self efficacy, activity or participation levels, impairments, health service usage, health behaviours (such as medication adherence or lifestyle behaviours), cost, participant satisfaction, or adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted prespecified data from all included studies and assessed trial quality and risk of bias. We performed meta-analyses where possible to pool results. MAIN RESULTS: We included 14 trials with 1863 participants. Evidence from six studies showed that self management programmes improved quality of life in people with stroke (standardised mean difference (SMD) random effects 0.34, 95% confidence interval (CI) 0.05 to 0.62, P = 0.02; moderate quality evidence) and improved self efficacy (SMD, random effects 0.33, 95% CI 0.04 to 0.61, P = 0.03; low quality evidence) compared with usual care. Individual studies reported benefits for health-related behaviours such as reduced use of health services, smoking, and alcohol intake, as well as improved diet and attitude. However, there was no superior effect for such programmes in the domains of locus of control, activities of daily living, medication adherence, participation, or mood. Statistical heterogeneity was mostly low; however, there was much variation in the types and delivery of programmes. Risk of bias was relatively low for complex intervention clinical trials where participants and personnel could not be blinded. AUTHORS' CONCLUSIONS: The current evidence indicates that self management programmes may benefit people with stroke who are living in the community. The benefits of such programmes lie in improved quality of life and self efficacy. These are all well-recognised goals for people after stroke. There is evidence for many modes of delivery and examples of tailoring content to the target group. Leaders were usually professionals but peers (stroke survivors and carers) were also reported - the commonality is being trained and expert in stroke and its consequences. It would be beneficial for further research to be focused on identifying key features of effective self management programmes and assessing their cost-effectiveness.

Implementing a complex rehabilitation intervention in a stroke trial: a qualitative process evaluation of AVERT.

BACKGROUND: The implementation of multidisciplinary stroke rehabilitation interventions is challenging, even when the intervention is evidence-based. Very little is known about the implementation of complex interventions in rehabilitation clinical trials. The aim of study was to better understand how the implementation of a rehabilitation intervention in a clinical trial within acute stroke units is experienced by the staff involved. This qualitative process evaluation was part of a large Phase III stroke rehabilitation trial (AVERT). METHODS: A descriptive qualitative approach was used. We purposively sampled 53 allied health and nursing staff from 19 acute stroke units in Australia, New Zealand and Scotland. Semi-structured interviews were conducted by phone, voice-internet, or face to face. Digitally recorded interviews were transcribed and analysed by two researchers using rigorous thematic analysis. RESULTS: Our analysis uncovered ten important themes that provide insight into the challenges of implementing complex new rehabilitation practices within complex care settings, plus factors and strategies that assisted implementation. Themes were grouped into three main categories: staff experience of implementing the trial intervention, barriers to implementation, and overcoming the barriers. Participation in the trial was challenging but had personal rewards and improved teamwork at some sites. Over the years that the trial ran some staff perceived a change in usual care. Barriers to trial implementation at some sites included poor teamwork, inadequate staffing, various organisational barriers, staff attitudes and beliefs, and patient-related barriers. Participants described successful implementation strategies that were built on interdisciplinary teamwork, education and strong leadership to 'get staff on board', and developing different ways of working. CONCLUSIONS: The AVERT stroke rehabilitation trial required commitment to deliver an intervention that needed strong collaboration between nurses and physiotherapists and was different to current care models. This qualitative process evaluation contributes unique insights into factors that may be critical to successful trials teams, and as AVERT was a pragmatic trial, success factors to delivering complex intervention in clinical practice. TRIAL REGISTRATION: AVERT registered with Australian New Zealand Clinical Trials Registry ACTRN12606000185561 .